South Carolina Regulatory Compliance Resources for Residential Care Facilities

Community Residential Care Facilities (CRCFs) are designed to accommodate residents’ changing needs and preferences, maximize their dignity, autonomy, privacy, independence, and safety, and encourage family and community involvement. While these facilities offer a beneficial or protected environment, particularly for individuals with mental illness or disabilities, they are not equipped to care for all conditions.

A facility shall admit and retain only those persons appropriate for placement in a CRCF in compliance with the standards of this regulation.

The sources specify certain conditions that prohibit admission or retention in a CRCF:

• Likelihood of Endangering Self or Others: Any person who is likely to endanger him/herself or others, as determined by a physician or other authorized healthcare provider, shall not be admitted or retained.
• Age Restriction: Generally, any person other than an adult (a person 18 years of age or older) shall not be admitted or retained. However, children of owners residing in the facility are an exception and shall be considered as residents in the staff/resident ratio for minimum staffing requirements.
• Need for Higher Levels of Care: Persons needing hospitalization or nursing home care shall not be admitted or retained. A resident shall be transferred within 30 days to a location that can meet their needs if the provision of care/services in the facility, combined with other appropriately licensed services (like hospice or home health), does not meet their needs, or if they become in need of continuous medical or nursing supervision, or if the facility does not have the capability to provide necessary care/services.
• Conditions Requiring Daily Skilled Monitoring or Frequent Adjustments: Persons needing daily skilled monitoring/observation due to an unstable or complex medical condition, such as brittle diabetes or dialysis patients with complications, shall not be admitted or retained. Also, persons needing medications that require frequent dosage adjustment or regulation are prohibited from admission or retention.
• Specific Medical/Physical Needs: Persons needing treatment of stage 2, 3, or 4 decubitus ulcers, multiple pressure sores, or other widespread skin disorder shall not be admitted or retained, particularly if signs of infection, full thickness tissue loss, or sterile technique is required. Persons needing nasogastric tube feeding or having to be fed by syringe or straw due to swallowing difficulties are prohibited. Gastronomy tube feedings not managed independently by the resident are also prohibited. Persons needing suctioning of the nose and/or mouth, needing a tracheostomy or sterile care of the tracheostomy that cannot be managed independently, or receiving oxygen for the first time which requires adjustment and evaluation of oxygen concentration shall not be admitted or retained.
• Behavioral Symptoms: Any person who has serious aggressive, violent, or socially inappropriate behavioral symptoms which cannot be controlled or improved in the facility shall not be retained.
• Total Dependency in Activities of Daily Living: Persons who have a dependency in all activities of daily living (ADLs), such as walking, bathing, dressing, eating, toileting, etc., for more than fourteen (14) consecutive days shall not be retained. This includes residents who are bedridden, incapable of locomotion, unable to transfer, totally incontinent of urinary and/or bowel function, must be totally bathed and dressed and toileted, and need extensive assistance to eat. The facility is required to develop a plan for transfer by the fifteenth (15th) day of total dependency if the resident is not improving.
• Need for Continuous Licensed Nursing Attention: Any person needing the continuous daily attention of a licensed nurse, such as for the care of a urinary catheter, shall not be retained.
• Communicable Diseases: If a resident or potential resident has a communicable disease, the administrator must seek advice from a physician or other authorized healthcare provider to ensure the facility can provide adequate care and prevent spread, or transfer the resident to an appropriate facility if necessary. Residents with contagious pulmonary tuberculosis shall be separated from other noninfected residents until declared noncontagious by a physician or other authorized healthcare provider. Residents known or suspected to have TB disease shall be transferred if the facility does not have an Airborne Infection Isolation room.

However, individuals declared to be in an emergency crisis stabilization status by Adult Protective Services or the Department of Mental Health may be admitted temporarily despite TB status, provided specific documentation (chest x-ray, negative assessment for signs/symptoms, declaration of emergency) is in place and the initial TB screening steps are completed shortly after admission.

Additionally, residents requiring restraint for more than 24 hours, as certified by a physician or other authorized healthcare provider, shall be transferred to an appropriate facility.

CRCFs in South Carolina are required to maintain various types of documentation to demonstrate compliance with regulations regarding licensing, staffing, resident care, safety, and facility operations. This includes records, plans, policies, and written agreements.

Key required documentation includes:

• Licensing and Facility Operations
  • Application for Licensure on a form prescribed by the Department.
  • Complete and accurate application submitted prior to initial licensing and periodically thereafter, signed by the owner(s), corporate officers, or governmental head.
  • Amended license requests via application for changes in ownership, licensed bed capacity, or location.
  • Letter from the licensee for changes in facility name or address.
  • Written notification of intent to close permanently and the effective date, submitted prior to closure.
  • Within 10 days of permanent closure, written notification to the Department regarding the provisions for record maintenance, identification of displaced residents, relocated sites, and resident refund details.
  • Written notification within fifteen (15) days prior to temporary closure, or within twenty-four (24) hours via telephone, email, or facsimile in an emergency, including the reason, resident transfer location, record storage method, and anticipated reopening date.
  • Written notification to the Department no later than the 100th day following the departure of the last active resident when there have been no residents for 90 days or more.
  • Written policies and procedures addressing each section of the regulation regarding resident care, rights, and facility operation, which are revised as required to accurately reflect actual operations.
  • Documentation of the time period established for review of all policies and procedures.
  • Written policies and procedures for private sitters.
  • Documentation of preventive maintenance activities for equipment and building components.
  • Documentation of flame spread rating and other safety criteria for cosmetic changes utilizing paint, wall covering, and floor covering, kept on file at the facility.
• Staffing and Training
  • Documentation of criminal background checks for staff members/direct care volunteers.
  • Accurate and current information for all staff members/volunteers, including address, phone number, and personal/work/training background.
  • Written assignment of duties and responsibilities for all staff members/direct care volunteers.
  • Written agreement with outside sources providing services normally provided by the facility (staffing, training, food service, etc.).
  • Written designation of a staff member to act in the administrator’s absence.
  • Documentation demonstrating the facility meets minimum staffing requirements.
  • Documentation of all inservice training, signed and dated by the provider and recipient.
  • Documented orientation for all new staff members/direct care volunteers within twenty-four (24) hours of their first day.
  • Documentation of a health assessment for all staff members/direct care volunteers who have resident contact, within 12 months prior to initial contact.
  • Tuberculin skin testing (TST) records or Blood Assay for Mycobacterium tuberculosis (BAMT) results for staff/direct care volunteers/private sitters, including baseline and post-exposure testing documentation as per risk classification. Copies of TB testing and health assessments accessible if staff work at multiple facilities. Written evidence of a symptom screen annually for private sitters with documented TB infection.
  • Written approval from the Department’s TB Control program for staff members/direct care volunteers/private sitters known or suspected to have TB disease to return to work.
  • Documentation of orientation to the facility (residents’ rights, confidentiality, disaster preparedness, emergency response, safety, infection control) for private sitters prior to resident contact.
  • Accurate current information regarding private sitters, including name, address, telephone number, and documentation of orientation.
  • Documentation of health assessment and criminal record check for private sitters.
• Resident Care and Records
  • Record of each accident and/or incident, including mechanical/physical restraint usage, involving residents, staff, or volunteers, which is documented, reviewed, investigated, and retained for six (6) years.
  • Immediate report of serious accidents/incidents (resident death, hospitalization from accident/incident, medication error with adverse reaction, severe injury/burn requiring medical attention/hospitalization, fracture, severe injury from restraints, attempted suicide, fire) via telephone, email, or facsimile within twenty-four (24) hours to the attending physician, next-of-kin or responsible party, and the Department. Written details of the serious incident.
  • Immediate notification (telephone) of local law enforcement and the responsible party when a cognitively impaired resident leaves the premises without notice.
  • Reporting changes in a resident’s condition to the extent that serious health concerns and/or injuries are evident.
  • Notification of the Department’s Bureau of Drug Control of any theft or loss of controlled substances.
  • Written notification to the Department by the relocating facility of individuals relocated due to emergency, including names, and the name, address, and phone number of the sheltering facility, no later than the following workday.
  • An organized record for each resident maintained on site containing documented information to identify the resident and responsible party, support care/services, justify care/services, note symptoms/changes, document response to care/medication/diet, and promote continuity of care.
  • Specific entries in the resident record, including consultations, orders/recommendations (signed/dated by provider within 3 business days; verbal orders documented with date/time/recipient), care/services provided, medications administered/errors, special procedures, notes of observation (daily for significant changes/incidents, monthly otherwise), time/circumstances of discharge/transfer/death, plan for routine/emergency medical care (physician name/number, payment, medication plan), special information (DNR, allergies, POA, responsible party). All entries shall be written legibly in ink, typed or electronic media, and signed and dated.
  • Photograph of resident (minimum size, dated, recent).
  • Written assessment of the resident conducted by a direct care staff member within 72 hours of admission, evidenced by signature and date.
  • Individual Care Plan (ICP) developed within seven (7) days of admission based on the assessment, describing resident needs (including ADL assistance details), arrangements for physician visits, advance directives/POA, recreational/social activities, nutritional needs, responsibilities of sponsor and facility, and goal-related objectives. The ICP shall be reviewed/revised as needs change, but not less than semi-annually, with participation and signatures of the resident, administrator/designee, and/or sponsor/responsible party.
  • Transfer summary forwarded to the receiving facility upon transfer, including copies of the most recent physical examination, two-step tuberculosis test results, the ICP, and medication administration record (MAR). The summary shall include the date sent and signature of the transferring staff.
  • Resident record completed within 30 days of discharge and filed.
  • Arrangements for preservation of records prior to facility closing, with written notification to the Department detailing arrangements and location.
  • Resident records maintained for at least six (6) years following discharge. Other required documents (fire drills, activity schedules) retained at least 12 months or since the last general inspection, whichever is longer.
  • Written agreement between the resident and/or responsible party and the facility prior to admission, revised upon changes, detailing specific care/services, fees, fee change notice, refund policy, personal needs allowance, transportation policy, and discharge/transfer provisions. Documentation of the explanation of the Resident’s Bill of Rights and grievance procedure included in the agreement.
  • Accurate accounting of residents’ personal monies, written evidence of facility purchases with resident authorization, and accounting of monies paid for care/services. Written consent for giving resident money to others. Receipts obtained if money is given to others.
  • Documentation of quarterly reports of resident finances provided to each resident.
  • Written orders from a physician or other authorized healthcare provider for the use of mechanical/physical restraints in emergencies.
  • Documentation of the release of unused medications to the resident, family member, or responsible party upon discharge, with a signature of the recipient.
  • Documentation that special diet menus have been planned or reviewed and approved by a professionally-qualified dietitian or a physician or other authorized healthcare provider, including their signature, title, and date. Written guidance provided by a registered dietitian, physician, or other authorized healthcare provider for preparing special diets, documented in the resident’s record.
  • Records of menus as served maintained for at least 30 days.
  • Written authorization from a physician or other authorized healthcare provider for a resident to engage in activities listed in the ICP that would normally be staff duties.
  • Written statement from a physician or other authorized healthcare provider assuring a resident is capable of maintaining a cleaning product/hazardous agent in a secure locked manner, with usage outlined in the ICP, if the facility permits a resident to use such items.
  • Documentation of emergency declaration by Adult Protective Services or the South Carolina Department of Mental Health for individuals admitted under emergency crisis stabilization status.
  • Written evidence of a chest x-ray within one (1) month prior to admission and a written assessment by a physician or other authorized healthcare provider for emergency crisis stabilization admissions.
• Emergency and Safety
  • Written plan for actions in the event of a disaster and/or emergency evacuation, developed with the county emergency preparedness agency, submitted to the Department for review prior to initial licensing or for increases in licensed bed capacity. The plan shall be reviewed and updated annually and rehearsed at least annually.
  • Letter of agreement signed by an authorized representative of each sheltering facility, updated at least every three years or whenever significant changes occur.
  • Written agreement with entities for relocating residents as part of the transportation plan.
  • Co-signed statement by an authorized representative of the sheltering facility if staffing is to be provided by the sheltering facility.
  • Written plan implemented to assure continuity of essential resident support services during power outage, water shortage, or workforce absence.
  • Written plans for actions in the event of fire (fire plan, evacuation plan), developed in coordination with the fire department/disaster preparedness agency.
  • Written agreement with the nearest fire department if located outside a public fire department’s service area.
  • Evacuation floor diagram posted in conspicuous public areas and a copy provided to each resident and/or responsible party.
  • Records of unannounced fire drills conducted at least quarterly for all shifts, indicating date, time, shift, description, evaluation, and names of participants.
  • Annual tuberculosis risk assessment documented in accordance with CDC guidelines.
  • Manufacturers’ certifications or documentation of treatment for flame spread and other safety criteria for construction materials, furnished and maintained.
• Quality Improvement
  • Written, implemented quality improvement program providing effective self-assessment and implementation of changes.
  • The QI program shall include documentation of established desired outcomes/criteria, identification/evaluation/causes of deviations, actions taken to correct/prevent deviations, analysis of ICPs/care, analysis of incidents/accidents/medication errors/deaths, analysis of infections/outbreaks, and systematic feedback methods.
• Construction/Physical Plant
  • Plans and specifications prepared by a registered architect and/or engineer in South Carolina for new construction, additions, alterations, major equipment replacement, first-time licensed buildings, license type changes, or increases in occupant load/capacity, submitted to the Department for review and approval.
  • All subsequent addenda, change orders, field orders, and documents altering the Department review must be submitted.

CRCFs are required to have sufficient and qualified staff present to meet the needs of the residents and ensure the facility’s operations comply with regulations.

Required staffing details include:

• Qualifications: Staff members/direct care volunteers shall be **capable of rendering care/services to residents**, have **sufficient education to be able to perform their duties and to speak, read, and write English**, and **demonstrate a working knowledge of applicable regulations**.
• Administrator: The facility administrator must be **licensed as a CRCF administrator** and demonstrate adequate knowledge of the regulations. A staff member must be designated in writing to act in the administrator’s absence.
• Presence: There shall be a **staff member actively on duty and present in the facility at all times that the facility is occupied by residents**. This staff member must be available for residents to immediately report injuries, symptoms of illness, or emergencies. They must also recognize and report significant changes in a resident’s condition and ensure appropriate action is taken.
• Sufficient Staffing: The number and qualifications of staff members/direct care volunteers shall be determined by the number and condition of the residents. There must be **sufficient staff members/direct care volunteers to provide supervision, direct care, and basic services for all residents**.
• Minimum Ratios: The minimum number of staff members/direct care volunteers to be maintained in all facilities is specified:
  • In each building, there shall be **at least one staff member/direct care volunteer for each eight (8) residents or fraction thereof on duty during all periods of peak hours**.
  • In each building, during **non-peak hours**, there shall be **at least one staff member/volunteer on duty for each thirty (30) residents or fraction thereof**. This staff member/volunteer must be **awake and dressed at all times** and able to appropriately respond to resident needs.
  • In multi-floor facilities licensed for more than 10 beds, there shall be a **staff member available on each floor at all times residents are present** on that floor.
• Children of Owners: If children of owners reside in the facility, they are considered as residents in the staff/resident ratio calculation for minimum staffing requirements.
• Private Sitters: Private sitters are **not** included in the minimum staffing requirements.
• Meal Service Personnel: Sufficient staff members/volunteers shall be available to serve food and provide individual attention and assistance as needed. There shall be trained staff members/volunteers to supervise the preparation and serving of the proper diet and have sufficient knowledge of food values to make appropriate substitutions.
• Specific Tasks: Only staff members authorized by the facility may receive medication/treatment orders. Medication doses shall be administered by the same staff member who prepared them. Facility staff members may administer routine medications if trained by licensed individuals. Facility staff may administer injections for diabetes and anaphylactic reactions under medical protocol. A licensed nurse may administer influenza and vitamin B-12 injections and perform TB skin tests. Facility staff may monitor blood sugar levels if trained and the facility has a CLIA “Certificate of Waiver,” but are prohibited from providing sliding scale insulin injections.