How to Complete the NC LHPS Form: Tasks, Signatures, and Reviews

The NC LHPS form is North Carolina’s Licensed Health Professional Support document, and completing it means having a qualified licensed professional evaluate a specific staff member’s competency to perform a specific covered task for a specific resident, then signing and dating the form before that staff member ever performs the task. The form goes into the resident’s clinical record and is refreshed through on-site reviews at least every quarter. Adult care homes with seven or more beds fall under 10A NCAC 13F .0903; family care homes with two to six beds follow the parallel rule at 10A NCAC 13G .0903.¹

Download a fresh copy of the current form from the DHSR Adult Care Licensure Section forms page each time you need one. Photocopying an older version from a previous resident’s file is one of the easier ways to draw a surveyor’s attention.²

When the Form Is Required

The requirement kicks in at two points: when a new resident is admitted with care needs that fall into one of 28 designated task categories, or when an existing resident’s condition changes and a new covered task becomes necessary. The initial on-site review must happen within 30 days of admission, or within 30 days of the date the existing resident develops the need for the task. Reviews must then occur at least quarterly.¹

Validation must happen before the staff person performs the task on any resident. A facility cannot have unlicensed staff perform a covered task and then obtain the paperwork retroactively. That sequence will not pass a survey.

Which Personal Care Tasks Trigger the Form

The 28 tasks listed in 10A NCAC 13F .0903(a) are the only ones that trigger the documentation requirement. If a resident’s care involves something not on this list, no LHPS form is needed for that task.

Wound and skin tasks include clean dressing changes (excluding wound packing and prescribed enzymatic debriding agents), pressure ulcer care up to and including Stage II, and prescribed heat therapy. Respiratory tasks include chest physiotherapy or postural drainage, inhalation medication by machine, oxygen administration and monitoring, oral suctioning (endotracheal suctioning is excluded), tracheostomy care for well-established tracheostomies only, and CPAP or BiPAP monitoring.

Medication and injection tasks cover gastrostomy tube medication administration through a well-established tube, tube feeding administration and monitoring through the same, and subcutaneous injection (excluding anticoagulants). Monitoring tasks include fingerstick blood sample collection and testing, fluid forcing and restricting, and intake and output tracking.

Elimination and catheter care covers urinary catheter bag positioning, emptying, and cleaning around the catheter; bowel or bladder training programs; enemas, suppositories, fecal impaction removal, and vaginal douches; and colostomy or ileostomy care for well-established ostomies. Mobility tasks include applying and removing ace bandages, TED hose, binders, braces, and splints; prosthetic device application and removal (post-operative shaping of an extremity is excluded); ambulation with assistive devices requiring physical assistance; range of motion exercises; other prescribed physical or occupational therapy; and transferring semi-ambulatory or non-ambulatory residents.

The remaining tasks are feeding techniques for residents with swallowing problems, physical restraint care and alternatives to restraints, and Nurse Aide II tasks as defined by the Nursing Practice Act and 21 NCAC 36.¹

Who Can Sign as the Validating Professional

A registered nurse can validate competency for all 28 tasks. Under 10A NCAC 13F .0504, other licensed professionals can also sign off on specific tasks within their scope of practice.³

A licensed respiratory care practitioner may validate chest physiotherapy, inhalation medication by machine, oxygen administration, oral suctioning, tracheostomy care, and CPAP/BiPAP monitoring. A licensed pharmacist may validate fingerstick blood sample collection and testing and inhalation medication by machine; an immunizing pharmacist may also validate subcutaneous injection administration. An occupational therapist or physical therapist may validate restraint care and alternatives to restraints, prescribed heat therapy, prosthetic devices, ambulation with assistive devices, range of motion exercises, other prescribed therapy, and transferring residents.

A Licensed Practical Nurse is not listed in 10A NCAC 13F .0504 as an authorized validator. Even where an LPN can supervise delegated tasks in other clinical settings, the competency validation on the LHPS form itself requires one of the professionals listed above.³

Filling Out the Form

Resident and Facility Identification

Enter the resident’s full legal name along with the facility’s name and identification information. Check the spelling against the resident’s admission paperwork. Surveyors compare form names to other records, and even a nickname used in place of a legal name can create confusion during inspection.

The Licensed Professional’s Credentials

The professional completing the evaluation enters their full name, professional title, and current North Carolina license number. That is what ties the validation to a verifiable credential. If the professional is a respiratory care practitioner or pharmacist signing for a task within their authorized scope, the title field should reflect that specific license rather than a generic descriptor.

Task Description and Return Demonstration

Each personal care task being validated must be clearly identified on the form, referenced to the specific task from the regulation’s list. Before signing, the licensed professional evaluates the staff person’s knowledge, skills, and abilities related to each task. The staff member must demonstrate they can actually perform the task. A written test alone does not satisfy the return-demonstration requirement.³

Signatures and Dates

Both the licensed professional and the staff member sign and date the form on the day the evaluation takes place. Signatures must be legible. Fill every field. A form dated weeks after the staff member began performing the task is a red flag during inspections, and incomplete forms are treated as deficient records.

Quarterly On-Site Reviews

Under 10A NCAC 13F .0903(c), the facility must arrange for a registered nurse, occupational therapist, or physical therapist to conduct on-site reviews at least every quarter. Each review must include a physical assessment of the resident’s current condition as it relates to the diagnosis or condition requiring the covered tasks, a progress evaluation of whether the care is effective, and recommendations for changes in care. All three must be documented.¹

Subsection (d) adds a follow-through requirement that is easy to overlook: the facility must act on the professional’s recommendations and, when necessary, inform the resident’s physician. The review itself is not enough if nothing is done with the findings.

Forms must also be updated whenever a resident’s medical condition changes or a new covered task is added. A quarterly review that reveals a new task triggers a fresh competency validation for any staff member who will perform it.

Physician-Authorized Temporary Care

A physician may certify that care beyond the facility’s normal scope can be provided on a temporary basis under G.S. 131D-2.2(a) to prevent relocating a resident. Even then, staff performing the physician-authorized tasks must go through the same competency validation. A physician’s order does not waive the LHPS documentation requirement. The physician determines how long “temporary” lasts based on the resident’s care needs.³

Where the Form Is Kept and for How Long

Once signed, the original form goes into the resident’s permanent clinical record. Organize forms chronologically so a surveyor can trace the timeline from initial validation through each quarterly review. Every quarterly review should be filed alongside the original.

North Carolina requires facilities to keep medical records on file for five years following a patient’s discharge under 10A NCAC 13D .2402.⁴ After a resident leaves, the LHPS forms remain part of the historical file and must be accessible if the state requests them.

What Happens If the Form Is Missing or Wrong

Missing or incomplete LHPS documentation puts a facility at risk during state surveys. North Carolina classifies adult care home violations as Type A, which create a substantial risk of death, serious physical harm, abuse, neglect, or exploitation, or Type B, which are detrimental to resident health, safety, or welfare but do not rise to that level. Type A violations must be corrected within 30 days and carry fines from $500 to $10,000 per violation for family care homes and $2,000 to $20,000 per violation for adult care homes. Type B violations carry a 45-day correction window.⁵

A Type A violation that is not corrected within the 30-day window can draw up to $1,000 per day for every day it continues. Uncorrected Type B violations past 45 days can also trigger additional penalties.⁵

Whether a missing LHPS form results in a Type A or Type B citation depends on the circumstances. A documentation gap with no harm to the resident lands differently than one where unlicensed staff performed a task they were never validated for and a resident was injured. The classification rests on the surveyor’s judgment of the actual or potential impact on residents.

1
North Carolina Office of Administrative Hearings. 10A NCAC 13F .0903 – Licensed Health Professional Support
2
North Carolina Division of Health Service Regulation. Adult Care Licensure Section – Forms and Applications
3
North Carolina Office of Administrative Hearings. 10A NCAC 13F .0504 – Competency Evaluation and Validation for Licensed Health Professional Support Tasks
4
Cornell Law Institute. 10A North Carolina Admin Code 13D 2402 – Preservation of Medical Records
5
NC Division of Health Service Regulation. Adult Care Home Violations and Penalties