North Carolina survey readiness

What North Carolina DHHS — Division of Health Service Regulation can ask you for, each line cited — and the ones you can't yet produce.

The building

North Carolina requirements loaded — the rules below are North Carolina’s own.

0 of 30 ready.

30 of the outstanding items are the ones a survey opens with.

North Carolina — Adult Care Home

What North Carolina DHHS — Division of Health Service Regulation can ask for, each cited. Checked July 2026.

Goes in the planIs the section written, and does it say what the rule requires?

A written fire evacuation plan including a DIAGRAMMED DRAWING, carrying the approval of the local code enforcement official, prepared in LARGE PRINT and posted in a central location ON EACH FLOOR. Three requirements most plans miss: the drawing, the outside approval, and the type size.

10A NCAC 13G .0316 · North Carolina DHHS — Division of Health Service Regulation

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Must be filed or approvedWas it sent — and where approval is required, was it approved?

Two separate filings, on two different clocks. A NEWLY LICENSED facility must submit its emergency preparedness plan to the local emergency management agency within 30 DAYS of obtaining the license; already-licensed facilities submit annually. Separately, records of the fire evacuation rehearsals are maintained and copies furnished to the COUNTY DEPARTMENT OF SOCIAL SERVICES annually.

10A NCAC 13G .0316 (fire safety and emergency preparedness plan / disaster plan) · Local emergency management agency; and the county department of social services

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A written fire evacuation plan including a DIAGRAMMED DRAWING, carrying the approval of the local code enforcement official, prepared in LARGE PRINT and posted in a central location ON EACH FLOOR. Three requirements most plans miss: the drawing, the outside approval, and the type size.

10A NCAC 13G .0316 · North Carolina DHHS — Division of Health Service Regulation

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Must be postedIs it up, in the place the rule names?

A written fire evacuation plan including a DIAGRAMMED DRAWING, carrying the approval of the local code enforcement official, prepared in LARGE PRINT and posted in a central location ON EACH FLOOR. Three requirements most plans miss: the drawing, the outside approval, and the type size.

10A NCAC 13G .0316 · North Carolina DHHS — Division of Health Service Regulation

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Must be done, on a scheduleWhen did it last happen, and was that inside the interval?

Drills at the required frequency: At least four rehearsals of the fire evacuation plan each year.

10A NCAC 13G .0316 (fire safety and emergency preparedness plan / disaster plan) · North Carolina DHHS — Division of Health Service Regulation

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Records to retainHow far back can you produce the records?

Drills at the required frequency: At least four rehearsals of the fire evacuation plan each year.

10A NCAC 13G .0316 (fire safety and emergency preparedness plan / disaster plan) · North Carolina DHHS — Division of Health Service Regulation

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Life-safety systems

The code-based tests a life-safety survey opens with. These are the starred ones — the full schedule is the compliance calendar.

Test record

NFPA 72 Table 14.4.3.2 (supervisory device testing) (2022) · national · keep: Minimum 5 years

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Certificate + inspection report

NFPA 72 §14.4 (annual ITM) (2022) · national · keep: Minimum 5 years

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Test record

NFPA 25 §5.3.3 / §13.7 (2023) · national · keep: Life of system

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Static + residual pressures; compare to prior; >10% drop investigated

NFPA 25 §5.3.3 (main drain quarterly where sole supply passes through backflow preventer or PRV) (2023) · national · keep: Life of system

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Pressures vs prior year

NFPA 25 §13.2.5 (2023) · national · keep: Life of system

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Written record for AHJ

NFPA 80 §5.2.1 (annual, 13 criteria) (2022) · national · keep: 3 years

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Report

NFPA 110 §8.3.1 (2022) · national · keep: Per authority

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Damper log with location, ID, pass/fail and corrective action.

NFPA 80 §19.4 / NFPA 105 Ch. 6 (2022) · national · keep: Until the next test, minimum 3 years

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Written report listing every damper by location with pass/fail

NFPA 80 §19.4 / NFPA 105 Ch. 6 (hospital 6-year interval) (2022) · national · keep: Until the next test, minimum 3 years

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Monthly firefighter service log.

ASME A17.1 §8.6.11.1 (2019) · state-governed · keep: Minimum 3 years

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Trip test report with trip time and water delivery time.

NFPA 25 §13.4.4.2.2 (3-year full trip) (2020) · national · keep: Minimum 3 years

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Tank inspection report.

NFPA 25 §9.2.6 (interior inspection) (2020) · national · keep: Until the next interior inspection

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Smoke control test report with fan and damper positions.

NFPA 92 §8.4.2 (dedicated: semiannual) (2021) · national · keep: Minimum 3 years

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Signed drill sheet: date, time, shift, participants, evacuation time.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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Signed drill sheet.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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Signed drill sheet.

NFPA 101 §19.7.1 / CMS LSC (2012) · national · keep: Survey cycle

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After-action report and improvement plan.

42 CFR §483.73(d)(2) (—) · national · keep: Minimum 3 years

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Signed HVA.

42 CFR §483.73(a)(1) (—) · national · keep: Minimum 3 years

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Dated plan revision.

42 CFR §483.73(a) (—) · national · keep: Minimum 3 years

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Dated plan revision and team roster.

ASHRAE 188 / CMS QSO-17-30 (2018) · national · keep: Survey cycle

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Readings against control limits.

ASHRAE 188 §7 (2018) · national · keep: Survey cycle

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Receptacle test record by room.

NFPA 99 §6.3.3.2 (12-month interval applies to receptacles not listed hospital grade) (2021) · national · keep: Minimum 3 years

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Rounds log.

NFPA 101 §19.3.6 (2012) · national · keep: Survey cycle

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Barrier log with locations.

NFPA 101 §19.3.7 (2012) · national · keep: Survey cycle

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Photo of posting with date.

29 CFR §1904.32(b)(6) (—) · national · keep: 5 years

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Temperature log by unit.

FDA Food Code §3-501.16 (cold holding, as adopted by your state) (2022) · state-governed · keep: Minimum 1 year

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Inspection report and corrective-action record.

Local AHJ (—) · local · keep: Minimum 3 years

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What North Carolina requires

Adult Care Home — Assisted living / residential care
  • Your fire and evacuation drill records for the period. Drills at the required frequency: At least four rehearsals of the fire evacuation plan each year. 10A NCAC 13G .0316 (fire safety and emergency preparedness plan / disaster plan)
  • Proof your plan was filed, and the date it went. Two separate filings, on two different clocks. A NEWLY LICENSED facility must submit its emergency preparedness plan to the local emergency management agency within 30 DAYS of obtaining the license; already-licensed facilities submit annually. Separately, records of the fire evacuation rehearsals are maintained and copies furnished to the COUNTY DEPARTMENT OF SOCIAL SERVICES annually. 10A NCAC 13G .0316 (fire safety and emergency preparedness plan / disaster plan)
  • The plan goes on the wall, in large print, approved by the code official. A written fire evacuation plan including a DIAGRAMMED DRAWING, carrying the approval of the local code enforcement official, prepared in LARGE PRINT and posted in a central location ON EACH FLOOR. Three requirements most plans miss: the drawing, the outside approval, and the type size. 10A NCAC 13G .0316
North Carolina DHHS — Division of Health Service Regulation · checked July 2026

The evidence, and where it comes from

Every item above needs something you can hand over. The North Carolina fire drill log produces the drill record at the frequency this state sets, the emergency plan builder writes the plan itself from the same research, and the compliance calendar puts the life-safety tests on dates. Anything you record against the building shows up on the checklist already ticked.

Everything else we’ve researched about North Carolina

Same state, the problems either side of this one. Each carries its own statute and the date we last checked it.

A self-assessment against published rules, not a compliance determination. CompliMaint issues nothing — North Carolina DHHS — Division of Health Service Regulation and your authority having jurisdiction do. Requirements we could not verify are absent rather than guessed at.