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PRINTED: 12/03/2020 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:NEW HANOVER HOUSE (X4) ID PREFIX

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How to fill out nc dhsr acls adult

01

Obtain a copy of the NC DHSR ACLS Adult form.

02

Review the form instructions to familiarize yourself with the information required.

03

Begin filling out the form by entering your personal information, such as your name, address, and contact information.

04

Provide the necessary details about the adult care home, including its name, address, and license number.

05

Indicate the type of application being filed, whether it is for initial certification, renewal, or modification.

06

Fill in the sections related to the facility's staffing information, including the number of beds, staff qualifications, and a staffing plan.

07

Include information about the facility's physical environment, safety measures, and emergency preparedness.

08

Answer all the questions regarding the services provided, including supervision, medication administration, dietary needs, and recreational activities.

09

Provide any additional required information, such as financial statements or proof of insurance.

10

Double-check that all sections of the form are completed accurately and all necessary supporting documents are attached.

11

Sign and date the form, indicating your agreement to comply with the regulations and guidelines set by the NC DHSR.

12

Submit the completed form and supporting documents to the specified address or online portal as instructed.

Who needs nc dhsr acls adult?

01

The NC DHSR ACLS Adult form is required by individuals or organizations seeking to operate an adult care home in the state of North Carolina.

02

Any person or entity planning to establish a new adult care home, renew an existing certification, or modify an existing facility would need to fill out this form.

03

This form serves as an application to the North Carolina Department of Health and Human Services, Division of Health Service Regulation (DHSR) for licensure and certification purposes.

04

Both for-profit and non-profit organizations are required to complete and submit this form to comply with the state's regulations and guidelines for operating an adult care home.

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What is nc dhsr acls adult?

NC DHSR ACLS Adult stands for North Carolina Department of Health Service Regulation Adult Care Licensure Section.

Who is required to file nc dhsr acls adult?

Any facility or individual providing adult care services in North Carolina is required to file NC DHSR ACLS Adult.

How to fill out nc dhsr acls adult?

To fill out NC DHSR ACLS Adult, you need to provide information about the adult care services being provided, the facility's information, and other required details.

What is the purpose of nc dhsr acls adult?

The purpose of NC DHSR ACLS Adult is to ensure that adult care facilities in North Carolina meet state regulations and provide quality care to residents.

What information must be reported on nc dhsr acls adult?

Information such as the facility's name and address, services provided, number of residents, staff qualifications, and compliance with regulations must be reported on NC DHSR ACLS Adult.

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