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North Carolina · Home care agency · 10A NCAC 13J
North Carolina home care policies and procedures: what 13J and DHSR require
Rule .1001(a) lists 11 written policies, other 13J rules add more, and DHSR’s Initial Survey Checklist lists 32 policy and procedure items. You send them when DHSR asks, after it confirms receipt of your application and fee, and DHSR reviews them before it licenses you. Here is every item, in the rule’s and DHSR’s own words, with the policy that answers it.
- Rule-verified October 1, 2026
- Quoted from 10A NCAC 13J and DHSR
- 48 requirements mapped
Quick answer
Rule .1001(a) of 10A NCAC 13J says "The governing body or its designee shall establish and implement written policies governing agency operation. Such policies shall be available for inspection by the Department." It lists 11 policies (13J .1001(a)), and other 13J rules add written policies on infection control (.1003(a)), personnel records, orientation and in-service education (.1003(d)), accepting clients (.1101), plans of care (.1201) and client records (.1401).
DHSR’s Home Care Initial Survey Checklist lists 32 policy and procedure items: 14 administrative, 12 client care and 6 personnel (DHSR checklist). After you mail your application, DHSR emails to confirm receipt of the packet and fee, then emails to request your policies, procedures and personnel documents, and "An initial survey is conducted by reviewing the policies, procedures, and personnel documents for compliance with licensure requirements." (DHSR).
DHSR says "The primary reason home care licensure applicants are not approved for licensure is because they do not understand and/or comply with the initial survey checklist and/or NC licensure rules."
The 11 policies Rule .1001(a) lists
In the rule’s order and words. "The policies shall include:" (10A NCAC 13J .1001(a)(1)-(11))
- (1)a description of the scope of services offeredIn CareRulebook’s manual: 1.1 Scope of services and geographic service area
- (2)admission and discharge policiesIn CareRulebook’s manual: 2.3 Acceptance of clients for service; 2.4 Discharge and reduction of services
- (3)supervision of personnelIn CareRulebook’s manual: 5.3 Supervision of personnel
- (4)development of, and updates to, the plan of careIn CareRulebook’s manual: 5.1 Initial assessment and plan of care
- (5)management of emergency care situations in the homeIn CareRulebook’s manual: 8.1 Emergency preparedness and response plan
- (6)time frame for completion and return of service records to the agencyIn CareRulebook’s manual: 5.4 Service records: completion and return
- (7)personnel qualificationsIn CareRulebook’s manual: 3.1 Personnel qualifications and job descriptions
- (8)an organizational chartIn CareRulebook’s manual: 1.2 Organizational structure and lines of authority
- (9)program evaluationIn CareRulebook’s manual: 9.1 Annual program evaluation and client record review
- (10)employee and client confidentialityIn CareRulebook’s manual: 10.2 Employee and client confidentiality
- (11)coordination of and referral to and from other community agencies and resourcesIn CareRulebook’s manual: 2.5 Coordination and referral
Item (2) is one line in the rule but two jobs in practice, accepting clients and discharging them, so the manual answers it with two policies. Item (3) is set out in more detail in Rule .1110 for in-home caregivers (13J .1110), and item (9) in Rule .1004 (13J .1004). The organizational chart and order of authority →
Other rules that ask for a written policy
Beyond .1001(a), these rules in 13J and the home care statute say a policy must exist, or that agency policy decides how something is done.
| Rule | What it asks for | Applies to | CareRulebook policy |
|---|---|---|---|
| .1001(e) | Agency policies define the order of authority when the administrator is absent. | Every agency | 1.2 Organizational structure and lines of authority |
| .1001(g) | Written policies naming the specific geographic area where the agency provides each service. | Every agency | 1.1 Scope of services and geographic service area |
| .1003(a) | Written policies on infection control and exposure to communicable diseases, including provisions for compliance with OSHA’s 29 CFR 1910. | Every agency | 7.1 Infection control; 7.2 Bloodborne pathogens exposure control plan |
| .1003(d) | Written policies on personnel record content, orientation and in-service education. | Every agency | 3.2 Personnel records; 4.1 Orientation and in-service education |
| .1003(f)(7) | Performance evaluations according to agency policy, and at least annually. | Every agency | 3.3 Annual performance evaluation |
| .1003(f)(9) | Agency policy defines the method for verifying staff competencies. | Every agency | 4.2 Competency verification and skills checklist |
| .1101 | Written policies on accepting clients and client services, covering eight listed points, including 48 hours’ notice before reducing or ending services. | Every agency | 2.3 Acceptance of clients for service; 2.4 Discharge and reduction of services |
| .1110(b) | The health care practitioner may delegate specific supervisory activities to in-home caregivers as agency policy designates, while staying available and accountable. | In-home caregivers not subject to occupational licensing, such as in-home aides | 5.3 Supervision of personnel |
| .1110(c) | The method and frequency of supervision for in-home caregivers subject to occupational licensing laws are defined in agency policy. | Agencies that employ licensed caregivers | 5.3 Supervision of personnel |
| .1201 | Written policies and procedures to make sure services are specified under a plan of care. | Every agency | 5.1 Initial assessment and plan of care |
| .1302(d) | Written policies and procedures for obtaining countersignatures on verbal orders within 60 days of the date of the verbal order. | Every agency | 5.5 Verbal orders and countersignatures |
| .1401(a), (b) | Written policies on the content and handling of client records, describing the system for keeping originals and copies. | Every agency | 10.1 Client records: content and handling; 10.3 Records retention |
| .1504(1) | Companions and sitters work under a supervisor designated by agency policy for the services assigned. | Companion, sitter or respite services | 4.2 Competency verification and skills checklist; 5.3 Supervision of personnel |
| G.S. 131E-144.4 | Each client gets a copy of the agency’s policies on client responsibilities for safety and care plan compliance. | Every agency | 2.1 Client rights, conduct and responsibilities |
Rule numbers are in 10A NCAC 13J unless stated.
Verbal orders apply to every agency. "The home care agency shall develop and implement written policies and procedures for obtaining countersignatures on verbal orders within 60 days of the date of the verbal order." (13J .1302(d)). The rule is not limited to agencies that give medications: care may start on a verbal order, and orders for in-home aide services are signed when they are required (13J .1302(a)). DHSR’s checklist does not list this policy among its 32 items, but CareRulebook’s manual includes it as Policy 5.5 (Verbal orders and countersignatures).
Rules for services CareRulebook’s manual does not cover
CareRulebook’s North Carolina manual is written for in-home aide services, with companion, sitter and respite services as an option. If you also offer nursing or other clinical services, these rules add policies you would need to write yourself:
- Medication and treatments. "If the agency administers any pharmaceuticals or medical treatments, it shall develop and implement policies and procedures relative to the administration of pharmaceuticals and treatments", with staff accountability for eight listed points (13J .1301). DHSR says in-home aides may not administer medications; they may assist clients with self-administration (DHSR FAQ 53).
- Infusion pharmacy. "If the agency provides or contracts for infusion pharmacy services there shall be policies and procedures governing the scope of pharmacy services provided." (13J .1108(c))
- Medical equipment and supplies. If you provide them with home care services, "the agency shall have policies and procedures governing their management", covering five listed points (13J .1112).
DHSR’s 32 checklist items, and where CareRulebook covers each
DHSR tells applicants: "Review the Initial Home Care Survey Checklist and use it as your guide." (DHSR). These are the policy and procedure items on its Home Care Initial Survey Checklist (rev. 9/21), in DHSR’s order and wording, with the rule DHSR prints beside each (two items print none) and the policy in CareRulebook’s manual that answers it.
Administrative policies · 14
| DHSR’s item | Rule DHSR prints | CareRulebook policy |
|---|---|---|
| Scope of Services policy | .1001(a)(1) | 1.1 Scope of services and geographic service area |
| Emergency preparedness | .1001(5) | 8.1 Emergency preparedness and response plan |
| Geographic Service area; In-home Aide Services | .1001(g); .1107(h) | 1.1 Scope of services and geographic service area |
| Agency Director job description | .1001(b)(d)(e) | 1.3 Agency director and service supervisors; 3.1 Personnel qualifications and job descriptions |
| Companion Sitter Agency Director (if applicable) | .1503(1) a-b | 1.3 Agency director and service supervisors |
| Service Supervisor job description | .1001(c)(d) | 1.3 Agency director and service supervisors; 3.1 Personnel qualifications and job descriptions |
| Job Descriptions for other positions | .1003(e) | 3.1 Personnel qualifications and job descriptions |
| Annual program evaluation policy | .1004(a, b, c, & e) | 9.1 Annual program evaluation and client record review |
| Client record review policy | .1004(d & e) | 9.1 Annual program evaluation and client record review |
| Infection control policies with Employee risk categories identified | .1003(a) | 7.1 Infection control |
| Blood borne pathogen policy (include training and updates) required for all in-home caregivers | none printed | 7.2 Bloodborne pathogens exposure control plan; 4.1 Orientation and in-service education |
| TB (tuberculin skin test) policy required for all in-home caregivers | .1003(b) | 3.5 Employee health and TB screening |
| Hepatitis B immunization / declination policy required for all in-home caregivers | none printed | 3.5 Employee health and TB screening; 7.2 Bloodborne pathogens exposure control plan |
| Exposure control plan & Post exposure follow-up plan policy | .1003(a) | 7.2 Bloodborne pathogens exposure control plan |
Client care policies · 12
| DHSR’s item | Rule DHSR prints | CareRulebook policy |
|---|---|---|
| Client’s rights and responsibilities policy | .1007(a)(b); G.S. 131E-144.3 | 2.1 Client rights, conduct and responsibilities |
| Coordination and referral policy | .1001(a)(11); .1101(8) | 2.5 Coordination and referral |
| Acceptance of Clients for Service Provision | .1101(1-8) | 2.3 Acceptance of clients for service |
| Initial Assessment policy (In-Home Aide Services) | .1107(d)(e) | 5.1 Initial assessment and plan of care |
| No Smoking policy | G.S. 131E-143 | 2.6 No smoking in clients’ homes |
| Supervision of Staff; Companion Sitters | .1001(a)(3); .1110(c-g); .1504(2) | 5.3 Supervision of personnel |
| Arrangements for Services with other Agencies or Individuals policy | .1111(a-d) | 1.6 Independent contractors and arranged services |
| Discharge policy | .1001(a)(2); .1402(2)(d) | 2.4 Discharge and reduction of services |
| Agency complaint policy with state hotline number(s) | .1007(b)(c); G.S. 131E-144.6(b) | 2.2 Complaints, grievances and investigations |
| Health Care Personnel Registry reporting policy | 10A NCAC 13O .0102 | 6.1 Reporting allegations to the Health Care Personnel Registry |
| Plan of care policy (include 90-day review); In-Home Aide Services | .1202(a-b); .1107(a)(b) | 5.1 Initial assessment and plan of care |
| Client record content & handling | .1401(a-f); .1402(a)(b) | 10.1 Client records: content and handling |
Personnel policies · 6
| DHSR’s item | Rule DHSR prints | CareRulebook policy |
|---|---|---|
| Competency verification, skills validation/checklist policy | .1003(e)(g); .1110(a)(b)(c); .1504(1) | 4.2 Competency verification and skills checklist |
| Personnel records policy and content | .1003(f) | 3.2 Personnel records |
| Annual performance evaluation policy | .1003(f)(7) | 3.3 Annual performance evaluation |
| In-service training policy | .1003(d) | 4.1 Orientation and in-service education |
| Orientation policy | .1003(d) | 4.1 Orientation and in-service education |
| Criminal background investigation policy | G.S. 131E-265 | 3.4 Criminal history checks and registry searches |
The checklist also asks for supporting documents, such as the organization chart, proof of premises and the annual projected budget, and complete personnel records for the agency director, service supervisor, in-home caregivers and companion sitters (checklist p. 1; p. 2). DHSR says the checklist and rules are minimum requirements: "It should be noted these are minimal requirements and failure to comply with them may result in delay of licensure for the applicant. Therefore, it is recommended that applicants be prepared for the initial survey in order to achieve the anticipated approval." (DHSR)
How the manual maps them. Every one of the 32 items has a policy in CareRulebook’s North Carolina manual, as the table shows. Each policy ends with a Rule basis section that quotes the 13J rule and, for most items, the line of DHSR’s checklist it answers, and Appendix A is a rule-to-policy crosswalk of all 48 requirements we map. The training items, competency, orientation and in-service, are explained on North Carolina caregiver training, and the criminal background investigation policy on caregiver background checks.
When DHSR sees your policies
Not with the application. DHSR’s page on establishing a home care agency sets out this order:
- 1
You mail the application
With the fee by check or money order, and proof of previously owning and operating a home care agency or of completing DHSR-approved training. The policies are not on this list. DHSR, Establishing a Home Care Agency
- 2
DHSR reviews the packet
For accuracy and completeness. DHSR
- 3
DHSR confirms receipt by email
The email confirms receipt of the license application packet and fee. DHSR
- 4
DHSR emails to request your documents
It asks for your policies, procedures and personnel documents. DHSR
- 5
The initial survey
Once DHSR receives them, it conducts the initial survey by reviewing the policies, procedures and personnel documents for compliance with licensure requirements. DHSR
- 6
Approval
If the initial survey is completed without the need for more information, DHSR emails the official approval letter with instructions to print your license. DHSR
You must finish within a year: "An applicant must be able to complete all necessary requirements within one year (12 months) from receipt of the initial application and fee date to obtain a license." (DHSR checklist). DHSR does not set a time frame for its review (FAQ 13). Our suggestion: have your policies written before you mail the application, so you can send them as soon as DHSR asks. The application, step by step →
What DHSR reads in them
- A sample. "The policies and procedures submitted by the agency represent a sampling of the policies and procedures necessary to direct all administrative, personnel, and client care operations of the agency as required by 10A NCAC 13J." (FAQ 15)
- A promise. "The policies and procedures reflect an assurance of compliance." (FAQ 15)
- Staff in place. "Personnel records are required to show proof of staff to provide the services your agency will provide." (FAQ 16)
- Not returned. DHSR says the documents submitted are discarded and will not be returned after the licensure process is complete (FAQ 17).
After you are licensed
The policies stay live documents. The rule says they "shall be available for inspection by the Department" (13J .1001(a)), a licensed agency is subject to inspections at any time (13J .0904(a)), and DHSR says all inspections and complaint investigations are unannounced (FAQ 35). How surveys and inspections work →
For a second site, DHSR asks for a letter saying the new site adopts the policies and procedures of your existing licensed site (DHSR, adding a site). To add a service, DHSR says "You will be asked to show evidence of the appropriate personnel and all the policies and procedures necessary to comply with the rules and regulations specific to the service provided." (FAQ 21)
Every North Carolina policy requirement, mapped
All 48 requirements we map from 13J, G.S. 131E, 10A NCAC 13O and OSHA’s bloodborne pathogens standard. Filter by topic or manual section. Each rule links to the official text.
48 rows
| Rule | What it requires | Policy in your manual |
|---|---|---|
| 10A NCAC 13J .1001(a)(1) | Scope of services A written description of the services the agency offers. "(1) a description of the scope of services offered;" | 1.1 Scope of services and geographic service area |
| 10A NCAC 13J .1001(g) | Geographic service area Written policies naming the area served for each service; 30 days’ notice to DHSR before expanding. "An agency shall have written policies which identify the specific geographic area in which the agency provides each service." | 1.1 Scope of services and geographic service area |
| 10A NCAC 13J .1107(h) | In-home aide service area limit In-home aide services limited to the county, contiguous counties or 90 minutes’ drive. "geographic service areas for these services shall be limited to the area that includes the county where the agency is located" | 1.1 Scope of services and geographic service area |
| 10A NCAC 13J .1001(a)(8) | Organizational chart An organizational chart among the operating policies. "(8) an organizational chart;" | 1.2 Organizational structure and lines of authority |
| 10A NCAC 13J .1001(e) | Order of authority Policies define who is in charge when the administrator is absent. "Agency policies shall define the order of authority in the absence of the administrator." | 1.2 Organizational structure and lines of authority |
| 10A NCAC 13J .1001(b), (d), (e) | Agency director Designate a qualified agency director, document their responsibilities and authority, and report a vacancy within five working days. "The agency shall designate an individual to serve as agency director." | 1.3 Agency director and service supervisors |
| 10A NCAC 13J .1001(c), (d) | Service supervisor Designate a person to supervise each type of home care service, with documented responsibilities and authority. "The agency shall designate a person responsible for supervising each type of home care service" | 1.3 Agency director and service supervisors |
| 10A NCAC 13J .1503 | Companion and sitter agency directorif the agency provides companion, sitter or respite services For companion, sitter or respite services, a director with a high school diploma or GED plus health care practitioner status or one year of relevant experience, and a designated supervisor. "The agency director shall be a high school graduate, or be certified under the G.E.D. Program" | 1.3 Agency director and service supervisors |
| 10A NCAC 13J .0903(f), (g) | Notices to DHSR Notify DHSR in writing 30 days before a change of ownership or name, or before adding a service. "The licensee shall notify the Department in writing of any proposed change in ownership or name at least 30 days prior to the effective date of the change." | 1.4 License, inspections and notices to DHSR |
| 10A NCAC 13J .0904(e), (f) | Inspections and plans of correction Allow immediate access for inspections and file a plan of correction within 10 working days. "The agency shall allow immediate access to its premises and the records necessary to conduct an inspection and determine compliance with the rules of this Subchapter." | 1.4 License, inspections and notices to DHSR |
| 10A NCAC 13J .1002(a) | Annual budget Keep and make available the home care annual budget. "The agency shall establish, maintain and make available for inspection the home care annual budget." | 1.5 Annual budget and statistical records |
| 10A NCAC 13J .1002(b), (c) | Statistical records Keep statistical records on staff, clients and units of service; keep records at least three years. "The agency shall record, maintain and make available as requested to the Department statistical records." | 1.5 Annual budget and statistical records |
| 10A NCAC 13J .1111 | Arrangements with other agencies or individualsif the agency arranges services through other agencies or individuals A signed written agreement with ten required elements for any contracted service, reviewed annually. "there shall be a written agreement, signed by both parties, which includes the following:" | 1.6 Independent contractors and arranged services |
| 10A NCAC 13J .1007(a); G.S. 131E-144.3 | Client rights and responsibilities Give each client written notice of rights and responsibilities before care, and document it. "An agency shall provide each client with a written notice of the client's rights and responsibilities in advance of furnishing care to the client or during the initial evaluation visit before the initiation of services." | 2.1 Client rights, conduct and responsibilities |
| G.S. 131E-144.4 | Notice to clients Give each client the declaration of rights, the client responsibilities policy and complaint contacts, with a signed receipt. "A copy of the agency's policies regarding client responsibilities as it relates to safety and care plan compliance." | 2.1 Client rights, conduct and responsibilities |
| G.S. 131E-144.6(b); 10A NCAC 13J .1007(b), (c) | Complaints Investigate client and family complaints within 72 hours and document the complaint and its resolution; give clients the state hotline. "A home care agency shall investigate, within 72 hours, complaints made to the agency by a home care client or the client's family" | 2.2 Complaints, grievances and investigations |
| 10A NCAC 13J .1101 | Acceptance of clients Written policies on accepting clients covering the eight listed points. "the agency shall develop and implement written policies governing the acceptance of clients and client services." | 2.3 Acceptance of clients for service |
| 10A NCAC 13J .1001(a)(2) | Admission and discharge Admission and discharge policies among the operating policies. "(2) admission and discharge policies;" | 2.3 Acceptance of clients for service2.4 Discharge and reduction of services |
| 10A NCAC 13J .1101(7) | Notice before reducing or ending services At least 48 hours’ notice to the client or responsible party, with the listed exceptions. "advance notification of at least 48 hours to the client or responsible party when service provision is to be reduced or terminated" | 2.4 Discharge and reduction of services |
| 10A NCAC 13J .1001(a)(11); .1101(8) | Coordination and referral Coordinate with, and refer to and from, other agencies, including when the agency cannot respond promptly. "(11) coordination of and referral to and from other community agencies and resources." | 2.5 Coordination and referral |
| G.S. 131E-143(a) | No smoking Prohibit employees from smoking while providing services in a client’s home, and inform clients. "Home care agencies and home assistance services providers shall inform their clients that employees are prohibited from smoking in a client's home." | 2.6 No smoking in clients’ homes |
| 10A NCAC 13J .1001(a)(7); .1003(e) | Personnel qualifications and job descriptions Written job descriptions for every position, with qualifications and responsibilities; assign only duties staff are trained and competent for. "Job descriptions for every position shall be established in writing which include qualifications and specific responsibilities." | 3.1 Personnel qualifications and job descriptions |
| 10A NCAC 13J .1003(d), (f) | Personnel records A personnel record for each employee with the nine listed items, kept one year after employment ends. "Personnel records shall be established and maintained for each home care employee." | 3.2 Personnel records |
| 10A NCAC 13J .1003(f)(7) | Annual performance evaluation Performance evaluations according to agency policy and at least annually. "performance evaluations according to agency policy and at least annually." | 3.3 Annual performance evaluation |
| G.S. 131E-265(a) | Criminal history checks Offers for positions entering clients’ homes are conditional on consent to a criminal history check. "An offer of employment by a home care agency licensed under this Chapter to an applicant to fill a position that requires entering the patient's home is conditioned on consent to a criminal history record check of the applicant." | 3.4 Criminal history checks and registry searches |
| 10A NCAC 13J .1003(c) | Health Care Personnel Registry check Do not hire anyone with a substantiated finding on the Health Care Personnel Registry. "The agency shall not hire any individual either directly or by contract who has a substantiated finding on the North Carolina Health Care Personnel Registry" | 3.4 Criminal history checks and registry searches |
| 10A NCAC 13J .1003(b) | TB screening Baseline TB skin test for hands-on care employees, with the steps for positive results. "Hands-on care employees must have a baseline skin test for TB." | 3.5 Employee health and TB screening |
| 10A NCAC 13J .1003(f)(5) | Hepatitis B Documentation of Hepatitis B immunization or declination for hands-on care employees. "documentation of Hepatitis B immunization or declination for hands-on care employees in accordance with the agency's exposure control plan;" | 3.5 Employee health and TB screening |
| 10A NCAC 13J .1003(d) | Orientation and in-service education Written policies on orientation and in-service education, with attendance records. "Written policies shall be established and implemented which include personnel record content, orientation and in-service education." | 4.1 Orientation and in-service education |
| 10A NCAC 13J .1003(f)(9), (g); .1110(a), (b) | Competency verification Verify by demonstration every skill a caregiver is assigned; RN verification of six core skills for aides not on the Nurse Aide Registry. "Each agency shall document that its in-home caregivers are competent to perform client care tasks or activities that they are assigned." | 4.2 Competency verification and skills checklist |
| 10A NCAC 13J .1504(1) | Companion and sitter competencyif the agency provides companion, sitter or respite services Documentation that companions and sitters are competent for their assigned tasks. "Each agency shall have documentation that its companion and sitters are competent to perform client care tasks or activities to which they are assigned." | 4.2 Competency verification and skills checklist |
| 10A NCAC 13J .1201; .1001(a)(4) | Plan of care Written policies so services are specified under a plan of care; development of and updates to the plan. "An agency shall develop and implement written policies and procedures to assure that services and items to be provided are specified under a plan of care." | 5.1 Initial assessment and plan of care |
| 10A NCAC 13J .1202 | Plan of care content and 90-day review The plan of care includes the listed items and is reviewed every 90 days. "The plan of care shall be reviewed every 90 days by the health care practitioner and revised as needed based on the client's needs." | 5.1 Initial assessment and plan of care |
| 10A NCAC 13J .1107(d), (e) | Initial assessment The health care practitioner assesses the client at home before the plan of care. "For agencies providing in-home aide services, the initial assessment shall be conducted in the client's home by the health care practitioner." | 5.1 Initial assessment and plan of care |
| 10A NCAC 13J .1107(a)-(c) | In-home aide services Aides work to a signed plan of care with ADL assistance levels; extensive assistance requires Nurse Aide Registry listing; aide duties as listed. "If the client's plan of care requires the in-home aide to provide extensive assistance, the in-home aide shall be listed on the Nurse Aide Registry" | 5.2 In-home aide duties and help with medication |
| 10A NCAC 13J .1001(a)(3); .1110(c)-(g) | Supervision of in-home caregivers Supervision policy; 90-day supervisory visits, annual visits during care, documentation, and practitioner availability. "The health care practitioner shall be available for supervision during the hours that in-home care services are provided." | 5.3 Supervision of personnel |
| 10A NCAC 13J .1504(2)-(4) | Companion and sitter supervisionif the agency provides companion, sitter or respite services Contact the client every three months, visit at least every six months and annually during care, with documentation. "by contacting the client receiving care every three months and by making a supervisory visit to each client's place of residence at least every six months" | 5.3 Supervision of personnel |
| 10A NCAC 13J .1001(a)(6) | Service record deadlines A time frame for completing and returning service records to the agency. "(6) time frame for completion and return of service records to the agency;" | 5.4 Service records: completion and return |
| 10A NCAC 13J .1302(d) | Verbal orders Written policies and procedures for getting verbal orders countersigned within 60 days of the order. "The home care agency shall develop and implement written policies and procedures for obtaining countersignatures on verbal orders within 60 days of the date of the verbal order." | 5.5 Verbal orders and countersignatures |
| 10A NCAC 13O .0102; G.S. 131E-256(g) | Health Care Personnel Registry reporting Report allegations against health care personnel to DHSR within 24 hours and investigation results within five working days. "shall be done within 24 hours of the health care facility becoming aware of the allegation." | 6.1 Reporting allegations to the Health Care Personnel Registry |
| 10A NCAC 13J .1003(a) | Infection control Written infection control and communicable disease policies, complying with 29 CFR 1910. "Written policies shall be established and implemented by the agency regarding infection control and exposure to communicable diseases" | 7.1 Infection control |
| 29 CFR 1910.1030(c)(1) | Exposure control plan A written exposure control plan for employees with occupational exposure, with the required elements. "shall establish a written Exposure Control Plan designed to eliminate or minimize employee exposure." | 7.2 Bloodborne pathogens exposure control plan |
| 10A NCAC 13J .1003(f)(6) | Bloodborne pathogen training Airborne and bloodborne pathogen training for hands-on care employees, with annual updates. "airborne and bloodborne pathogen training for hands on care employees, including annual updates" | 7.2 Bloodborne pathogens exposure control plan |
| 10A NCAC 13J .1001(a)(5) | Emergencies in the home Policies on managing emergency care situations in the home. "(5) management of emergency care situations in the home;" | 8.1 Emergency preparedness and response plan |
| 10A NCAC 13J .1001(a)(9); .1004(a)-(c), (e) | Annual program evaluation Annual evaluation of the agency’s total operation, with the listed review and data, and documentation. "The agency's governing body or its designee shall annually conduct a comprehensive evaluation of the agency's total operation." | 9.1 Annual program evaluation and client record review |
| 10A NCAC 13J .1004(d), (e) | Quarterly client record review Review sample active and closed client records every 90 days. "The agency's governing body or its designee shall evaluate the agency's client records every 90 days." | 9.1 Annual program evaluation and client record review |
| 10A NCAC 13J .1401; .1402 | Client records Written policies on client record content and handling; the listed record contents; security, sign-out and retention. "The agency shall develop and implement written policies governing content and handling of client records." | 10.1 Client records: content and handling10.3 Records retention |
| 10A NCAC 13J .1001(a)(10) | Confidentiality Employee and client confidentiality policies. "(10) employee and client confidentiality; and" | 10.2 Employee and client confidentiality |
The yearly policy and administration review
Rule .1004 makes policy review part of a yearly evaluation (13J .1004):
- Every year. "The agency's governing body or its designee shall annually conduct a comprehensive evaluation of the agency's total operation." (.1004(a))
- What it is for. "The evaluation shall review the quality of the agency's services with findings used to verify policy implementation, to identify problems, and to establish problem resolution and policy revision as necessary." (.1004(b))
- What it covers. A policy and administration review of the scope of services, arrangements with other agencies or individuals, admission and discharge policies, supervision and plan of care, emergency care, service records, personnel qualifications and program evaluation, with data on the number of clients and visits or hours for each service, client outcomes, whether staffing meets client needs, and the reasons for non-acceptance and discharge (.1004(c)).
- Every 90 days. A review of sample active and closed client records "to ensure that agency policies are followed in providing services, both direct and under contract" (.1004(d)).
- Written up. The documentation includes the names and qualifications of the people who did the evaluation, the criteria and methods used, and any action taken (.1004(e)).
DHSR’s checklist lists both as policies: the annual program evaluation policy and the client record review policy (DHSR checklist). In CareRulebook’s manual they are Policy 9.1 (Annual program evaluation and client record review), and the builder asks for the date you adopt the manual and your next review date.
DHSR also says the agency should have a policy and procedures on how changes to the plan of care are handled, and "There should be evidence that the client or responsible party was informed in advance of any change to the POC." (FAQ 49)
Format tips
13J and DHSR do not prescribe a format. These are our suggestions, not DHSR requirements, from what DHSR says it reads in the policies.
Write the procedure, not just the policy
DHSR’s FAQ says a policy is a course of action to guide decision making and a procedure describes a method to carry it out, often in steps. Give each policy its steps and who does them.
DHSR FAQ 14Promise only what you will do
DHSR says the policies reflect an assurance of compliance. By our reading, anything a policy promises beyond the rule, a surveyor can expect you to do.
DHSR FAQ 15Fill every blank
Your agency name, site, director, RN supervisor, counties served and numbers the rules leave to you, such as in-service hours, which DHSR says your policy should specify.
DHSR FAQ 54Cite the rule under each policy
DHSR prints a rule number beside most checklist items. Quoting the rule under each policy shows the reviewer which requirement it answers.
DHSR checklistKeep a full copy and date it
DHSR discards the documents you send. Keep the version you submitted, with the date the governing body adopted it.
DHSR FAQ 17
CareRulebook
Every item on DHSR’s checklist, written for your agency
Answer a few questions and CareRulebook writes these policies for your agency, at the minimum each rule requires, with the 13J rule quoted under every policy and recommended practice added only if you choose it.
- 32 policies, 48 rule requirements mapped
- All 32 items on DHSR’s Initial Survey Checklist
- Live preview of your own manual before you pay
- Editable Word and PDF, delivered instantly
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$199CareRulebook founding price for the first 50 North Carolina agencies, then $249. Not a DHSR fee.
Frequently asked questions
What policies does a North Carolina home care agency need?
The 11 written policies 10A NCAC 13J .1001(a) lists, from a description of the scope of services to coordination and referral, plus the policies other 13J rules ask for, such as infection control, personnel records, orientation and in-service education, accepting clients, plans of care and client records. DHSR’s Initial Survey Checklist lists 32 policy and procedure items in three groups: 14 administrative, 12 client care and 6 personnel.
Do I send my policies with the license application?
No. DHSR’s process page lists the application, the fee and proof of past ownership or approved training as what you mail. DHSR then emails to confirm receipt of the packet and fee, and emails again to request your policies, procedures and personnel documents. Our suggestion: have them written before you mail the application, because you must complete every requirement within 12 months of DHSR receiving your application and fee.
When does DHSR review my policies?
Before it licenses you. Once it receives the documents it asked for, DHSR conducts the initial survey by reviewing the policies, procedures and personnel documents for compliance with licensure requirements. If nothing more is needed, it emails the approval letter. After licensing, the rule says your policies must be available for inspection by the Department, and DHSR says all inspections are unannounced.
Will DHSR return the policies I send?
No. DHSR’s FAQ says the documents submitted are discarded and will not be returned after the licensure process is complete, so keep a full copy.
How often must I review my policies?
Rule .1004 requires a comprehensive evaluation of the agency’s total operation every year, which consists of a policy and administration review of the listed areas, with findings used to verify that policies are carried out and to revise them as necessary. By our reading, the rule asks for that yearly review, not a rewrite of every policy each year. The governing body or its designee also reviews sample client records every 90 days to check that policies are followed.
Does a second site need its own policies?
DHSR’s process for adding a site asks for a letter saying the new site adopts the policies and procedures of your existing licensed site, with that agency’s name, address and license number. The new site also needs its own application and fee.
Do companion, sitter and respite services need extra policies?
If your home care agency provides them, DHSR’s checklist adds the companion sitter agency director (if applicable) and supervision of companion sitters, and the rules require documentation that companions and sitters are competent for their assigned tasks. A companion-only business is a home assistance services provider, a different license; we have not confirmed which rules DHSR applies to it.
Can I use a policy manual written for another state?
Our view: start from North Carolina’s rules instead. 13J has its own requirements, such as an RN’s verification of six core skills for aides not on the Nurse Aide Registry, supervisory visits every 90 days, the in-home aide service area (neighboring counties or 90 minutes’ drive, whichever is greater) and 48 hours’ notice before reducing or ending services. DHSR says the main reason applicants are not approved is not understanding or complying with its checklist and the rules.
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Keep reading
North Carolina
How to start a home care agency in North Carolina
The license, DHSR’s 32-item checklist, staffing and supervision.
North Carolina
North Carolina survey and inspections
The review of your policies before licensing, unannounced inspections and plans of correction.
North Carolina
North Carolina caregiver training
The orientation, in-service and competency policies, and the RN’s six core skills.
North Carolina
The North Carolina license application
What you mail, and when DHSR asks for your policies.
North Carolina
Agency director and RN
The job descriptions, organizational chart and order of authority.
Tool
North Carolina license checklist
Every step, tailored to your agency, emailed to you.
Georgia
Georgia home care policies and procedures
The same map for Chapter 111-8-65, where DCH publishes no list.
Virginia
Virginia home care policies and procedures
The same map for 12VAC5-381.
Texas
Texas home care policies and procedures
The same map for Chapter 558.
US
Home care policy requirements by state
When each state checks your policies, side by side.
Sources
- 10A NCAC 13J, The Licensing of Home Care Agencies · NC Office of Administrative Hearings · retrieved October 1, 2026
- N.C. General Statutes Chapter 131E, Article 6 (home care agency licensure and home care clients’ bill of rights) · North Carolina General Assembly · retrieved October 1, 2026
- Home Care Initial Survey Checklist (rev. 9/21) · NC DHSR · retrieved October 1, 2026
- Home Care Frequently Asked Questions (rev. 5/30/25) · NC DHSR · retrieved October 1, 2026
- Requirements for Establishing a Home Care Agency · NC DHSR · retrieved October 1, 2026
- 10A NCAC 13O, Health Care Personnel Registry · NC Office of Administrative Hearings · retrieved October 1, 2026
- 29 CFR 1910.1030, Bloodborne pathogens · eCFR (OSHA) · retrieved October 1, 2026
- Requirements for Adding an Additional Home Care Site · NC DHSR · retrieved October 1, 2026