Iowa Admin. Code r. 441-77.25 - Home- and community-based habilitation services

Current through Register Vol. 44, No. 20, April 6, 2022

To be eligible to participate in the Medicaid program as an approved provider of home- and community-based habilitation services, a provider shall meet the general requirements in subrules 77.25(2), 77.25(3), 77.25(4), and 77.25(5) and shall meet the requirements in the subrules applicable to the individual services being provided.

(1) Definitions.

"Certified employment specialist" or "CES" means a person who has demonstrated a sufficient level of knowledge and skill to provide integrated employment support services to a variety of client populations and has earned a CES certification through a nationally recognized accrediting body.

"Guardian" means a guardian appointed in probate or juvenile court.

"Individual placement and support" or "IPS" means the evidence-based practice of supported employment that is guided by IPS practice principles outlined by the IPS Employment Center at Westat, and as measured by its most recently published 25-item supported employment fidelity scale available online at ipsworks.org/wp-content/uploads/2017/08/ips-fidelity-manual-3rd-edition_2-4-16.pdf. The IPS practice principles are:

1. Focus on competitive employment: Agencies providing IPS services are committed to competitive employment as an attainable goal for people with behavioral health conditions seeking employment. Mainstream education and specialized training may enhance career paths.
2. Zero exclusion criteria based on client choice: People are not excluded on the basis of readiness, diagnoses, symptoms, substance use history, psychiatric hospitalizations, homelessness, level of disability, or legal system involvement.
3. Integration of rehabilitation and mental health services: IPS programs are closely integrated with mental health treatment teams.
4. Attention to worker preferences: Services are based on each person's preferences and choices, rather than providers' judgments.
5. Personalized benefits counseling: Employment specialists help people obtain personalized, understandable, and accurate information about their social security, Medicaid, and other government entitlements.
6. Rapid job search: IPS programs use a rapid job search approach to help job seekers obtain jobs directly, rather than providing lengthy preemployment assessment, training, and counseling. If further education is part of their plan, IPS specialists assist in these activities as needed.
7. Systematic job development: Employment specialists systematically visit employers, who are selected based on job seeker preferences, to learn about their business needs and hiring preferences.
8. Time-unlimited and individualized support: Job supports are individualized and continue for as long as each worker wants and needs the support.

"Intensive residential service homes" or "intensive residential services" means intensive, community-based services provided 24 hours per day, 7 days per week, 365 days per year to individuals with a severe and persistent mental illness who have functional impairments and may also have multi-occurring conditions. Providers of intensive residential service homes are enrolled with Medicaid as providers of HCBS habilitation or HCBS intellectual disability waiver supported community living and meet additional criteria specified in 441-subrule 25.6(8).

"IPS 25-item supported employment fidelity scale" means the fidelity scale published by the IPS Employment Center at Westat, resulting in scores of exemplary fidelity, good fidelity, fair fidelity, or not supported employment.

"IPS implementation" means the process advocated by the IPS Employment Center at Westat, which consists of the following phases:

1. Formation of IPS team steering group and one-day meeting with the IPS trainer and team members.
2. Completion of the IPS Readiness Assessment developed by the IPS Employment Center at Westat and individual review with the IPS trainer.
3. Completion of a one-day IPS kick-off team training with the IPS trainer and team members.
4. Participation in individual team training and monthly consultations as follows:

* Two-and-a-half-day individual team training with the IPS trainer and team members.

* Virtual training by the IPS Employment Center at Westat for at least three people per team.

* Leadership training for two people per team at the IPS Employment Center at Westat.

* Virtual monthly technical assistance for two hours per month per team.

5. Participation in the International Learning Collaborative, including:

* Participation in the International Learning Collaborative annual conference by two people per state.

* Virtual monthly technical assistance calls with the IPS Employment Center at Westat mentor assigned to the team.

* Participation in the prescribed data tracking and management activities.

6. Completion of one baseline fidelity review per IPS team, with two IPS reviewers on site for two days per review.
7. Evaluation and development of next steps, with an on-site half-day meeting for the IPS trainer and the team.

"IPS reviewer" means a person who is qualified to complete fidelity reviews of IPS services and is one of the following:

1. A person who has provided IPS services or has supervised an IPS team in Iowa which has obtained a fidelity score of "good" or better, has completed the IPS Employment Center at Westat's training to become an IPS reviewer, and has shadowed one or more IPS fidelity reviews;
2. An existing IPS reviewer from a state which is a member of the IPS International Learning Collaborative;
3. An IPS reviewer contracted directly from the IPS Employment Center at Westat;
4. A CES with a bachelor's degree who has completed the IPS Employment Center at Westat's training to become an IPS reviewer and has shadowed one or more IPS fidelity reviews.

"IPS team" means, at a minimum, an IPS employment specialist, a behavioral health specialist, Iowa Vocational Rehabilitation Services (IVRS) counselor, and a case manager or care coordinator.

"IPS trainer" means a person who is qualified to provide training and technical assistance for IPS implementation and is one of the following:

1. A person who has provided IPS services or has supervised an IPS team in Iowa which has obtained a fidelity score of "good" or better, and has completed the IPS Employment Center at Westat's training to become an IPS trainer;
2. An existing IPS trainer from a state which is a member of the IPS International Learning Collaborative;
3. An IPS trainer contracted directly from the IPS Employment Center at Westat;
4. A CES with a bachelor's degree who has completed the IPS Employment Center at Westat's training to become an IPS trainer.

"Major incident" means an occurrence involving a member during service provision that:

1. Results in a physical injury to or by the member that requires a physician's treatment or admission to a hospital;
2. Results in the death of any person;
3. Requires emergency mental health treatment for the member;
4. Requires the intervention of law enforcement;
5. Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
6. Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph "1," "2," or "3"; or
7. Involves a member's location being unknown by provider staff who are assigned protective oversight.

"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of "health maintenance organization" as defined in Iowa Code section 514B.1.

"Member" means a person who has been determined to be eligible for Medicaid under 441-Chapter 75.

"Minor incident" means an occurrence involving a member during service provision that is not a major incident and that:

1. Results in the application of basic first aid;
2. Results in bruising;
3. Results in seizure activity;
4. Results in injury to self, to others, or to property; or
5. Constitutes a prescription medication error.

"Prospective IPS team" means a group that is forming an IPS team to deliver IPS services but who has not yet completed implementation phase 4a.

"Provider-owned or controlled setting" means a setting where the HCBS provider owns the property where the member resides, leases the property from a third party, or has a direct or indirect financial relationship with the property owner that impacts either the care provided to or the financial conditions applicable to the member. The unit or dwelling is a specific physical space that can be owned, rented, or occupied under a legally enforceable agreement by the member receiving services, and the member has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the state, county, city, or other designated entity. For the settings in which landlord tenant laws do not apply, the state must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS member and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord tenant law.

"Provisionally approved IPS team" means a group that has (1) formed a team to deliver IPS services, (2) completed implementation phase 4a, and (3) begun to deliver IPS services.

(2) Organization and staff.
a. The prospective provider shall demonstrate the fiscal capacity to initiate and operate the specified programs on an ongoing basis.
b. The provider shall complete child abuse, dependent adult abuse, and criminal background screenings pursuant to Iowa Code section 249A.29 before employing a person who will provide direct care.
c. A person providing direct care shall be at least 16 years of age.
d. A person providing direct care shall not be an immediate family member of the member.
(3) Incident management and reporting. As a condition of participation in the medical assistance program, HCBS habilitation service providers must comply with the requirements of Iowa Code sections 232.69 and 235B.3 regarding the reporting of child abuse and dependent adult abuse and with the incident management and reporting requirements in this subrule.
a. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member's supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the member's file.
b. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident:
(1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:
1. The staff member's supervisor.
2. The member or the member's legal guardian. Exception: Notification to the member is required only if the incident took place outside of the provider's service provision. Notification to the guardian, if any, is always required.
3. The member's case manager.
(2) By the end of the next calendar day after the incident, the staff member who observed or first became aware of the incident shall also report as much information as is known about the incident to the member's managed care organization in the format defined by the managed care organization. If the member is not enrolled with a managed care organization, the staff member shall report the information to the department's bureau of long-term care either:
1. By direct data entry into the Iowa Medicaid Provider Access System, or
2. By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
(3) The following information shall be reported:
1. The name of the member involved.
2. The date and time the incident occurred.
3. A description of the incident.
4. The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other members or nonmembers who were present must be maintained by the use of initials or other means.
5. The action that the provider staff took to manage the incident.
6. The resolution of or follow-up to the incident.
7. The date the report is made and the handwritten or electronic signature of the person making the report.
(4) Submission of the initial report will generate a workflow in the Individualized Services Information System (ISIS) for follow-up by the case manager. When complete information about the incident is not available at the time of the initial report, the provider must submit follow-up reports until the case manager is satisfied with the incident resolution and follow-up. The completed report shall be maintained in a centralized file with a notation in the member's file.
c. Tracking and analysis. The provider shall track incident data and analyze trends to assess the health and safety of members served and determine if changes need to be made for service implementation or if staff training is needed to reduce the number or severity of incidents.
(4) Restraint, restriction, and behavioral intervention. The provider shall have in place a system for the review, approval, and implementation of ethical, safe, humane, and efficient behavioral intervention procedures. All members receiving home- and community-based habilitation services shall be afforded the protections imposed by these rules when any restraint, restriction, or behavioral intervention is implemented.
a. The system shall include procedures to inform the member and the member's legal guardian of the restraint, restriction, and behavioral intervention policy and procedures at the time of service approval and as changes occur.
b. Restraint, restriction, and behavioral intervention shall be used only for reducing or eliminating maladaptive target behaviors that are identified in the member's restraint, restriction, or behavioral intervention program.
c. Restraint, restriction, and behavioral intervention procedures shall be designed and implemented only for the benefit of the member and shall never be used as punishment, for the convenience of the staff, or as a substitute for a nonaversive program.
d. Restraint, restriction, and behavioral intervention programs shall be time-limited and shall be reviewed at least quarterly.
e. Corporal punishment and verbal or physical abuse are prohibited.
(5) Residential and nonresidential settings. Effective March 17, 2022, all home- and community-based services (HCBS), whether residential or nonresidential, shall be provided in integrated, community-based settings that support full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. Settings shall optimize individual initiative, autonomy, and independence in making life choices, including but not limited to daily activities, physical environment, and with whom to interact.
a. Nursing facilities, institutions for mental diseases, intermediate care facilities for persons with an intellectual disability, and hospitals are not considered integrated, community-based settings.
b. Any HCBS setting that is located in a building that is also a publicly or privately operated facility, identified in paragraph 77.25(5)"a," that provides inpatient treatment or in a building on the grounds of, or immediately adjacent to, a public institution, identified in paragraph 77.25(5)"a," or any setting that has the effect of isolating members receiving Medicaid HCBS from the broader community will be presumed to be a setting that has the qualities of an institution unless the department conducts a site-specific review and determines otherwise.
c. Residential services may be provided in provider-owned or controlled settings. In provider-owned or controlled residential settings:
(1) The member selects the setting from among setting options, including non-disability-specific settings and an option for a private unit in a residential setting.
(2) The setting options are identified and documented in the person-centered service plan and are based on the member's needs, preferences, and resources available for room and board.
(3) Members have choices regarding services and supports received and who provides them.
(4) Members are assured the rights of privacy, dignity, respect, and freedom from coercion and undue restraint.
(5) Services and supports shall optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to daily activities, physical environment, and with whom to interact.
(6) Each member shall be afforded privacy in the member's sleeping and living unit. Living unit entrance doors and bedroom doors may be locked by the member, and only appropriate staff shall have keys. Staff access to keys must be identified in the member's person-centered plan.
(7) Members shall have a choice of roommates in that setting.
(8) Members shall have the freedom to furnish and decorate their sleeping or living areas as desired as permitted by any operative lease or other agreement.
(9) Members shall have the freedom and support to control their own schedules and activities and shall have access to food at any time.
(10) Members may have visitors of their choosing at any time.
(11) The setting shall be physically accessible to the member.
(6) Case management. A provider is eligible to participate in the home- and community-based habilitation services program as a provider of case management services if accredited as a case management provider pursuant to 441-Chapter 24.
(7) Day habilitation.
a. The following providers may provide day habilitation:
(1) An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide services that qualify as day habilitation under 441-subrule 78.27(8).
(2) An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide other services and began providing services that qualify as day habilitation under 441-subrule 78.27(8) since the agency's last accreditation survey. The agency may provide day habilitation services until the current accreditation expires. When the current accreditation expires, the agency must qualify under subparagraph 77.25(7)"a"(1), 77.25(7)"a"(4), or 77.25(7)"a"(7).
(3) An agency that is not accredited by the Commission on Accreditation of Rehabilitation Facilities but has applied to the Commission within the last 12 months for accreditation to provide services that qualify as day habilitation under 441-subrule 78.27(8). An agency that has not received accreditation within 12 months after application to the Commission is no longer a qualified provider.
(4) An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
(5) An agency that has applied to the Council on Quality and Leadership in Supports for People with Disabilities for accreditation within the last 12 months. An agency that has not received accreditation within 12 months after application to the Council is no longer a qualified provider.
(6) An agency that is accredited under 441-Chapter 24 to provide day treatment or supported community living services.
(7) An agency that is accredited by the International Center for Clubhouse Development.
(8) An agency that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
b. Direct support staff providing day habilitation services shall meet the following minimum qualifications in addition to other requirements outlined in administrative rule:
(1) A person providing direct support without line-of-sight supervision shall be at least 18 years of age and possess a high school diploma or equivalent degree. A person providing direct support with line-of-sight supervision shall be 16 years of age or older.
(2) A person providing direct support shall not be an immediate family member of the member.
(3) A person providing direct support shall, within six months of hire or within six months of February 1, 2021, complete at least 9.5 hours of training in supporting members in the activities listed in 701-paragraph 78.27(8)"a," as offered through DirectCourse or Relias or other nationally recognized training curriculum.
(4) A person providing direct support shall annually complete 4 hours of continuing education in supporting members in the activities listed in 701-paragraph 78.27(8)"a," as offered through DirectCourse or Relias or other nationally recognized training curriculum.
(8) Home-based habilitation.
a. The following agencies may provide home-based habilitation services:
(1) An agency that is certified by the department to provide supported community living services under:
1. The home- and community-based services intellectual disability waiver pursuant to rule 441-77.37 (249A); or
2. The home- and community-based services brain injury waiver pursuant to rule 441-77.39 (249A).
(2) An agency that is accredited under 441-Chapter 24 to provide supported community living services.
(3) An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as a community housing or supported living service provider.
(4) An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
(5) An agency that is accredited by the Council on Accreditation of Services for Families and Children.
(6) An agency that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
b. Direct support staff providing home-based habilitation services shall meet the following minimum qualifications in addition to the other requirements outlined in this rule:
(1) A person providing direct support shall be at least 18 years old and have a high school diploma or its equivalent.
(2) A person providing direct support shall not be an immediate family member of the member receiving services.
(3) A person providing direct support to members receiving intensive residential habilitation services shall complete 48 hours of training within the first year of employment and 24 hours of training each year thereafter in mental health and multi-occurring conditions pursuant to 441-subrule 25.6(8).
(4) A person providing direct support to members receiving home-based habilitation services shall complete a minimum of 24 hours of training within the first year of employment in mental health and multi-occurring conditions, including but not limited to the following topics:
1. Mental health diagnoses, symptomology, and treatment;
2. Intervention strategies that may include applied behavioral analysis, motivational interviewing, or other evidence-based practices;
3. Crisis management, intervention, and de-escalation;
4. Psychiatric medications, common medications, and potential side effects;
5. Member-specific medication protocols, supervision of self-administration of medication, and documentation;
6. Substance use disorders and treatment;
7. Other diagnoses or conditions present in the population served; and
8. Individual-person-centered service plan, crisis plan, and behavioral support plan implementation.
(5) A person providing direct support to members receiving home-based habilitation services shall complete a minimum of 12 hours of training annually on the topics listed in subparagraph 77.25(8)"b"(4) or other topics related to serving individuals with severe and persistent mental illness.
c. The department shall approve living units designed to serve up to four persons except as necessary to prevent an overconcentration of supported community living units in a geographic area.
d. The department shall approve a living unit designed to serve five persons if both of the following conditions are met:
(1) Approval will not result in an overconcentration of supported community living units in a geographic area; and
(2) The county in which the living unit is located provides to the bureau of long-term care verification in writing that the approval is needed to address one or more of the following issues:
1. The quantity of services currently available in the county is insufficient to meet the need; or
2. The quantity of affordable rental housing in the county is insufficient to meet the need; or
3. Approval will result in a reduction in the size or quantity of larger congregate settings.
(9) Prevocational habilitation.
a. The following providers may provide prevocational services:
(1) An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as an organizational employment service provider or a community employment service provider.
(2) An agency that is accredited by the Council on Quality and Leadership.
(3) An agency that is accredited by the International Center for Clubhouse Development.
(4) An agency that is certified by the department to provide prevocational services under:
1. The home- and community-based services intellectual disability waiver pursuant to rule 441-77.37 (249A); or
2. The home- and community-based services brain injury waiver pursuant to rule 441-77.39 (249A).
b. Providers responsible for the payroll of members shall have policies that ensure compliance with state and federal labor laws and regulations, which include, but are not limited to:
(1) Subminimum wage laws and regulations, including the Workforce Investment Opportunity Act.
(2) Member vacation, sick leave and holiday compensation.
(3) Procedures for payment schedules and pay scale.
(4) Procedures for provision of workers' compensation insurance.
(5) Procedures for the determination and review of commensurate wages.
c. Direct support staff providing prevocational services shall meet the following minimum qualifications in addition to other requirements outlined in administrative rule:
(1) A person providing direct support without line-of-sight supervision shall be at least 18 years of age and possess a high school diploma or equivalent degree. A person providing direct support with line-of-sight supervision shall be 16 years of age or older.
(2) A person providing direct support shall not be an immediate family member of the member.
(3) A person providing direct support shall, within 6 months of hire or within 6 months of May 4, 2016, complete at least 9.5 hours of employment service training as offered through DirectCourse or through the Association of Community Rehabilitation Educators (ACRE) certified training program.
(4) Prevocational direct support staff shall complete 4 hours of continuing education in employment services annually.
(10) Supported employment habilitation.
a. The following agencies may provide supported employment services:
(1) An agency that is certified by the department to provide supported employment services under:
1. The home- and community-based services intellectual disability waiver pursuant to rule 441-77.37 (249A); or
2. The home- and community-based services brain injury waiver pursuant to rule 441-77.39 (249A).
(2) An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as an organizational employment service provider or a community employment service provider.
(3) An agency that is accredited by the Council on Accreditation.
(4) An agency that is accredited by the Joint Commission.
(5) An agency that is accredited by the Council on Quality and Leadership.
(6) An agency that is accredited by the International Center for Clubhouse Development.
b. Providers responsible for the payroll of members shall have policies that ensure compliance with state and federal labor laws and regulations, which include, but are not limited to:
(1) Subminimum wage laws and regulations, including the Workforce Investment Opportunity Act.
(2) Member vacation, sick leave and holiday compensation.
(3) Procedures for payment schedules and pay scale.
(4) Procedures for provision of workers' compensation insurance.
(5) Procedures for the determination and review of commensurate wages.
c. Direct support staff providing individual or small-group supported employment or long-term job coaching services shall meet the following minimum qualifications in addition to other requirements outlined in administrative rule:
(1) Individual supported employment: bachelor's degree or commensurate experience, preferably in human services, sociology, psychology, education, human resources, marketing, sales or business. The person must also hold nationally recognized certification (ACRE or College of Employment Services (CES) or similar) as an employment specialist or must earn this credential within 24 months of hire.
(2) Long-term job coaching: associate degree, or high school diploma or equivalent and 6 months' relevant experience. A person providing direct support shall, within 6 months of hire or within 6 months of May 4, 2016, complete at least 9.5 hours of employment services training as offered through DirectCourse or through the ACRE certified training program. The person must also hold or obtain, within 24 months of hire, nationally recognized certification in job training and coaching.
(3) Small-group supported employment: associate degree, or high school diploma or equivalent and 6 months' relevant experience. A person providing direct support shall, within 6 months of hire or within 6 months of May 4, 2016, complete at least 9.5 hours of employment services training as offered through DirectCourse or through the ACRE certified training program. The person must also hold or obtain, within 24 months of hire, nationally recognized certification in job training and coaching.
(4) Supported employment direct support staff shall complete 4 hours of continuing education in employment services annually.
d. Providers qualified to offer IPS services shall meet the following requirements:
(1) Providers shall meet the provider qualifications listed in this subrule.
(2) Providers shall be accredited to provide supported employment and have provided supported employment for a minimum of two years.
(3) Providers shall demonstrate adequate funding has been secured for the training and technical assistance required for IPS implementation. Adequate funding is defined as at least the amount required for the start-up of one IPS team to complete all phases of IPS implementation. Evidence of such funding shall be made available to the department at the time of enrollment. Evidence may include a written funding agreement or other documentation from the funder.
(4) Providers shall receive training and technical assistance throughout IPS implementation from an IPS trainer. Evidence of the IPS team's agreement for such training and technical assistance shall be made available to the department at the time of enrollment.
(5) Prospective IPS teams shall complete IPS implementation as defined in subrule 77.25(1) and as outlined by the IPS Employment Center at Westat.
(6) Prospective IPS teams are provisionally approved until the IPS team has obtained at least a "fair" score on a baseline fidelity review completed by IPS reviewers.
(7) Provisionally approved IPS teams shall complete IPS implementation phases 1 through 4a within 12 months of enrolling.
(8) Upon completion of IPS implementation phase 4a, provisionally approved IPS teams shall deliver IPS services according to the IPS outcomes model.
(9) Upon completion of IPS implementation phase 7, IPS teams are qualified to deliver IPS services, subject to the following:
1. IPS teams must obtain a baseline fidelity review score of "fair" or better within 14 months of completion of IPS implementation phase 1. The fidelity review must be completed by IPS reviewers. The fidelity reviews shall be provided to the department upon receipt by the IPS team.
2. In the event an IPS team fails to achieve a fidelity score of "fair" or better, the IPS team shall receive technical assistance to address areas recommended for improvement as identified in the fidelity review. If the subsequent fidelity review results in a score of less than "fair" fidelity, the IPS team will be provisionally approved for no more than 12 months or until the fidelity score again reaches "fair" fidelity, whichever date is earliest.
3. IPS teams who do not achieve a "fair" fidelity score within 12 months from being provisionally approved will no longer be qualified to deliver IPS services until they again reach the minimum "fair" fidelity score.

This rule is intended to implement Iowa Code section 249A.4.

Notes

Iowa Admin. Code r. 441-77.25
ARC 7936B, IAB 7/1/09, effective 9/1/09; ARC 9314B, IAB 12/29/10, effective 3/1/11; ARC 0848C, IAB 7/24/2013, effective 7/1/2013; ARC 1051C, IAB 10/2/2013, effective 11/6/2013 Amended by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016 Amended by IAB March 30, 2016/Volume XXXVIII, Number 20, effective 5/4/2016 Amended by IAB July 5, 2017/Volume XL, Number 01, effective 8/9/2017 Amended by IAB July 4, 2018/Volume XLI, Number 1, effective 8/8/2018 Amended by IAB December 2, 2020/Volume XLIII, Number 12, effective 2/1/2021 Amended by IAB July 28, 2021/Volume XLIV, Number 2, effective 9/1/2021 Amended by IAB September 8, 2021/Volume XLIV, Number 5, effective 11/1/2021

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