"Abuse" means any of the following which
occurs as a result of the willful or negligent acts or omissions of a nursing
1. Physical injury
to, or injury which is at a variance with the history given of the injury, or
unreasonable confinement or unreasonable punishment or assault as defined in
Iowa Code section 708.1 of a resident.
2. The commission of a sexual offense under
Iowa Code chapter 709 or Iowa Code section
728.12, subsection 1, or sexual
exploitation under Iowa Code chapter 235B, as a result of the acts or omissions
of the facility employee responsible for the care of the resident with or
against a resident.
of a resident which means the act or process of taking unfair advantage of a
resident or the resident's physical or financial resources for one's own
personal or pecuniary profit without the informed consent of the resident,
including theft, by the use of undue influence, harassment, duress, deception,
false representation or false pretenses.
4. The deprivation of the minimum food,
shelter, clothing, supervision, physical or mental health care, or other care
necessary to maintain a resident's life or health.
"Advance directive" means a written
instruction, such as a living will or durable power of attorney for health
care, recognized under state law and related to the provision of health care
when the resident is incapacitated.
"Allowable costs" means the price a prudent,
cost-conscious buyer would pay a willing seller for goods or services in an
arm's-length transaction, not to exceed the limitations set out in
"Beginning eligibility date" means date of
an individual's admission to the facility or date of eligibility for medical
assistance, whichever is the later date.
"Case mix" means a measure of the intensity
of care and services used by similar residents in a facility.
"Case-mix index" means a numeric score
within a specific range that identifies the relative resources used by similar
residents and represents the average resource consumption across a population
"Civil penalty" shall mean a civil money
penalty not to exceed the amount authorized under Iowa Code section
135C.36 for health care facility
"Clinical experience" means application or
learned skills for direct resident care in a nursing facility.
"Clock hour" means 60 minutes.
"Complete replacement" means completed
construction on a new nursing facility to replace an existing licensed and
certified nursing facility. The replacement facility shall have no more
licensed beds than the facility being replaced and shall be located either in
the same county as the facility being replaced or within 30 miles from the
facility being replaced.
"Cost normalization" refers to the process
of removing cost variations associated with different levels of resident case
mix. Normalized cost is determined by dividing a facility's per diem direct
care component costs by the facility cost report period case-mix index.
"Denial of critical care" is a pattern of
care in which the resident's basic needs are denied or ignored to such an
extent that there is imminent or potential danger of the resident suffering
injury or death, or is a denial of, or a failure to provide the mental health
care necessary to adequately treat the resident's serious social maladjustment,
or is a gross failure of the facility employee to meet the emotional needs of
the resident necessary for normal functioning, or is a failure of the facility
employee to provide for the proper supervision of the resident.
"Department" means the Iowa department of
"Direct care component" means the portion of
the Medicaid reimbursement rates that is attributable to the salaries and
benefits of registered nurses, licensed practical nurses, certified nursing
assistants, rehabilitation nurses, and contracted nursing services. "Direct
care component" also includes costs related to therapy services provided to
residents during inpatient stays and not billed as an outpatient
"Discharged resident" means a resident whose
accounts and records have been closed out and whose personal effects have been
taken from the facility. When a resident is discharged, the facility shall
notify the department via Form 470-0042, Case Activity Report.
"Facility" means a licensed nursing facility
certified in accordance with the provisions of
483.5 as amended to December 4, 2017, to
provide health services and includes hospital-based nursing facilities that are
Medicare-certified and provide only skilled level of care and swing-bed
hospitals unless stated otherwise.
"Facility-based nurse aide training program"
means a nurse aide training program that is offered by a nursing facility and
taught by facility employees or under the control of the licensee.
"Facility cost report period case-mix index"
is the average of quarterly facility wide average case-mix indices, carried to
four decimal places. The quarters used in this average will be the quarters
that most closely coincide with the financial and statistical reporting period.
For example, a 01/01/2000-12/31/2000 financial and statistical reporting period
would use the facility wide average case-mix indices for quarters ending
03/31/00, 06/30/00, 09/30/00 and 12/31/00.
"Facility wide average case-mix index" is
the simple average, carried to four decimal places, of all resident case-mix
indices based on the last day of each calendar quarter.
"Informed consent" means a resident's
agreement to allow something to happen that is based on a full disclosure of
known facts and circumstances needed to make the decision intelligently, i.e.,
with knowledge of the risks involved or alternatives.
"Iowa Medicaid enterprise" means the entity
comprised of department staff and contractors responsible for the management
and reimbursement of Medicaid services.
"Laboratory experience" means practicing
care-giving skills prior to contact in the clinical setting.
"Level I review" means screening to identify
persons suspected of having mental illness or intellectual disability as
defined in 42 CFR
483.102 as amended to July 1, 2014.
"Level II review" means the evaluation of a
person identified in a Level I review to determine whether nursing facility
services and specialized services are needed.
"Major renovations" means new construction
or facility improvements to an existing licensed and certified nursing facility
in which the total depreciable asset value of the new construction or facility
improvements exceeds $750,000. The $750,000 threshold shall be calculated based
on the total depreciable asset value of new construction or facility
improvements placed into service during a two-year period ending on the date
the last asset was placed into service. When the property costs of an asset
have been included in a facility's financial and statistical report that has
already been used in a biennial rebasing, the costs of that asset shall not be
considered in determining whether the facility meets the $750,000
"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
"Medicaid average case-mix index" is the
simple average, carried to four decimal places, of all resident case-mix
indices where Medicaid is known to be the per diem payor source on the last day
of the calendar quarter.
"Minimum data set" or "MDS"
refers to a federally required resident assessment tool. Information from the
MDS is used by the department to determine the facility's case-mix index for
purposes of normalizing per diem allowable direct care costs as provided by
paragraph 81.6(16)"b," for determining the Medicaid average
case-mix index to adjust the direct care component pursuant to paragraphs
81.6(16)"c" and "e," the excess payment
allowance pursuant to paragraph 81.6(16)"d," and the limits on
reimbursement components pursuant to paragraph 81.6(16)"f."
MDS is described in subrule 81.13(9).
"Minimum food, shelter, clothing, supervision,
physical or mental health care, or other care" means that food,
shelter, clothing, supervision, physical or mental health care, or other care
which, if not provided, would constitute denial of critical care.
"Mistreatment" means any intentional act, or
threat of an act, coupled with the apparent ability to execute the act, which
causes or puts another person in fear of mental anguish, humiliation,
deprivation or physical contact which is or will be painful, insulting or
offensive. Actions utilized in providing necessary treatment or care in
accordance with accepted standards of practice are not considered
"New construction" means the construction of
a new nursing facility that does not replace an existing licensed and certified
facility and that requires the provider to obtain a certificate of need
pursuant to Iowa Code chapter 135, division VI.
"Non-direct care component" means the
portion of Medicaid reimbursement rates attributable to administrative,
environmental, property, and support care costs reported on the financial and
"Non-facility-based nurse aide training
program" means a nurse aide training program that is offered by an
organization that is not licensed to provide nursing facility services.
"Non-state government owned nursing
facility" or "NSGO nursing facility" is a nursing
facility owned by a governmental entity that is not the state.
"Nurse aide" means any individual who is not
a licensed health professional or volunteer providing nursing or
nursing-related services to residents in a nursing facility.
"Nurse aide registry" means Nurse Aide
Registry, Department of Inspections and Appeals, Third Floor, Lucas State
Office Building, Des Moines, Iowa 50319.
"Nurse aide training and competency evaluation
programs (NATCEP)" are educational programs approved by the department
of inspections and appeals for nurse aide training as designated in subrule
"Nursing facility level of care" means that
the following conditions are met:
The presence of a physical or mental impairment which restricts the member's
daily ability to perform the essential activities of daily living, bathing,
dressing, and personal hygiene, and impedes the member's capacity to live
2. The member's
physical or mental impairment is such that self-execution of required nursing
care is improbable or impossible.
"PASRR" means a Level I screening or a Level
II evaluation for mental illness or intellectual disability for all persons who
live in or seek entry to a Medicaid-certified nursing facility, as required by
42 CFR Part 483 , Subpart C, as amended to July 1, 2014.
"Patient-day-weighted median cost" means the
per diem cost of the nursing facility that is at the median per diem cost of
all nursing facilities based on patient days provided when per diem allowable
costs are ranked from low to high. A separate patient-day-weighted median cost
amount shall be determined for the direct care and non-direct care
"Physical abuse" means any nonaccidental
physical injury, or injury which is at variance with the history given of it,
suffered by a resident as the result of the acts or omissions of a person
responsible for the care of the resident.
"Physical injury" means damage to any bodily
tissue to the extent that the tissue must undergo a healing process in order to
be restored to a sound and healthy condition, or damage to any bodily tissue to
the extent that the tissue cannot be restored to a sound and healthy condition,
or damage to any bodily tissue which results in the death of the person who has
sustained the damage.
"Poor performing facility (PPF)" is a
facility designated by the department of inspections and appeals as a poor
performing facility (PPF) based on surveys conducted by the department of
inspections and appeals pursuant to subrule 81.13(1). A facility shall be
designated a PPF if it has been cited for substandard quality of care on the
current standard survey and it:
been cited for substandard quality of care or immediate jeopardy on at least
one of the previous two standard surveys;
2. Has a history of substantiated complaints
during the last two years;
3. Has a
current deficiency for not having a quality assurance program; or
4. Does not have an effective quality
assurance program as defined in paragraph
"Primary instructor" means a registered
nurse responsible for teaching a state-approved nurse aide training
"Program coordinator" means a registered
nurse responsible for administrative aspects of a state-approved nurse aide
"Rate determination letter" means the letter
that is distributed quarterly by the Iowa Medicaid enterprise to each nursing
facility notifying the facility of the facility's Medicaid reimbursement rate
calculated in accordance with this rule and of the effective date of the
"Skilled nursing facility level of care"
means that the following conditions are met:
The member's medical condition requires
skilled nursing services or skilled rehabilitation services as defined in
Services are provided in accordance with
the general provisions for all Medicaid providers and services as described in
Documentation submitted for review
indicates that the member has:
a. A physician
order for all skilled services.
Services that require the skills of medical personnel, including registered
nurses, licensed practical nurses, physical therapists, occupational
therapists, speech pathologists, or audiologists.
c. An individualized care plan that
identifies support needs.
Confirmation that skilled services are provided to the member.
e. Skilled services that are provided by, or
under the supervision of, medical personnel as described above.
f. Skilled nursing services that are needed
and provided seven days a week or skilled rehabilitation services that are
needed and provided at least five days a week.
"Skills performance record" means a record
of major duties and skills taught which consists of, at a minimum:
1. A listing of the duties and skills
expected to be learned in the program.
2. Space to record the date when the aide
performs the duty or skill.
Space to note satisfactory or unsatisfactory performance.
4. The signature of the instructor
supervising the performance.
"Special population nursing facility" refers
to a nursing facility that serves the following populations:
1. One hundred percent of the residents
served are aged 30 and under and require the skilled level of care.
2. Seventy percent of the residents served
require the skilled level of care for neurological disorders.
3. One hundred percent of the residents
require care from a facility licensed by the department of inspections and
appeals as an intermediate care facility for persons with mental
4. One hundred percent of
the residents require care from a facility licensed by the department of
inspections and appeals as an intermediate care facility for persons with
"Surgical or other invasive procedure" means
an operative procedure in which skin or mucous membranes and connective tissue
are incised or an instrument is introduced through a natural body orifice.
Surgical or other invasive procedures include a range of procedures from
minimally invasive dermatological procedures (biopsy, excision, and deep
cryotherapy for malignant lesions) to extensive multiorgan transplantation.
Surgical or other invasive procedures include all procedures described by the
codes in the surgery section of the Current Procedural Terminology (CPT)
published by the American Medical Association and other invasive procedures
such as percutaneous transluminal angioplasty and cardiac catheterization.
Surgical or other invasive procedures include minimally invasive procedures
involving biopsies or placement of probes or catheters requiring the entry into
a body cavity through a needle or trocar. "Surgical or other invasive
procedure" does not include use of instruments such as otoscopes for
examinations or very minor procedures such as drawing blood.
"Terminated from the Medicare or Medicaid
program" means a facility has lost the final appeal to which it is
"Testing entity" means a person, agency,
institution, or facility approved by the department of inspections and appeals
to take responsibility for obtaining, keeping secure and administering the
competency test and reporting nurse aide scores to the nurse aide
This rule is intended to implement Iowa Code sections
"a," and 249A.4.