Know Where You Are Going and What to Expect Before You Get There (Understanding Long-Term Care Facility Options)

Michael J. McCann, Legal Services Developer, Elder Rights Section, North Carolina Division of Aging

There are many names for long-term care facilities in the market place. In practice, it is useful to compare facilities by the services they offer, rather than by the name they are called. Nevertheless, the official designation is meaningful in how a facility is regulated and what public funding sources are available to pay for care.

This article will briefly introduce the reader to the various types of long-term care facilities, the laws and regulations that pertain to each, sources of payment, and some common questions that arise in the different settings.

People tend to group all long-term care institutional services under the term “nursing home.” However, there exists a wide variety of long-term care options other than nursing homes. There are assisted living facilities/adult care homes, continuing care retirement communities and subsidized senior housing.(1) When less intensive and restrictive forms of care are needed, a mix of services and/or programs sometimes referred to as “alternatives to institutional care” may be most appropriate.

Most long-term care is still provided at home by relatives and friends. However, the number and variety of community-based health and supportive services and specialized living arrangements are increasing nationally.

The home and community-based services available include the following: home health care, respite care,(2) adult day/day health care, home-delivered meals, group meal programs, care management, home improvement, transportation, and hospice services. The home and community care options and subsidized senior housing are topics for another article. This article will focus on nursing homes, assisted living /adult care homes, and continuing care retirement communities.

Nursing Homes

In North Carolina, nursing homes are defined as facilities that provide nursing or convalescent care for three or more persons unrelated to the licensee.(3) A nursing home provides long term care of chronic conditions or short term convalescent or rehabilitative care of remedial ailments, for which medical and nursing care are indicated. Persons in nursing homes need medical and nursing services and supervision, but they are not sick enough to require general hospitalization.

In practice, most nursing homes offer several levels of care. Skilled Nursing Care (referred to as SNF level) provides skilled nursing services, as ordered by a physician, on a 24-hour basis, seven days a week.(4) Intermediate Nursing Care (referred to ICF level) provides a minimum of eight hours of licensed nursing care daily, but does not require 24-hour skilled nursing services.(5) Nursing homes also may have specialty units designed to address the needs of certain types of residents. Such units may include an Alzheimer’s unit, a ventilator unit, or a subacute unit.(6)

Before admission to a nursing home, a doctor must designate the level of care that is needed. This designation is typically made on a Division of Medical Assistance form called the “FL-2.” After the initial designation, the level of care will be evaluated at determined intervals and upon any major change in condition of the resident.

All nursing homes must be licensed in accordance with North Carolina State law by the North Carolina Department of Health and Human Service’s Division of Facility Services Licensure & Certification Section.(7) Nursing homes are licensed annually. The licensing regulations contain detailed requirements relating to administration, nursing and physician services, dental, pharmaceutical and dietary services, design, safety, resident care planning, recreation, and activities.(8)

Currently, there are 362 free-standing, 53 hospital-based and 5 State-operated licensed nursing homes in North Carolina.(9) The Division of Facility Services regulates the number and location of nursing homes within North Carolina through the Certificate of Need program. The maximum number and locations of nursing home beds are designated in the Annual State Medical Facilities Plan.(10) To build or expand a nursing home, a nursing home developer must apply for a certificate of need (CON).(11)

Nursing homes that wish to receive Medicare and/or Medicaid reimbursement must also meet certification standards established by federal law.(12) The federal law governing nursing facilities has largely grown out of the 1987 Nursing Home Reform Amendments Act and its subsequent revisions. The Reform Act was included in the Omnibus Reconciliation Act of 1987 and is generally referred to as “OBRA.” It amended the Medicare and Medicaid chapters of the Social Security Act.

Some of the major reforms mandated by OBRA include an enhancement of residents’ rights, improved care planning for residents, required training and registration of nurse aides, and development of survey procedures designed to measure outcomes and quality of care. The spirit of the law is evidenced in the primary mandate of the OBRA reforms which requires that certified nursing homes promote, maintain, and enhance the quality of each patient’s life and that the homes provide services and activities that help each patient reach or maintain his or her “highest practicable physical, mental and psychosocial well-being.”(13)

The agency responsible for promulgating and enforcing the federal nursing home regulations is the Health Care Financing Administration (HCFA). Its authoritative interpretations of the regulations are called the Interpretive Guidelines. The Guidelines are organized according to “F” tags, from F-1 through F-522, with each F tag corresponding roughly to a discrete provision of the law.(14)

The Guidelines are used by state surveyors and complaint investigators to determine compliance with the federal regulations. The surveyors and investigators are employees of the Division of Facility Services, referenced above, which is the state agency responsible for enforcing the federal and state nursing home laws in North Carolina.(15)

In North Carolina, all but 17 nursing homes are Medicare/Medicaid certified. The 17 non-Medicare/Medicaid facilities are regulated only by the state licensing laws as referenced above. Therefore, the majority of nursing homes in North Carolina have the additional protection of the federal law.

Facilities that violate licensure rules or the certification standards can be subject to sanctions, which include: required plans of correction, monetary fines, suspension of admissions, temporary management, or (for certified facilities) termination from the Medicare and Medicaid programs.

Paying for nursing home care is a major concern for many families as well as the government. Residents and their families pay a substantial part of the cost, which in 1997 averaged between $3,000 and $6,000 per month depending on the services provided and the location of the facility.

Funding options for nursing home care includes private funding, long-term care insurance, Medicare (limited SNF care only), and in large part, Medicaid. (16) Medicaid coverage is limited to those persons needing skilled or intermediate care who meet specific income and resource tests. For more information on Medicaid eligibility for nursing home care in North Carolina, see Medicaid Eligibility for Nursing Home Care, A Guide for North Carolinians.

Common Questions About Nursing Homes

[NOTE: The federal law discussed in the two questions below is part of the federal Nursing Home Reform Law, which applies to every nursing home which accepts money from the Medicare program and/or the Medicaid program, even if payment for the particular resident involved does not come from either Medicare or Medicaid.(17)]

What is the best way to influence care for a resident in a nursing home? Residents, their family members or other interested parties (if the resident wishes) need to be involved in the care-planning process. Nursing home residents upon admission (e.g. no later than 14 days after admission),(18) at regular intervals, and upon a significant change in condition, must have a multidisciplinary comprehensive assessment completed which details the resident’s functional abilities, assistance needs, patterns, and preferences.(19)

Once the assessment is completed a care plan is developed to illustrate how the individual’s needs and/or problems will be addressed. Within the care plan, goals, approaches, timetables and specific staff persons are identified to meet each need or problem. The resident and his or her family and interested parties can influence the assessment and ensuing care plan by making the facility staff aware of the resident’s strengths, customary routines, preferences, abilities, particular concerns, and in general what makes a good day for the particular resident.

The care plan is the blue print for exactly what care is going to be provided to the resident and what the resident’s daily life will be like. It is the best place for residents, family members, and advocates to address needs and problems. Because the care plan sets out clearly the care and responsibilities of the facility, it has been argued that the care plan is the “real” contract in nursing homes.(20)

Do nursing home residents have protections against being discharged? Under federal law, a nursing home resident generally has the right to remain in the nursing home. A resident can only be involuntarily transferred or discharged under one of five circumstances.(21)

The transfer or discharge is necessary to meet the resident’s welfare and the resident needs services that cannot be provided in the nursing home.
The transfer or discharge is appropriate because the resident’s health has improved so that he or she no longer needs the services provided by the nursing home.
The resident’s presence in the nursing home endangers the health or safety of other residents.
The resident has failed, after reasonable and appropriate notice to pay (or to have paid under Medicare or Medicaid) for his or her stay at the nursing home.
The nursing home is ceasing operations.

For reasons one through three, the nursing facility and the resident’s doctor must document the assessments done and the attempts to address any problems through the care planning process. Further, a nursing home must provide sufficient preparation and orientation to the resident to ensure safe and orderly transfer or discharge from the facility.(22)

The nursing home must notify the resident and, if known, a family member or legal representative that the resident is being transferred or discharged. Generally, notice of transfer or discharge must be given at least 30 days before the date of the proposed eviction.(23) The transfer/discharge notice must include: the reason for the transfer/discharge; the effective date; the location to which the resident will be transferred or discharged; a statement of the resident’s right to appeal the transfer/discharge to the State; and the name, address, and phone number of the State Long Term Care Ombudsman.(24)

Transfer/discharge hearings are held through the Division of Medical Assistance Hearing Unit.(25) The hearings can either take place in person (in Raleigh) or via telephone. The resident or representative must appeal to the Division of Medical Assistance within 11 days of the date of the facility’s notice.

Assisted Living Facilities

In North Carolina, an assisted living residence is defined as “… any group housing and services program for two or more unrelated adults, by whatever name it is called (emphasis added), that makes available at a minimum, one meal a day and house-keeping services and provides personal care services directly or through a formal written agreement with one or more licensed home care or hospice agencies.”(26)

Assisted living settings in which the services are delivered may include self-contained apartment units or single or shared room units with private or area baths.(27) People in assisted living typically need a place to live, some help with personal care (such as dressing, grooming, and keeping up with medications), and some limited supervision. Medical care may be provided on occasion but is not routinely needed.

Included under the umbrella term of “assisted living” are adult care homes, group homes for developmentally disabled adults and multi-unit assisted housing with services. An adult care home is defined as “an assisted living residence in which the housing management provides 24 hour scheduled and unscheduled personal care services … either directly or for scheduled needs, through a formal written agreement with licensed home care or hospice agencies.”(28) Some licensed adult care homes provide supervision to persons with cognitive impairments and allow designated trained staff to administer medications. Adult care homes that provide care for two to six unrelated residents are referred to as “family care homes.”(29)

A group home for developmentally disabled adults is an adult care home that has two to nine developmentally disabled adult(30) residents. Multi-Unit Housing with Services is defined as an assisted living residence in which hands-on personal care services and nursing care are arranged by housing management and are provided by a licensed home care provider through a written plan of care.(31) Persons in Multi-Unit Housing with Services must not be in need of twenty-four hour supervision.

All adult care homes must be licensed in accordance with North Carolina State law by the North Carolina Department of Health and Human Service’s Division of Facility Services Group Care Section.(32) There are approximately 1,450 licensed adult care homes maintaining over 30,000 beds. The rules governing adult care homes, as adopted by the Social Services Commission, set out requirements pertaining to issues including personnel, the building, fire safety, services, resident assessment and care, admissions and discharge.(33) The statutes also set out a list of persons for whom adult care homes are inappropriate. This list includes individuals dependent upon a ventilator, patients requiring continuous licensed nursing care, and patients whose physicians have certified that such placement is no longer appropriate.(34)

Multi-Unit Housing with Services facilities do not require a license. Rather, such facilities must register with the Division of Facility Services and provide a disclosure statement. The disclosure statement is also required to be a part of the annual contract which must contain a description of facility specific information including the following:

the emergency response system
charges for services offered
limitations of tenancy
limitation of services
resident responsibilities
financial/legal relationship between housing management and home-care or hospice agencies
a listing of all home care and community services in the area
an appeals process
procedures for required initial and annual resident screening and referrals for services.(35)

There are currently only eight registered Multi-Unit Housing with Services facilities, but the number is growing. Like adult care homes, the statutes limit the types of persons who can be served in Multi-Unit Housing with Services. The list of persons who cannot be served in Mult-Unit Housing with Services includes those persons who are ventilator dependent, have certain types of dermal ulcers, certain airborne infectious diseases, are taking certain psychotropic medications, or have a nasogastric tube.(36)

Payment sources for assisted living/adult care homes includes the following: private funding, State/County Special Assistance (SA),(37) limited Medicaid assistance for personal care services and medical transportation for SA residents, and some forms of long term care insurance. Personnel at county departments of social services can answer questions about qualification for and use of SA and Medicaid funds.

Common Questions About Assisted Living Facilities

What is the best way to enhance care for a resident in an assisted living facility? Similar to nursing homes, licensed assisted living/adult care homes must conduct resident assessments and develop care plans to address the needs identified in the assessment.(38)The assessment must be completed within 30 days of admission, annually, and upon a significant change in the resident’s condition.

The assessment seeks to determine a resident’s level of functioning and includes routines, preferences, needs, psychological well being, cognitive status, and functioning in activities of daily living. The facility is then responsible for developing a care plan to address the needs identified in the assessment.

The care plan, at a minimum must include a statement of the care and services to be provided and the frequency of the service provision.(39) It is incumbent on residents and family to make sure that this is not just a paper process but rather, a clear plan for meeting an individual’s needs and preferences.

What is the monitoring structure for licensed assisted living/adult care homes? The regulatory monitoring system is divided between the State Division of Facility Services Group Care Section and the county Departments of Social Services offices. The routine monitoring (e.g. visits every two months) and the majority of the complaint investigations are handled by persons within the county Departments of Social Services called Adult Home Specialists. The State Group Care Section of the Division of Facility Services also has professional staff (e.g. pharmacists, dieticians, and social workers) available for consultation to facilities and adult home specialists and to provide assistance with complaint investigations as is necessary.

Continuing Care Retirement Communities

Continuing Care Retirement Communities (CCRC) sometimes known as “life care facilities” are another living alternative for retirement age individuals and couples. Continuing care is defined as, “the furnishing to an individual other than an individual by blood, marriage, or adoption to the person furnishing the care, of lodging together with nursing services, medical services, or other health related services pursuant to an agreement effective for the life of the individual or for a period in excess of one year.” (40) In this type of setting, in exchange for monthly fees and possibly an entrance fee, residents will receive whatever level of care they need over the course of their lives.(41)

Typically, a CCRC will have an independent apartment or town-home section, an assisted living section and a nursing home section. An individual or retired couple may move into an independent unit and as the individual’s or couple’s needs increase, move to the assisted living unit and, if needed, the nursing home. There are some CCRCs that allow persons to enter the community at levels higher than the independent section.

According to the North Carolina Department of Insurance, continuing care facilities typically offer one (or more) of four types of agreements or contracts.(42)

The extensive, or life care contract provides independent living and health related services in exchange for a price, usually consisting of an entrance and monthly fees. No additional fees are generally required as one moves from one level of service to another.
The modified contract provides independent living and a specified amount of health related services in exchange for an entrance fee and monthly fees. Health related services are provided at a subsidized rate or are free for a specified number of days.
The fee for service contract provides independent living and guaranteed access to health related services in exchange for an entrance fee and monthly fees. Health related services are provided at the going, full per diem rate.
The equity contract involves an actual real estate purchase, with a transfer of ownership of the unit. Health related service arrangements vary.

In addition to the licensure requirements for the nursing home and assisted living sections of CCRC, as set out under the corresponding subheadings above, a CCRC must also be licensed by the Department of Insurance.(43) The additional requirements placed on CCRC pertain primarily to the community’s fiscal soundness, mandated disclosures and essential contract provisions.

Required disclosures include: a clear breakdown of all fees (entrance, monthly, periodic, and additional), health and financial condition required of an individual to be accepted into and to remain in a CCRC, and a current independently certified financial statements illustrating the fiscal health of the facility.(44) Relevant contract provisions include the right of cancellation or recision and terms for required refunds.(45)

Payment in CCRCs is largely through private means. However, within the assisted living or nursing home portions of a CCRC long-term care insurance, Medicare, Medicaid and Special Assistance for Older Adults may be accepted. It is important to discuss all the payment options available with each individual CCRC.

Common Questions about CCRCs

What if the management of a CCRC says a resident needs to move to the next level and the resident wants to remain in the independent section? This question emphasizes one of the more important contract terms that individuals should be certain about before signing the initial contract. A prospective resident should be sure to understand:

the specific criteria a CCRC will use in determining when a resident needs to be transferred from independent living to a higher level of care
who will be involved in the determination
how a resident can appeal the determination
when a transfer becomes permanent instead of temporary.(46)

North Carolina law requires disclosure of such issues,(47) but does not set out specific terms to be followed. Consequently, it is important to know the specific terms in advance of signing a contract and to use the protections that these procedures may provide in protecting the interest of the resident.

What if a resident or prospective resident wants to cancel the contract or move out–are any of the entrance fees refundable? North Carolina law provides that all CCRC contracts may be rescinded within 30 days following the later of the execution of the contract or the receipt by the prospective resident of the required disclosure statement.(48) For those persons who die before moving into the unit or who cannot occupy a unit on account of illness, injury, or other condition set out in the contract, the contract is canceled.(49)

For contracts rescinded or canceled due to the conditions mentioned above, the North Carolina statutes control the terms of the refund. For refunds under other conditions, the contract is required to spell out the terms governing the refund of any portion of the entrance fee.(50) An individual should look to the contract to spell out a formula for a pro rata refund of entrance fees based on the length of stay in the facility.

North Carolina’s Long Term Care Ombudsman Program

The Long Term Care Ombudsman Program(51) consists of state and regional ombudsmen who help residents of long term care facilities to exercise their rights. In addition to being an advocate for residents, they educate the public and facility staff about rights and a variety of long-term care issues and help resolve grievances between residents/families and facilities.

The regional ombudsmen, who are located within Area Agencies on Aging, also help support the efforts of Adult Care Home and Nursing Home Community Advisory Committees.(52)These local committees, which are composed of volunteers appointed by county commissioners, routinely visit facilities, serve as advocates for residents, help ensure that the intent of the resident’s bill of rights is maintained, and work to increase community involvement in long term care facilities. There are over 1,100 such volunteers statewide, with committees in each county.

The services provided by the Ombudsman Program include:

answering questions and giving guidance about the long term care system (e.g. information on: long term care options, specific facilities, Medicare and Medicaid and other long term care topics)
educating community groups and long term care providers on various topics such as residents’ rights, restraint use, care planning, activities and new laws
investigating and assessing matters to help families, residents and families resolve concerns and problems (common areas of complaints include: medical and personal issues, financial concerns such as handling of residents’ funds, Medicare, Medicaid and Social Security issues, rights of residents, and admission to or discharge from facilities);
working with appropriate regulatory agencies and referring individuals to such agencies when resolution of issues are not possible through the Ombudsman Program alone
raising long term care issues of concern to policymakers

To better serve clients seeking guidance on long term care options and issues, professionals working with the elderly need to understand the distinctions between the various types of long-term care facilities and the services such facilities offer.

Author

Michael J. McCann, Legal Services Developer, Elder Rights Section, North Carolina Division of Aging.

Cite this article:

McCann, Michael. “Know Where You Are Going and What to Expect Before You Get There (Understanding Long-Term Care Facility Options).” The Forum for Family and Consumer Issues 3.1 (1998): 52 pars. 7 March 1998.

Notes

1. There are federal and state programs that subsidize housing for older adults with low to moderate incomes. Some of these facilities offer assistance to residents who need help with a limited number of tasks, but residents generally live independently in an apartment within the senior housing complex. [Return to text.]

2. Services provided on a short-term basis to a dependent person whose usual caregiver is temporarily unavailable or in need of a break from caregiving. [Return to text.]

3. N.C.G.S. 131E-101(6) (1997). [Return to text.]

4. See Level of Care Criteria Guidelines (Division of Medical Assistance, Raleigh, N.C.) August 1996, at page 1. To obtain this document contact the DMA hearings Officer at (919) 733-6964. [Return to text.]

5. Id. at 4. [Return to text.]

6. Subacute care is defined as comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process. It is goal oriented treatment rendered immediately after, or instead of acute hospitalization to treat one or more specific active complex treatments, in the context of a person’s underlying long-term conditions and overall situation. This is the definition was adopted by the American Health Care Association’s Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO). [Return to text.]

7. N.C.G.S. 131E-100 through -154 (1997). For a complete list of licensed nursing facilities, the North Carolina Division of Facility Services Licensure & Certification Section can be reached by calling (919) 733-1610. [Return to text.]

8. N.C. ADMIN. CODE. tit 10, ch. 3H. The administrative code sections pertaining to nursing homes are set out in a booklet entitled “Rules for the Licensing of Nursing Homes and Beds in Homes for the Aged Licensed as Part of a Nursing Home.” Copies are available by contacting the Division of Facility Services Licensure & Certification Section at (919) 733-7461. [Return to text.]

9. For a complete list of licensed nursing facilities, the North Carolina Division of Facility Services Licensure & Certification Section can be reached by calling (919) 733-7461. [Return to text.]

10. McCann and Saxon, The Law and the Elderly in North Carolina 2d ed. (Chapel Hill, North Carolina: The University of North Carolina Institute of Government 1996), page 184.[Return to text.]

11. N.C.G.S. 131E-178 (1997). [Return to text.]

12. 42 U.S.C. 1395i-3 et. seq. (1996)(Medicare); 42 U.S.C. 1396r et. seq (1996) (Medicaid); 42 C.F.R. 483 et. seq (1996).[Return to text.]

13. 42 U.S.C. 1396r(b)(2) (1996); 42 C.F.R. 483.15(g) (1996). [Return to text.]

14. See Jeff Crollard, Nursing Home Law in Washington State, (Seattle, Washington Evergreen Legal Services 1994) page 3. [Return to text.]

15. The Division of Facility Services Licensure and Certification Section can be reached by calling (919) 733-7461 [Return to text.]

16. A good basic resource on Medicare coverage and limitations is the 1997 Medicare Handbook, produced by the Health Care Financing Administration (HCFA). It is available through the Seniors Health Insurance Information Program [(919) 733-0111) or your local Area Agency on Aging. A good basic resource on Medicaid coverage and limitations is the North Carolina Cooperative Extension Service Publication, Medicaid Eligibility for Nursing Home Care- A Guide for North Carolinians, by Carol Schwab Esq. It can be obtained by calling (919) 515-9132. [Return to text.]

17. 42 U.S.C. 1396r ( c)(4)(1996); 42 C.F.R. 483.12(c)(1) (1996). [Return to text.]

18. 42 C.F.R. 483.20(b) (4) (1996). [Return to text.]

19. A review of some sections of the assessment are done quarterly and a reassessment is completed annually; 42 C.F.R. 483.20(b) (1996). [Return to text.]

20. See H. Kennard Bennett, Esq. Nursing Home: The Care Plan is the Contract; (National Academy of Elder Law Attorneys, Inc. May 1997). For a good resource on life in nursing homes and methods to positively impact care a book called, Nursing Homes -Getting Good Care There prepared by the National Citizens’ Coalition for Nursing Home Reform can be obtained by calling (202) 332-2275. [Return to text.]

21. 42 C.F.R. 483.12(a)(2) (1996). [Return to text.]

22. 42 C.F.R. 483.12(a)(7) (1996). [Return to text.]

23. 42 C.F.R. 483.12(a)(5) (1996). Notice may be made as soon as practicable before the transfer or discharge when: the health or safety of individuals in the facility would otherwise be endangered; the residents health has improved sufficiently to allow a more immediate discharge; a more immediate discharge is needed to meet a resident’s urgent medical needs; or if a resident has not resided in a facility for 30 days. [Return to text.]

24. 42 C.F.R. 483.12(a)(5) (1996). [Return to text.]

25. The DMA Hearing Unit can be reached by calling (919) 733-6964. [Return to text.]

26. N.C.G.S. 131D-2(1d) (1997). [Return to text.]

27. Id. [Return to text.]

28. N.C.G.S. 131D-2(1b) (1997). [Return to text.]

29. N.C.G.S. 131D-2(1b)& (5) (1997). [Return to text.]

30. N.C.G.S. 131D-2 (2) (1997). “Developmentally disabled adult” means a person who has attained the age of 18 years and who has a developmental disability defined as a severe, chronic disability of a person which: a. Is attributed to a mental or physical impairment or a combination of mental and physical impairments; b. Is manifested before the person attains the age of 22; c. Is likely to continue indefinitely; d. Results in substantial functional limitations in three or more of the following areas of major life activity: (i) self-care, (ii) receptive and expressive language, (iii) learning, (iv) mobility, (v) self direction, (vi) capacity for independent living, and (vii) economic self-sufficiency; and e. Reflects the person’s need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are lifelong or extended duration and are individually planned and coordinated. [Return to text.]

31. N.C.G.S. 131D-2 (7a) (1997). [Return to text.]

32. N.C.G.S. 131D-2(b) (1997). To obtain a complete list of licensed adult care homes, the North Carolina Division of Facility Services Group Care Section can be reached by calling (919) 733-6650. [Return to text.]

33. N.C.Admin. Code tit. 10: ch. 42D&42C. A booklet containing the applicable sections of the administrative code titled Rules for Licensing of Adult Care Homes is available from the North Carolina Division of Facility Services Group Care Section. This section can be reached by calling (919) 733-6650. [Return to text.]

34. N.C.G.S. 131D-2(a1) (1997). [Return to text.]

35. N.C.G.S. 131D-2(7a) (1997). [Return to text.]

36. N.C.G.S. 131D-2(a2) (1997). [Return to text.]

37. N.C.G.S. 108A40 et. seq. (1994). [Return to text.]

38. N.C.Admin.Code tit.10: ch. 42C .3701and .3702 (1997). [Return to text.]

39. N.C.Admin.Code tit. 10: ch. 42C .3702 (1997). [Return to text.]

40. N.C.G.S. 58-64-1(1) (1997). [Return to text.]

41. McCann and Saxon, The Law and the Elderly in North Carolina 2d ed. (Chapel Hill, North Carolina: The University of North Carolina Institute of Government 1996), page 204.[Return to text.]

42. North Carolina Department of Insurance, Continuing Care Retirement Communities Reference Guide, (Raleigh, North Carolina July 1996) page 2. [Return to text.]

43. N.C.G.S. 58-64-1 et. seq. (1997). [Return to text.]

44. N.C.G.S. 58-64-20 (1997). [Return to text.]

45. N.C.G.S. 58-64-25 (1997). [Return to text.]

46. H. Margolis, Retirement Housing Checklist, Portfolio 5-Housing Options in The Elder Law Portfolio Series (Boston, Mass.: Little Brown & Co., 1993.) [Return to text.]

47. N.C.G.S. 58-64-20(a)(7)d. and 58-64-20(a)(8) 1997. [Return to text.]

48. N.C.G.S. 58-64-25(a)(1) 1997. [Return to text.]

49. N.C.G.S. 58-64-25(a)(2) 1997. [Return to text.]

50. N.C.G.S. 58-64-25(b) 1997. [Return to text.]

51. N.C.G.S 143B 181.15-181.25 (1997). A list of the regional ombudsmen giving their names, addresses, phone numbers and counties they serve is available by calling the State Ombudsman at (919) 733-3983. [Return to text.]

52. N.C.G.S. 131E-128 and 131D-3 (1997). [Return to text.]

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