Iowa Admin. Code r. 441-81.13 - [Effective 7/1/2025] Nurse aide requirements and training and testing programs
(1)
Deemed
meeting of requirements. A nurse aide is deemed to satisfy the
requirement of completing a nurse aide training and competency evaluation
approved by the department of inspections, appeals, and licensing if:
a. The nurse aide successfully completed a
nurse aide training and competency evaluation program before July 1, 1989, and
(1) At least 60 clock hours were substituted
for 75 clock hours, and the person has made up at least the difference in the
number of clock hours in the program the person completed and 75 clock hours in
supervised practical nurse aide training or in regular in-service nurse aide
education, or
(2) The person was
found to be competent (whether or not by the state) after completion of a nurse
aide training of at least 100 clock hours' duration, or
(3) The person can demonstrate that the
person served as a nurse aide at one or more facilities of the same employer in
Iowa for at least 24 consecutive months before December 19, 1989, or
(4) The person completed, before July 1,
1989, a nurse aide training and competency evaluation program that the
department of inspections, appeals, and licensing determines would have met the
requirements for approval at the time it was offered; or
b. The person is a veteran, an active duty
service member, or a member of the reserve forces, who has:
(1) Successfully completed a U.S. military
training program that includes a curriculum comparable to the nurse aide
training program required by this rule and has documented successful completion
of that program with either a diploma, certifications, or Form DD 214 showing
completion of hospital corpsman or medical service specialist or equivalent
training, and
(2) Provided
documentation showing that the person has 75 clock hours of practical
experience in a nurse aide role, which may include classroom instruction, prior
equivalent experience, or a combination of the two, and
(3) Successfully completed the nurse aide
training and competency examination.
(2)
State review and approval of
nurse aide training and competency evaluation programs or competency evaluation
programs.
a. The department of
inspections, appeals, and licensing will, in the course of all surveys,
determine whether the nurse aide training and evaluation requirements of
paragraph 81.11(19)"e" and subrule 81.14(1) are met.
b. Requirements for approval of programs.
(1) Before the department of inspections,
appeals, and licensing approves a nurse aide training and competency evaluation
program or competency evaluation program, the department of inspections,
appeals, and licensing will determine whether:
1. A nurse aide training and competency
evaluation program meets the course requirements of 81.14(3).
2. A nurse aide competency evaluation program
meets the requirements of 81.14(4).
(2) Except as provided by paragraph
81.14(2)"f," the department of inspections, appeals, and
licensing will not approve a nurse aide training and competency evaluation
program or competency evaluation program offered by or in a facility that, in
the previous two years:
1. Has operated under
a nurse staffing waiver for a period in excess of 48 hours per week;
or
2. Has been subject to an
extended or partial extended survey; or
3. Has been assessed a civil money penalty of
not less than $5,000; or
4. Has
operated under temporary management appointed to oversee the operation of the
facility and to ensure the health and safety of the facility's residents;
or
5. Pursuant to state action, was
closed or had its residents transferred; or
6. Has been terminated from participation in
the Medicaid or Medicare program; or
7. Has been denied payment.
c. Application process.
Applications shall be submitted to the department of inspections, appeals, and
licensing before a new program begins and every two years thereafter on a form
prescribed by the department. The department of inspections, appeals, and
licensing will, within 90 days of the date of a request or receipt of
additional information from the requester:
(1)
Advise the requester whether or not the program has been approved; or
(2) Request additional information from the
requesting entity.
d.
Duration of approval. The department of inspections, appeals, and licensing
will not grant approval of a nurse aide training and competency evaluation
program for a period longer than two years. A program shall notify the
department of inspections, appeals, and licensing and the department of
inspections, appeals, and licensing will review that program when there are
substantive changes made to that program within the two-year period.
e. Withdrawal of approval. The department of
inspection, appeals, and licensing will follow the provision of
42 CFR
483.151(e) (as amended to
August 1, 2024) regarding withdrawals of approvals.
f. An exception to subparagraph
81.14(2)"b"(2) may be granted by the department of
inspections, appeals, and licensing for 75-hour nurse aide training courses
offered in (but not by) a facility under the following conditions:
(1) The facility has submitted a Nurse Aide
Education Program Waiver Request, to the department of inspections, appeals,
and licensing to request a waiver for each 75-hour nurse aide training course
to be offered in (but not by) the facility.
(2) The 75-hour nurse aide training is
offered in a facility by an approved NATCEP.
(3) No other NATCEP is offered within ten
minutes' travel from the facility, unless the facility can demonstrate the
distance or program would create a hardship for program participants.
(4) The facility is in substantial compliance
with the federal requirements related to nursing care and services.
(5) The facility is not a poor performing
facility.
(6) Employees of the
facility do not function as instructors for the program unless specifically
approved by the department of inspections, appeals, and licensing.
(7) The NATCEP sponsoring the 75-hour nursing
aide training course is responsible for program administration and for ensuring
that program requirements are met.
(8) The NATCEP has submitted an evaluation to
the department of inspections, appeals, and licensing indicating that an
adequate teaching and learning environment exists for conducting the
course.
(9) The NATCEP has
developed policies for communicating and resolving problems encountered during
the course, including notice by the facility to the program instructor and
students on how to contact the department of inspections, appeals, and
licensing to register any concerns encountered during the course.
(10) The NATCEP shall require the program
instructor and students to complete an evaluation of the course. The instructor
shall return the completed evaluations to the NATCEP that shall return the
evaluations to department of inspections, appeals, and licensing.
(3)
Requirements for approval of a nurse aide training and competency
evaluation program. The department has designated the department of
inspections, appeals, and licensing to approve required nurse aide training and
competency evaluation programs. Policies and procedures governing approval of
the programs are set forth in
42 CFR
483.152 (as amended to August 1, 2024).
a. If a person who is not employed, or does
not have an offer to be employed, as a nurse aide becomes employed by, or
receives an offer of employment from, a facility no later than 12 months after
completing a nurse aide training and competency evaluation program or
competency evaluation program, the facility shall reimburse the nurse aide for
costs incurred in completing the program or competency evaluation on a pro rata
basis during the period in which the person is employed as a nurse aide. The
formula for paying the nurse aides on a pro rata basis shall be as follows:
(1) Add all costs incurred by the nurse aide
for the course, books, and competency evaluations.
(2) Divide the total arrived at in
subparagraph (1) above by 12 to prorate the costs over a one-year period and
establish a monthly rate.
(3) The
nurse aide shall be reimbursed the monthly rate each month the nurse aide works
at the facility until one year from the time the nurse aide completed the
course.
b. Setting and
equipment. The classroom shall have appropriate equipment, be of adequate size,
and not interfere with resident activities.
c. Records and reports. Nurse aide education
programs approved by the department of inspections, appeals, and licensing
shall:
(1) Notify the department of
inspections, appeals, and licensing:
1. Of
dates of classroom and clinical sessions as well as location of classrooms and
clinical practice sites before each course begins and if the course is
canceled.
2. When a facility or
other training entity will no longer be offering nurse aide training
courses.
3. Whenever the person
coordinating the training program is hired or terminates employment.
(2) Keep a list of faculty members
and their qualifications available for department review.
(3) Provide each nurse aide a record of
skills for which the nurse aide has been found competent during the course and
which may be performed before completion of the competency
evaluation.
(4) Complete a lesson
plan for each unit that includes behavioral objectives, a topic outline and
student activities and experiences.
(5) Provide the student, within 30 days of
the last class period, evidence of having successfully completed the
course.
(4)
Nurse aide competency evaluation. Nurse aid competency
evaluation program shall be administered in accordance with
42 CFR
483.154 (as amended to August 1, 2024).
a. Successful completion of the competency
evaluation program.
(1) A score of 70 percent
or above is passing for both the written or oral and skills demonstration parts
of the test.
(2) A record of
successful completion of the competency evaluation shall be included in the
nurse aide registry within 30 days of the date the person is found to be
competent.
(3) The competency
testing entity shall inform the nurse aide of the test score within 30 calendar
days of the completion of the test and shall inform the nurse aide registry of
the nurse aide's scores within 20 calendar days after the test is
administered.
b.
Unsuccessful completion of the competency evaluation program.
(1) If the person does not complete the
evaluation satisfactorily, the person shall be advised in writing within ten
working days after the test is scored:
1. Of
the areas that the person did not pass.
2. That the person has three opportunities to
take the evaluation.
(2)
Each person shall have three opportunities to pass each part of the test. If
one part of the test is failed, only that part need be taken a second or third
time. If either part of the test is failed three times, the 75-hour course
shall be taken or retaken before the test can be taken again.
c. Storage of evaluation
instrument. The person responsible for administering a competency evaluation
shall provide secure storage of the evaluation instruments when they are not
being administered or processed.
d.
Application process. Entities wishing to secure approval for a competency
evaluation program shall submit a copy of the evaluation plan and procedures to
the department of inspections, appeals, and licensing. The department of
inspections, appeals, and licensing shall notify the applicant of its decision
within 90 days of receipt of the application. The notification shall include
the reason for not giving approval if approval is denied and the applicable
rule citation.
(5)
Registry of nurse aides.
a.
Establishment of registry. The department of inspections, appeals, and
licensing shall establish and maintain a registry of nurse aides in accordance
with 42 CFR
483.156 (as amended to August 1, 2024). In
addition, the registry shall contain a record of known convictions by a court
of law of a person convicted of abuse, neglect, mistreatment, or
misappropriation of resident property.
b. Placement of names on nurse aide registry.
The facility shall ensure that the name of each person employed as a nurse aide
in a Medicare- or Medicaid-certified nursing facility in Iowa is submitted to
the registry.
(1) Persons employed as nurse
aides shall complete the Nurse Aide Registry Application within the first 30
days of employment. This form shall be submitted to the department of
inspections, appeals, and licensing. The application may be obtained by
telephone or by electronic request from the nurse aide registry.
(2) A nurse aide who is not employed may
apply for inclusion on the registry by submitting a copy of completed
application to the nurse aide registry.
(3) When the registry has received a signed
application and entered the required training and testing information on the
registry, an electronic notification will be sent to the nurse aide that
includes the registry ID number for the nurse aide to use when accessing the
online registry. A nurse aide may obtain a copy of the information on the
registry by accessing the information on the registry database.
(6)
Hearing. When there is an allegation of abuse against a nurse
aide, the department of inspections, appeals, and licensing will investigate
that allegation. When the investigation makes a finding of an act of abuse, the
nurse aide named will be notified of this finding and the right to a hearing.
The nurse aide shall have 30 days to request a hearing. The request shall be in
writing and shall be sent to the department of inspections, appeals, and
licensing. The hearing shall be held pursuant to 481-Chapter 10. After 30 days,
if the nurse aide fails to appeal, or when all appeals are exhausted, the nurse
aide registry will include a notation that the nurse aide has a founded abuse
report on record if the final decision indicates the nurse aide performed an
abusive act.
(7)
Appeals. Adverse decisions made by the department of
inspections, appeals, and licensing in administering these rules may be
appealed pursuant to 481-Chapter 10.
This rule is intended to implement Iowa Code section 249A.4.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
All nursing facilities shall enter into a contractual agreement with the
(1) Procedures for establishing health care facilities as Medicaid facilities. All survey procedures and certification process shall be in accordance with Department of Health and Human Services publication "State Operations Manual."
a. The facility shall obtain the applicable license from the department of inspections and appeals and must be recommended for certification by the department of inspections and appeals.
b. The facility shall request an application, Form 470-0254, Iowa Medicaid Provider Enrollment Application, from the Iowa Medicaid enterprise provider services unit.
c. The Iowa Medicaid enterprise provider services unit shall transmit an application form and a copy of the nursing facility provider manual to the facility .
d. The facility shall complete its portion of the application form and submit it to the Iowa Medicaid enterprise provider services unit.
e. The Iowa Medicaid enterprise provider services unit shall review the application form and verify with the department of inspections and appeals that the facility is licensed and has been recommended for certification.
f. Prior to requesting enrollment, the facility shall contact the department of inspections and appeals to schedule a survey. The department of inspections and appeals shall schedule and complete a survey of the facility .
g. The department of inspections and appeals shall notify the facility of any deficiencies and ask for a plan for the correction of the deficiencies.
h. The facility shall submit a plan of correction within ten days after receipt of written deficiencies from the health facilities division department of inspections and appeals. This plan must be approved before the facility can be certified.
i. The department of inspections and appeals shall evaluate the survey findings and plan of correction and either recommend the facility for certification or recommend denial of certification. The date of certification will be the date of approval of the plan of corrections.
j. When certification is recommended, the department of inspections and appeals shall notify the department recommending a provider agreement.
(2) Medicaid provider agreements. The health care facility shall be recommended for certification by the department of inspections and appeals for participation as a nursing facility before a provider agreement may be issued. All survey procedures and certification process shall be in accordance with Department of Health and Human Services publication "Providers Certification State Operations Manual." The effective date of a provider agreement may not be earlier than the date of certification.
a. to d. Reserved.
e. When it becomes necessary for the department to cancel or refuse to renew a Title XIX provider agreement, federal financial participation may continue for 30 days beyond the date of cancellation, if the extension is necessary to ensure the orderly transfer of residents.
(3) Distinct part requirement. All facilities which provide nursing facility care and also provide other types of care shall set aside a distinct or identifiable part for the provision of the nursing facility care.
a. The distinct part shall meet the following conditions:
(1) The distinct part shall meet all requirements for a nursing facility .
(2) The distinct part shall be identifiable as a unit such as a designated group of rooms, an entire ward or contiguous wards, wings, floor, or building. It shall consist of all beds and related facilities in the unit for whom payment is being made for nursing facility services. It shall be clearly identified and licensed by the department of inspections and appeals.
(3) The appropriate personnel shall be assigned to the identifiable unit and shall work regularly therein. Immediate supervision of staff shall be provided in the unit at all times by qualified personnel as required for licensure.
(4) The distinct part may share such central services and facilities as management services, dietary services, building maintenance and laundry with other units.
(5) When members of the staff share time between units of the facility , written records shall be maintained of the time assigned to each unit.
b. Hospitals participating as nursing facilities shall meet all of the same conditions applicable to freestanding nursing facilities.
c. Nothing herein shall be construed as requiring transfer of a resident within or between facilities when in the opinion of the attending physician the transfer might be harmful to the physical or mental health of the resident. The opinion of the physician shall be recorded on the resident's medical chart and stands as a continuing order unless the circumstances requiring the exception change.
(4) Civil rights. The nursing facility shall comply with Title VI of the Civil Rights Act of 1964 in all areas of administration including admissions, records, services and physical facilities, room assignments and transfers, attending physicians' privileges and referrals. Written statements of compliance shall be available to residents, employees, attending physicians and other members of the public.
(5) Resident rights. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility . A facility shall protect and promote the rights of each resident, including each of the following rights:
a. Exercise of rights.
(1) The resident has the right to exercise rights as a resident of the facility and as a citizen of the United States.
(2) The resident has the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights.
(3) In the case of a resident adjudged incompetent under the laws ofa state, by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under state law to act on the resident's behalf.
(4) In the case of a resident who has not been adjudged incompetent by the state court, any legal-surrogate designated in accordance with state law may exercise the resident's rights to the extent provided by state law.
b. Notice of rights and services.
(1) The facility shall inform the resident, both orally and in writing in a language that the resident understands, of the resident's rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . The facility shall also provide the resident with the pamphlet "Medicaid for People in Nursing Homes and Other Care Facilities," Comm. 52. This notification shall be made prior to or upon admission and during the resident's stay. Receipt of this information, and any amendments to it, must be acknowledged in writing.
(2) The resident or the resident's legal representative has the right, upon an oral or written request, to access all records pertaining to the resident including clinical records within 24 hours (excluding weekends and holidays); and after receipt of the records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and two working days' advance notice to the facility .
(3) The resident has the right to be fully informed in language that the resident can understand of the resident's total health status, including, but not limited to, medical condition.
(4) The resident has the right to refuse treatment and to refuse to participate in experimental research.
(5) The facility shall:
1. Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or when the resident becomes eligible for Medicaid, of the items and services that are included in nursing facility services under the state plan and for which the resident may not be charged and of those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services.
2. Inform each resident when changes are made to the items and services specified in number "1" of this subparagraph.
(6) The facility shall inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility 's per diem rate.
(7) The facility shall furnish a written description of legal rights which includes:
1. A description of the manner of protecting personal funds.
2. A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment which determines the extent of a couple's nonexempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in the resident's process of spending down to Medicaid eligibility levels.
3. A posting of names, addresses, and telephone numbers of all pertinent state client advocacy groups such as the state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit.
4. A statement that the resident may file a complaint with the state survey and certification agency concerning resident abuse , neglect and misappropriation of resident property in the facility .
(8) The facility shall inform each resident of the name, specialty and way of contacting the physician responsible for the resident's care.
(9) The facility shall prominently display in the facility written information and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by these benefits.
(10) Notification of changes.
1. A facility shall immediately inform the resident, consult with the resident's physician, and, if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility .
2. The facility shall also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment or a change in resident rights under federal or state law or regulations.
3. The facility shall record and periodically update the address and telephone number of the resident's legal representative or interested family member.
c. Protection of resident funds.
(1) The resident has the right to manage the resident's financial affairs and the facility may not require residents to deposit their personal funds with the facility .
(2) Management of personal funds. Upon written authorization of a resident, the facility shall hold, safeguard, manage and account for the personal funds of the resident deposited with the facility , as specified in subparagraphs (3) to (8) of this paragraph.
(3) Deposit of funds. The facility shall deposit any residents' personal funds in excess of $50 in an interest-bearing account that is separate from any of the facility 's operating accounts, and that credits all interest earned on the resident's funds to that account. In pooled accounts, there must be a separate accounting for each resident's share.
The
(4) Accounting and records. The facility shall establish and maintain a system that ensures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
1. The system shall preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
2. The individual financial record shall be available through quarterly statements and on request to the resident or the resident's legal representative.
(5) Notice of certain balances. The facility shall notify each resident that receives Medicaid benefits:
1. When the amount in the resident's account reaches $200 less than the SSI resource limit for one person.
2. That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.
(6) Conveyance upon death. Upon the death of a resident with a personal fund deposited with the facility , the facility shall convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate.
(7) Assurance of financial security. The facility shall purchase a surety bond, or otherwise provide assurance satisfactory to the department of inspections and appeals and the department of human services, to ensure the security of all personal funds of residents deposited with the facility .
(8) Limitation on charges to personal funds. The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare.
d. Free choice. The resident has the right to:
(1) Choose a personal attending physician.
(2) Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being.
(3) Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.
e. Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of personal and clinical records.
(1) Personal privacy includes accommodations, medical treatment, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.
(2) The facility must respect the resident's right to personal privacy, including the right to privacy in the resident's oral (that is, spoken or sign language), written, and electronic communications.
(3) Except as provided in subparagraph (4) below, the resident may approve or refuse the release of personal and clinical records to any person outside the facility .
(4) The resident's right to refuse release of personal and clinical records does not apply to the following:
1. The release of personal and clinical records to a health care institution to which the resident is transferred; or
2. A record release that is required by law.
f. Grievances. A resident has the right to:
(1) Voice grievances without discrimination or reprisal for voicing the grievances. The grievances include those with respect to treatment which has been furnished as well as that which has not been furnished.
(2) Prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.
g. Examination of survey results. A resident has the right to:
(1) Examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility . The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability.
(2) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.
h. Work. The resident has the right to:
(1) Refuse to perform services for the facility .
(2) Perform services for the facility if the resident chooses, when:
1. The facility has documented the need or desire for work in the plan of care.
2. The plan specifies the nature of the services performed and whether the services are voluntary or paid.
3. Compensation for paid services is at or above prevailing rates.
4. The resident agrees to the work arrangement described in the plan of care.
i. Mail. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident, whether delivered by a postal service or by other means, including the right to:
(1) Privacy of such communications consistent with this section; and
(2) Access to stationary, postage, and writing implements at the resident's own expense.
j. Access and visitation rights.
(1) The resident has the right and the facility shall provide immediate access to any resident by the following:
1. Any representative of the secretary of the Department of Health and Human Services.
2. Any representative of the state.
3. The resident's individual physician.
4. The state long-term care ombudsman.
5. The agency responsible for the protection and advocacy system for developmentally disabled individuals.
6. The agency responsible for the protection and advocacy system for mentally ill individuals.
7. Immediate family or other relatives of the resident subject to the resident's right to deny or withdraw consent at any time.
8. Others who are visiting with the consent of the resident subject to reasonable restrictions and to the resident's right to deny or withdraw consent at any time.
(2) The facility shall provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.
(3) The facility shall allow representatives of the state ombudsman to examine a resident's clinical records with the permission of the resident or the resident's legal representative, and consistent with state law.
k. Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard.
l. Personal property. The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
m. Married couples. The resident has the right to share a room with the resident's spouse when married residents live in the same facility and both spouses consent to the arrangement.
n. Self-administration of drugs. An individual resident has the right to self-administer drugs if the interdisciplinary team has determined that this practice is safe.
o. Refusal of certain transfers.
(1) A person has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate a resident of a skilled nursing facility from the distinct part of the institution that is a skilled nursing facility to a part of the institution that is not a skilled nursing facility or, if a resident of a nursing facility , from the distinct part of the institution that is a nursing facility to a distinct part of the institution that is a skilled nursing facility .
(2) A resident's exercise of the right to refuse transfer under subparagraph (1) does not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits.
p. Advance directives.
(1) The nursing facility , at the time of admission, shall provide written information to each resident which explains the resident's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives and the nursing facility 's policies regarding the implementation of these rights.
(2) The nursing facility shall document in the resident's medical record whether or not the resident has executed an advance directive .
(3) The nursing facility shall not condition the provision of care or otherwise discriminate against a resident based on whether or not the resident has executed an advance directive .
(4) The nursing facility shall ensure compliance with requirements of state law regarding advance directives.
(5) The nursing facility shall provide for education for staff and the community on issues concerning advance directives.
Nothing in this paragraph shall be construed to prohibit the application of a state law which allows for an objection on the basis of conscience for any nursing
q. Electronic communication. The resident has the right to have reasonable access to and privacy in the resident's use of electronic communications, including, but not limited to, email and video communications, and for Internet research:
(1) If accessible to the facility ;
(2) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident; and
(3) To the extent that such use may comply with state and federal law.
(6) Admission, transfer and discharge rights.
a. Transfer and discharge.
(1) Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility .
(2) Transfer or discharge requirements. The facility shall permit each resident to remain in the facility , and not transfer or discharge the resident from the facility unless:
1. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .
2. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .
3. The safety of persons in the facility is endangered.
4. The health of persons in the facility would otherwise be endangered.
5. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility . For a resident who becomes eligible for Medicaid after admission to a facility , the facility may charge a resident only allowable charges under Medicaid.
6. The facility ceases to operate.
(3) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in subparagraph (2), numbers 1 through 5 above, the resident's clinical record shall be documented. The documentation shall be made by:
1. The resident's physician when transfer or discharge is necessary under subparagraph (2), number 1 or 2.
2. A physician when transfer or discharge is necessary under subparagraph (2), number 4.
(4) Notice before transfer. Before a facility transfers or discharges a resident, the facility shall:
1. Notify the resident, the resident's case manager for those residents enrolled with a managed care organization and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.
2. Record the reasons in the resident's clinical record.
3. Include in the notice the items in subparagraph (6) below.
(5) Timing of the notice. The notice of transfer or discharge shall be made by the facility at least 30 days before the resident is transferred or discharged except that notice shall be made as soon as practicable before transfer or discharge when:
1. The safety of persons in the facility would be endangered.
2. The health of persons in the facility would be endangered.
3. The resident's health improves sufficiently to allow a more immediate transfer or discharge.
4. An immediate transfer or discharge is required by the resident's urgent medical needs.
5. A resident has not resided in the facility for 30 days.
(6) Contents of the notice. The written notice shall including the following:
1. The reason for transfer or discharge.
2. The effective date of transfer or discharge.
3. The location to which the resident is transferred or discharged.
4. A statement that the resident has the right to appeal the action to the department .
5. The name, address, and telephone number of the state long-term care ombudsman.
6. The mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals for residents with developmental disabilities.
7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals for residents who are mentally ill.
(7) Orientation for transfer or discharge. A facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility .
b. Notice of bed-hold policy and readmission.
(1) Notice before transfer. Before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the facility shall provide written information to the resident and a family member or legal representative that specifies:
1. The duration of the bed-hold policy under the state plan during which the resident is permitted to return and resume residence in the facility .
2. The facility 's policies regarding bed-hold periods, which shall be consistent with subparagraph (3) below, permitting a resident to return.
(2) Notice upon transfer. At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility shall provide written notice to the resident and a family member or legal representative, which specifies the duration of the bed-hold policy described in subparagraph (1) above.
(3) Permitting resident to return to facility . A nursing facility shall establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the state plan, is readmitted to the facility immediately upon the first availability of a bed in a semiprivate room if the resident requires the services provided by the facility and is eligible for Medicaid nursing facility services.
c. Equal access to quality care.
(1) A facility shall establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the state plan for all persons regardless of source of payment.
(2) The facility may charge any amount for services furnished to non-Medicaid residents consistent with the notice requirement in 81.13(1)"a" (5).
(3) The state is not required to offer additional services on behalf of a resident other than services provided in the state plan.
d. Admissions policy.
(1) The facility shall not require residents or potential residents to:
1. Waive their rights to Medicare or Medicaid; or
2. Give oral or written assurance that they are not eligible for, or will not apply for, Medicare or Medicaid benefits. However, a continuing care retirement community or a life care community that is licensed, registered, certified, or the equivalent by the state, including a nursing facility that is part of such a community, may require in its contract for admission that before a resident applies for medical assistance, the resources that the resident declared for the purposes of admission must be spent on the resident's care, subject to 441-subrule 75.5(3), 441-paragraph 75.5(4)"a," and 441-subrule 75.16(2).
(2) The facility shall not require a third-party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility . However, the facility may require a person who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.
(3) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the state plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility . However:
1. A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the state plan as included in the term "nursing facility services" so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of these additional services.
2. A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid-eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid-eligible resident.
(4) States or political subdivisions may apply stricter admission standards under state or local laws than are specified in these rules, to prohibit discrimination against persons entitled to Medicaid.
(7) Resident behavior and facility practices.
a. Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms.
b. Abuse . The resident has the right to be free from verbal, sexual, physical, or mental abuse , corporal punishment, and involuntary seclusion.
c. Staff treatment of residents. The facility shall develop and implement written policies and procedures that prohibit mistreatment , neglect, and abuse of residents and misappropriation of resident property.
* (1) Facility staff shall not use verbal, mental, sexual, or physical abuse , including corporal punishment, or involuntary seclusion of residents. The facility shall not employ persons who have been found guilty by a court of law of abusing, neglecting or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse , neglect, mistreatment of residents or misappropriation of their property.
The
*See Objection filed 8/25/92 published herein at end of 441-Chapter 81.
(2) The facility shall ensure that all alleged violations involving mistreatment , neglect or abuse including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility or to other officials (including the department of inspections and appeals) in accordance with state law through established procedures.
(3) The facility shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.
(4) The results of all investigations conducted by facility staff shall be reported to the administrator or the administrator's designated representative or to other officials (including the department of inspections and appeals) in accordance with state law within five working days of the incident and if the alleged violation is verified, take appropriate corrective action.
(8) Quality of life. A facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.
a. Dignity. The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of the resident's individuality.
b. Self-determination and participation. The resident has the right to:
(1) Choose activities, schedules, and health care consistent with the resident's interests, assessments and plans of care.
(2) Interact with members of the community both inside and outside the facility .
(3) Make choices about aspects of life in the facility that are significant to the resident.
c. Participation in resident and family groups.
(1) A resident has the right to organize and participate in resident groups in the facility .
(2) A resident's family has the right to meet in the facility with the families of other residents in the facility .
(3) The facility shall provide a resident or family group, if one exists, with private space.
(4) Staff or visitors may attend meetings at the group's invitation.
(5) The facility shall provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings.
(6) When a resident or family group exists, the facility shall listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility .
d. Participation in other activities. A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility .
e. Accommodation of needs. A resident has the right to:
(1) Reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.
(2) Receive notice before the resident's room or roommate in the facility is changed.
f. Activities.
(1) The facility shall provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.
(2) The activities program shall be directed by a qualified professional who meets one of the following criteria:
1. Is a qualified therapeutic recreation specialist or an activities professional who is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990.
2. Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting.
3. Is a qualified occupational therapist or occupational therapy assistant.
4. Has completed a training course approved by the state.
g. Social services.
(1) The facility shall provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident.
(2) A facility with more than 120 beds shall employ a qualified social worker on a full-time basis.
(3) Qualifications of social worker. A qualified social worker is a person who meets both of the following criteria:
1. A bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, special education, rehabilitation, counseling and psychology.
2. One year of supervised social work experience in a health care setting working directly with individuals.
h. Environment. The facility shall provide:
(1) A safe, clean, comfortable and homelike environment, allowing the resident to use personal belongings to the extent possible.
(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.
(3) Clean bed and bath linens that are in good condition.
(4) Private closet space in each resident room.
(5) Adequate and comfortable lighting levels in all areas.
(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, shall maintain a temperature range of 71 to 81 degrees Fahrenheit.
(7) For the maintenance of comfortable sound levels.
(9) Resident assessment. The facility shall conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional ability.
a. Admission orders. At the time each resident is admitted, the facility shall have physician orders for the resident's immediate care.
b. Comprehensive assessments.
(1) The facility shall make a comprehensive assessment of a resident's needs which is based on the minimum data set (MDS ) specified by the department of inspections and appeals, which describes the resident's capability to perform daily life functions and significant impairments in functional capacity.
(2) The assessment process shall include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. The comprehensive assessment shall include at least the following information:
1. Identification and demographic information.
2. Customary routine.
3. Cognitive patterns.
4. Communication.
5. Vision.
6. Mood and behavior patterns.
7. Psychosocial well-being.
8. Physical functioning and structural problems.
9. Continence.
10. Disease diagnoses and health conditions.
11. Dental and nutritional status.
12. Skin condition.
13. Activity pursuit.
14. Medications.
15. Special treatments and procedures.
16. Discharge potential.
17. Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.
18. Documentation of participation in assessment.
19. Additional specification relating to resident status as required in Section S of the MDS .
(3) Frequency. Assessments shall be conducted:
1. Within 14 calendar days after admission or readmission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. "Readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.
2. Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. A "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and that requires either interdisciplinary review, revision of the care plan, or both.
3. In no case less often than once every 12 months.
(4) Review of assessments. The facility shall examine each resident no less than once every three months, and as appropriate, revise the resident's assessment to ensure the continued accuracy of the assessment.
(5) Maintenance and use. A facility shall maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results to develop, review and revise the resident's comprehensive plan of care.
(6) Coordination. The facility shall coordinate assessments with any state-required preadmission screening program to the maximum extent practicable to avoid duplicative testing and effort.
(7) Automated data processing requirement.
1. Entering data. Within seven days after a facility completes a resident's assessment, a facility shall enter the following information for the resident into a computerized format that meets the specifications defined in numbered paragraphs "2" and "4" below.
* Admission assessment.
* Annual assessment updates.
* Significant change in status assessments.
* Quarterly review assessments.
* A subset of items upon a resident's transfer, reentry, discharge, and death.
* Background (face sheet) information, if there is no admission assessment.
2. Transmitting data. Within seven days after a facility completes a resident's assessment, a facility shall be capable of transmitting to the state each resident's assessment information contained in the MDS in a format that conforms to standard record layouts and data dictionaries and that passes edits that ensure accurate and consistent coding of the MDS data as defined by the Centers for Medicare and Medicaid Services (CMS ) and the department of human services or the department of inspections and appeals.
3. Monthly transmittal requirements. On at least a monthly basis, a facility shall input and electronically transmit accurate and complete MDS data for all assessments conducted during the previous month, including the following:
* Admission assessment.
* Annual assessment.
* Significant correction of prior full assessment.
* Significant correction of prior quarterly assessment.
* Quarterly review.
* A subset of items upon a resident's transfer, reentry, discharge, and death.
* Background (face sheet) information, for an initial transmission of
4. The facility must transmit MDS data in the format specified by CMS .
(8) Resident-identifiable information. A facility shall not release information that is resident-identifiable to the public. The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
c. Accuracy of assessments. The assessment shall accurately reflect the resident's status.
(1) Coordination. Each assessment shall be conducted or coordinated with the appropriate participation of health professionals. Each assessment shall be conducted or coordinated by a registered nurse.
(2) Certification. Each person who completes a portion of the assessment shall sign and certify the accuracy of that portion of the assessment. A registered nurse shall sign and certify that the assessment is completed.
(3) Penalty for falsification. An individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment. An individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.
Clinical disagreement does not constitute a material and false statement.
(4) Use of independent assessors. If the department of human services or the department of inspections and appeals determines, under a survey or otherwise, that there has been a knowing and willful certification of false statements under subparagraph (3) above, the department of human services or the department of inspections and appeals may require that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the department of human services or the department of inspections and appeals for a period specified by the agency.
d. Comprehensive care plans.
(1) The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
The care plan shall describe the following:
1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under subrule 81.13(10).
2. Any services that would otherwise be required under subrule 81.13(10), but are not provided due to the resident's exercise of rights under subrule 81.13(5), including the right to refuse treatment under subrule 81.13(5), paragraph"b," subparagraph (4).
(2) A comprehensive care plan shall be developed within seven days after completion of the comprehensive assessment by an interdisciplinary team and with the participation of the resident, the resident's case manager as appropriate and as allowed by the resident for those residents enrolled with a managed care organization , and the resident's family or legal representative to the extent practicable, and shall be periodically reviewed and revised by a team of qualified persons after each assessment.
The interdisciplinary team shall include the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs.
(3) The services provided or arranged by the facility shall meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care.
e. Discharge summary. When the facility anticipates discharges, a resident shall have a discharge summary that includes:
(1) A recapitulation of the resident's stay.
(2) A final summary of the resident's status to include items in paragraph"b," subparagraph (2) above, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative.
(3) A postdischarge plan of care developed with the participation of the resident and resident's family which will assist the resident to adjust to a new living environment.
f. Reserved.
g. Preadmission resident assessment. The facility shall conduct prior to admission a resident assessment of all persons seeking nursing facility placement. The assessment information gathered shall be similar to the data in the minimum data set (MDS ) resident assessment tool.
(10) Quality of care. Each resident shall receive and the facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
a. Activities of daily living. Based on the comprehensive assessment of a resident, the facility shall ensure that:
(1) A resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress and groom; transfer and ambulate; toilet; eat, and to use speech, language or other functional communication systems.
(2) A resident is given the appropriate treatment and services to maintain or improve the resident's abilities specified in subparagraph (1) above.
(3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
b. Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility shall, if necessary, assist the resident:
(1) In making appointments.
(2) By arranging for transportation to and from the office of a medical practitioner specializing in the treatment of vision impairment or the deaf or hard of hearing or the office of a professional specializing in the provision of vision or hearing assistive devices.
c. Pressure sores. Based on the comprehensive assessment of a resident, the facility shall ensure that:
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable.
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
d. Urinary incontinence. Based on the resident's comprehensive assessment, the facility shall ensure that:
(1) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.
(2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
e. Range of motion. Based on the comprehensive assessment of a resident, the facility shall ensure that:
(1) A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable.
(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion to prevent further decrease in range of motion.
f. Mental and psychosocial functioning. Based on the comprehensive assessment of a resident, the facility shall ensure that:
(1) A resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem.
(2) A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern was unavoidable.
g. Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility shall ensure that:
(1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable.
(2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasalpharyngeal ulcers and to restore, if possible, normal eating skills.
h. Accidents. The facility shall ensure that:
(1) The resident environment remains as free of accident hazards as is possible.
(2) Each resident receives adequate supervision and assistive devices to prevent accidents.
i. Nutrition. Based on a resident's comprehensive assessment, the facility shall ensure that a resident:
(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible.
(2) Receives a therapeutic diet when there is a nutritional problem.
j. Hydration. The facility shall provide each resident with sufficient fluid intake to maintain proper hydration and health.
k. Special needs. The facility shall ensure that residents receive proper treatment and care for the following special services:
(1) Injections.
(2) Parenteral and enteral fluids.
(3) Colostomy, ureterostomy or ileostomy care.
(4) Tracheostomy care.
(5) Tracheal suctioning.
(6) Respiratory care.
(7) Foot care.
(8) Prostheses.
l. Unnecessary drugs.
(1) General. Each resident's drug regimen shall be free from unnecessary drugs. An unnecessary drug is any drug when used:
1. In excessive dose including duplicate drug therapy; or
2. For excessive duration; or
3. Without adequate monitoring; or
4. Without adequate indications for its use; or
5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
6. Any combinations of the reasons above.
(2) Antipsychotic drugs. Based on a comprehensive assessment of a resident, the facility shall ensure that:
1. Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.
2. Residents who use antipsychotic drugs receive gradual dose reductions and behavioral programming, unless clinically contraindicated in an effort to discontinue these drugs.
m. Medication errors. The facility shall ensure that:
(1) It is free of significant medication error rates of 5 percent or greater.
(2) Residents are free of any significant medication errors.
(11) Nursing services. The facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
a. Sufficient staff.
(1) The facility shall provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
1. Except when waived under paragraph"c," licensed nurses.
2. Other nursing personnel.
(2) Except when waived under paragraph"c," the facility shall designate a licensed nurse to serve as a charge nurse on each tour of duty.
b. Registered nurse.
(1) Except when waived under paragraph"c," the facility shall use the services of a registered nurse for at least eight consecutive hours a day, seven days a week.
(2) Except when waived under paragraph"c," the facility shall designate a registered nurse to serve as the director of nursing on a full-time basis.
(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
c. Nursing facilities. Waiver of requirement to provide licensed nurses on a 24-hour basis. A facility may request a waiver from either the requirement that a nursing facility provide a registered nurse for at least eight consecutive hours a day, seven days a week, as specified in paragraph"b," or the requirement that a nursing facility provide licensed nurses on a 24-hour basis, including a charge nurse as specified in paragraph"a," if the following conditions are met:
(1) The facility demonstrates to the satisfaction of the state that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel.
(2) The department of inspections and appeals determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility .
(3) The department of inspections and appeals finds that, for any periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility .
(4) A waiver granted under the conditions listed in paragraph"c" is subject to annual department of inspections and appeals review.
(5) In granting or renewing a waiver, a facility may be required by the department of inspections and appeals to use other qualified, licensed personnel.
(6) The department of inspections and appeals shall provide notice of a waiver granted under this paragraph to the state long-term care ombudsman established under Section 307(a)(12) of the Older Americans Act of 1965 and the protection and advocacy system in the state for the mentally ill and mentally retarded.
(7) The nursing facility that is granted a waiver under this paragraph shall notify residents of the facility or, where appropriate, the guardians or legal representatives of the residents and members of their immediate families of the waiver.
(12) Dietary services. The facility shall provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.
a. Staffing. The facility shall employ a qualified dietitian either full-time, part-time or on a consultant basis.
(1) If a qualified dietitian is not employed full-time, the facility shall designate a person to serve as the director of food services who receives frequently scheduled consultation from a qualified dietitian.
(2) A qualified dietitian is one who is licensed by the state according to Iowa Code chapter 152A.
b. Sufficient staff. The facility shall employ sufficient support personnel competent to carry out the functions of the dietary service.
c. Menus and nutritional adequacy. Menus shall:
(1) Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.
(2) Be prepared in advance.
(3) Be followed.
d. Food. Each resident receives and the facility provides:
(1) Food prepared by methods that conserve nutritive value, flavor and appearances.
(2) Food that is palatable, attractive and at the proper temperature.
(3) Food prepared in a form designed to meet individual needs.
(4) Substitutes offered of similar nutritive value to residents who refuse food served.
e. Therapeutic diets. Therapeutic diets shall be prescribed by the attending physician.
f. Frequency of meals.
(1) Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.
(2) There shall be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in subparagraph (4) below.
(3) The facility shall offer snacks at bedtime daily.
(4) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.
g. Assistive devices. The facility shall provide special eating equipment and utensils for residents who need them.
h. Sanitary conditions. The facility shall:
(1) Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(2) Store, prepare, distribute and serve food under sanitary conditions.
(3) Dispose of garbage and refuse properly.
(13) Physician services. A physician shall personally approve in writing a recommendation that an individual be admitted to a facility . Each resident shall remain under the care of a physician.
a. Physician supervision. The facility shall ensure that:
(1) The medical care of each resident is supervised by a physician.
(2) Another physician supervises the medical care of residents when their attending physician is unavailable.
b. Physician visits. The physician shall:
(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph"c" below.
(2) Write, sign and date progress notes at each visit.
(3) Sign and date all orders.
c. Frequency of physician visits.
(1) The resident shall be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
(2) A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.
(3) Except as provided in paragraph"e," all required physician visits shall be made by the physician personally.
d. Availability of physicians for emergency care. The facility shall provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.
e. Performance of physician tasks in nursing facilities. Any required physician task in a nursing facility (including tasks which the rules specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility , but who is working in collaboration with a physician except where prohibited by state law.
(14) Specialized services. When indicated, specialized services shall be provided to residents as follows:
a. Specialized rehabilitative services. Specialized rehabilitative services shall be provided by qualified personnel under the written order of a physician. If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, and occupational therapy, are required in the resident's comprehensive plan of care, the facility shall:
(1) Provide the required services; or
(2) Obtain the required services from an outside provider of specialized rehabilitative services.
b. Specialized services for mental illness. "Specialized services for mental illness" means services provided in response to an exacerbation of a resident's mental illness that:
(1) Are beyond the normal scope and intensity of nursing facility responsibility;
(2) Involve treatment other than routine nursing care, supportive therapies such as activity therapy, and supportive counseling by nursing facility staff;
(3) Are provided through a professionally developed plan of care with specific goals and interventions;
(4) May be provided only by a specialized licensed or certified practitioner;
(5) Are expected to result in specific, identified improvements in the resident's psychiatric status to the level before the exacerbation of the resident's mental illness; and
(6) May include:
1. Acute inpatient psychiatric treatment. When inpatient psychiatric treatment may be prevented through specialized services provided in the nursing facility , services provided in the nursing facility are preferred.
2. Initial psychiatric evaluation to determine a resident's diagnosis and to develop a plan of care.
3. Follow-up psychiatric services by a psychiatrist to evaluate resident response to psychotropic medications, to modify medication orders and to evaluate the need for ancillary therapy services.
4. Psychological testing required for a specific differential diagnosis that will result in the adoption of appropriate treatment services.
5. Individual or group psychotherapy as part of a plan of care addressing specific symptoms.
6. Any clinically appropriate service which is available for which the member meets eligibility criteria.
c. Specialized services for intellectual disability. "Specialized services for intellectual disability" means services that:
(1) Are beyond the normal scope and intensity of nursing facility responsibility;
(2) Involve treatment other than routine nursing care, supportive therapies such as activity therapy, and supportive counseling by nursing facility staff;
(3) Are provided through a professionally developed plan of care with specific goals and interventions;
(4) Must be supervised by a qualified intellectual disability professional; and
(5) May include:
1. A functional assessment of maladaptive behaviors.
2. Development and implementation of a behavioral support plan.
3. Community living skills training for members who desire to live in a community setting and for whom community living is appropriate as determined by the Level II evaluation. Training may include adaptive behavior skills, communication skills, social skills, personal care skills, and self-advocacy skills.
(15) Dental services. The facility shall assist residents in obtaining routine and 24-hour emergency dental care. The facility shall:
a. Provide or obtain from an outside resource the following dental services to meet the needs of each resident:
(1) Routine dental services to the extent covered under the state plan.
(2) Emergency dental services.
b. If necessary, assist the resident in making appointments; and by arranging for transportation to and from the dentist's office.
c. Promptly refer residents with lost or damaged dentures to a dentist.
(16) Pharmacy services. The facility shall provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement. The nursing facility may permit a certified medication aide to administer drugs, but only under the general supervision of a licensed nurse.
a. Procedures. A facility shall provide pharmaceutical services (including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
b. Service consultation. The facility shall employ or obtain the services of a licensed pharmacist who:
(1) Provides consultation on all aspects of the provision of pharmacy services in the facility .
(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.
(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
c. Drug regimen review.
(1) The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist.
(2) The pharmacist shall report any irregularities to the attending physician and the director of nursing, and these reports shall be acted upon.
d. Labeling of drugs and biologicals. Drugs and biologicals used in the facility shall be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
e. Storage of drugs and biologicals.
(1) In accordance with state and federal laws, the facility shall store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys.
(2) The facility shall provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse , except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
f. Consultant pharmacists. When the facility does not employ a licensed pharmacist, it shall have formal arrangements with a licensed pharmacist to provide consultation on methods and procedures for ordering, storage, administration and disposal and record keeping of drugs and biologicals. The formal arrangements with the licensed pharmacist shall include separate written contracts for pharmaceutical vendor services and consultant pharmacist services. The consultant's visits are scheduled to be of sufficient duration and at a time convenient to work with nursing staff on the resident care plan, consult with the administrator and others on developing and implementing policies and procedures, and planning in-service training and staff development for employees. The consultant shall provide monthly drug regimen review reports. The facility shall provide reimbursement for consultant pharmacists based on fair market value. Documentation of consultation shall be available for review in the facility .
(17) Infection control. The facility shall establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection.
a. Infection control program. The facility shall establish an infection control program under which it:
(1) Investigates, controls and prevents infections in the facility .
(2) Decides what procedures, such as isolation, should be applied to an individual resident.
(3) Maintains a record of incidents and corrective actions related to infections.
b. Preventing spread of infection.
(1) When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility shall isolate the resident.
(2) The facility shall prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.
(3) The facility shall require staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice.
c. Linens. Personnel shall handle, store, process, and transport linens so as to prevent the spread of infection.
(18) Physical environment. The facility shall be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public.
a. Life safety from fire. Except as provided in subparagraph (1) or (3) below, the facility shall meet the applicable provisions of the 1985 edition of the Life Safety Code of the National Fire Protection Association.
(1) A facility is considered to be in compliance with this requirement as long as the facility :
1. On November 26, 1982, complied with or without waivers with the requirements of the 1967 or 1973 editions of the Life Safety Code and continues to remain in compliance with those editions of the code; or
2. On May 9, 1988, complied, with or without waivers, with the 1981 edition of the Life Safety Code and continues to remain in compliance with that edition of the Code.
(2) When Medicaid nursing facilities and Medicaid distinct part nursing facility providers request a waiver of Life Safety Code requirements in accordance with Subsection 1919(d)(2)(B)(i) of the Social Security Act, the department of inspections and appeals shall forward the requests to the Centers for Medicare and Medicaid Services Regional Office for review and approval.
(3) The provisions of the Life Safety Code do not apply in a state where the Centers for Medicare and Medicaid Services finds that afire and safety code imposed by state law adequately protects patients, residents and personnel in long-term care facilities.
b. Emergency power.
(1) An emergency electrical power system shall supply power adequate at least for lighting all entrances and exits, equipment to maintain the fire detection, alarm and extinguishing systems, and life support systems in the event the normal electrical supply is interrupted.
(2) When life support systems are used that have no nonelectrical backup, the facility shall provide emergency electrical power with an emergency generator, as defined in NFPA 99, Health Care Facilities, that is located on the premises.
c. Space and equipment. The facility shall:
(1) Provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident's plan of care.
(2) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.
d. Resident rooms. Resident rooms shall be designed and equipped for adequate nursing care, comfort and privacy of residents.
(1) Bedrooms shall:
1. Accommodate no more than four residents.
2. Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms.
3. Have direct access to an exit corridor.
4. Be designed or equipped to ensure full visual privacy for each resident.
5. In facilities initially certified after March 31, 1992, except in private rooms, each bed shall have ceiling-suspended curtains, which extend around the bed to provide total visual privacy, in combination with adjacent walls and curtains.
6. Have at least one window to the outside.
7. Have a floor at or above grade level.
(2) The facility shall provide each resident with:
1. A separate bed of proper size and height for the convenience of the resident.
2. A clean, comfortable mattress.
3. Bedding appropriate to the weather and climate.
4. Functional furniture appropriate to the resident's needs and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident.
(3) The department of inspections and appeals may permit variations in requirements specified in paragraph"d," subparagraph (1), numbers 1 and 2 above relating to rooms in individual cases when the facility demonstrates in writing that the variations are required by the special needs of the residents and will not adversely affect residents' health and safety.
e. Toilet facilities. Each resident room shall be equipped with or located adjacent to toilet facilities unless a waiver is granted by the department of inspections and appeals. Additionally, each resident room shall be equipped with or located adjacent to bathing facilities.
f. Resident call system. The nurse's station shall be equipped to receive resident calls through a communication system from:
(1) Resident rooms.
(2) Toilet and bathing facilities.
g. Dining and resident activities. The facility shall provide one or more rooms designated for resident dining and activities. These rooms shall:
(1) Be well lighted.
(2) Be well ventilated, with nonsmoking areas identified.
(3) Be adequately furnished.
(4) Have sufficient space to accommodate all activities.
h. Other environmental conditions. The facility shall provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The facility shall:
(1) Establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply.
(2) Have adequate outside ventilation by means of windows or mechanical ventilation or a combination of the two.
(3) Equip corridors with firmly secured handrails on each side.
(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
(19) Administration. A facility shall be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
a. Licensure. A facility shall be licensed under applicable state and federal law.
b. Compliance with federal, state and local laws and professional standards. The facility shall operate and provide services in compliance with all applicable federal, state, and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility .
c. Relationship to other Department of Health and Human Services (HHS) regulations. In addition to compliance with these rules, facilities shall meet the applicable provisions of other HHS regulations, including, but not limited to, those pertaining to nondiscrimination on the basis of race, color, or national origin, nondiscrimination on the basis of handicap, nondiscrimination on the basis of age, protection of human subjects of research, and fraud and abuse . Although these regulations are not in themselves considered requirements under these rules, their violation may result in the termination or suspension of, or the refusal to grant or continue payment with federal funds.
d. Governing body.
(1) The facility shall have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility .
(2) The governing body appoints the administrator who is:
1. Licensed by the state.
2. Responsible for management of the facility .
e. Required training of nurse aides.
(1) Definitions.
"Licensed health professional" means a physician; physician assistant; nurse practitioner; physical, speech or occupational therapist; registered professional nurse; licensed practical nurse; or licensed or certified social worker.
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(2) General rule. A facility shall not use any person working in the facility as a nurse aide for more than four months, on a permanent basis, unless:
1. That person is competent to provide nursing and nursing-related services.
2. That person has completed a training and competency evaluation program or a competency evaluation program approved by the department of inspections and appeals; or that person has been deemed or determined competent by the department of inspections and appeals.
(3) Nonpermanent employees. A facility shall not use on a temporary, per diem, leased, or any basis other than a permanent employee any person who does not meet the requirements in subparagraph (2).
(4) Competency. A facility shall not use any person who has worked less than four months as a nurse aide in that facility unless the person:
1. Is a permanent employee and is in a nurse aide training and competency evaluation program approved by the department of inspections and appeals;
2. Has demonstrated competence through satisfactory participation in a nurse aide training and competency evaluation program or competency evaluation program approved by the department of inspections and appeals; or
3. Has been deemed or determined competent by the department of inspections and appeals.
(5) Registry verification. Before allowing a person to serve as a nurse aide , a facility shall receive registry verification that the person has met competency evaluation requirements unless:
1. The person is a permanent employee and is in a training and competency evaluation program approved by the department of inspections and appeals; or
2. The person can prove that the person has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the department of inspections and appeals and has not yet been included in the registry. Facilities shall follow up to ensure that such a person actually becomes registered.
(6) Multistate registry verification. Before allowing a person to serve as a nurse aide , a facility shall seek information from every state registry the facility believes will include information on the person.
(7) Required retraining. If since October 1, 1990, there has been a continuous period of 24 consecutive months during none of which the person provided nursing or nursing-related services for monetary compensation, the person shall complete a new training and competency evaluation program or a new competency evaluation program.
(8) Regular in-service education. The facility shall complete a performance review of every nurse aide at least once every 12 months and shall provide regular in-service education based on the outcome of these reviews. The in-service training shall:
1. Be sufficient to ensure the continuing competencies of nurse aides, but shall be no less than 12 hours per year.
2. Address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff.
3. For nurse aides providing services to persons with cognitive impairments, also address the care of the cognitively impaired.
f. Proficiency of nurse aides. The facility shall ensure that nurse aides are able to demonstrate competency in skills and technique necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
g. Staff qualifications.
(1) The facility shall employ on a full-time, part-time, or consultant basis those professionals necessary to carry out the provisions of these conditions of participation.
(2) Professional staff shall be licensed, certified or registered in accordance with applicable state laws.
h. Use of outside resources.
(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility , the facility shall have that service furnished to residents by a person or agency outside the facility under an arrangement described in Section 1861(w) of the Omnibus Budget Reconciliation Act of 1987 or an agreement described in subparagraph (2) below.
(2) Arrangements or agreements pertaining to services furnished by outside resources shall specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility and for the timeliness of the services.
i. Medical director.
(1) The facility shall designate a physician to serve as medical director.
(2) The medical director is responsible for implementation of resident care policies and the coordination of medical care in the facility .
j. Laboratory services.
(1) The facility shall provide or obtain clinical laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
1. If the facility provides its own laboratory services, the services shall meet the applicable conditions for coverage of the services furnished by laboratories specified in 42 CFR Part 493 as amended to October 1, 1990.
2. If the facility provides blood bank and transfusion services, it shall meet the requirements for laboratories specified in 42 CFR Part 493 as amended to October 1, 1990.
3. If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory shall be approved or licensed to test specimens in the appropriate specialties or subspecialties of service in accordance with 42 CFR Part 493 as amended to October 1, 1990.
4. If the facility does not provide laboratory services on site, it shall have an agreement to obtain these services only from a laboratory that meets the requirements of 42 CFR Part 493 as amended to October 1, 1990, or from a physician's office.
(2) The facility shall:
1. Provide or obtain laboratory services only when ordered by the attending physician.
2. Promptly notify the attending physician of the findings.
3. Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance.
4. File in the resident's clinical record signed and dated reports of clinical laboratory services.
k. Radiology and other diagnostic services.
(1) The facility shall provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
1. If the facility provides its own diagnostic services, the services shall meet the applicable conditions of participation for hospitals.
2. If the facility does not provide its own diagnostic services, it shall have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.
(2) The facility shall:
1. Provide or obtain radiology and other diagnostic services only when ordered by the attending physician.
2. Promptly notify the attending physician of the findings.
3. Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance.
4. File in the resident's clinical record signed and dated reports of X-ray and other diagnostic services.
l. Clinical records.
(1) The facility shall maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized.
(2) Clinical records shall be retained for:
1. The period of time required by state law.
2. Five years from the date of discharge when there is no requirement in state law.
3. For a minor, three years after a resident reaches legal age under state law.
(3) The facility shall safeguard clinical record information against loss, destruction, or unauthorized use.
(4) The facility shall keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by:
1. Transfer to another health care institution.
2. Law.
3. Third-party payment contract.
4. The resident.
(5) The clinical record shall contain:
1. Sufficient information to identify the resident.
2. A record of the resident's assessments.
3. The plan of care and services provided.
4. The results of any preadmission screening conducted by the state.
5. Progress notes.
m. Disaster and emergency preparedness.
(1) The facility shall have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.
(2) The facility shall train all employees in emergency procedures when they begin to work in the facility , periodically review the procedures with existing staff, and carry out staff drills using those procedures.
n. Transfer agreement.
(1) The facility shall have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs that reasonably ensures that:
1. Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician.
2. Medical and other information needed for care and treatment of residents, and, when the transferring facility deems it appropriate, for determining whether the residents can be adequately cared for in a less expensive setting than either the facility or the hospital, will be exchanged between the institutions.
(2) The facility is considered to have a transfer agreement in effect if the facility has attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible.
o. Quality assessment and assurance.
(1) A facility shall maintain a quality assessment and assurance committee consisting of the director of nursing services, a physician designated by the facility , and at least three other members of the facility 's staff.
(2) The quality assessment and assurance committee:
1. Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary.
2. Develops and implements appropriate plans of action to correct identified quality deficiencies.
(3) The state or the Secretary of the Department of Health and Human Services may not require disclosure of the records of the committee except insofar as the disclosure is related to the compliance of the committee with the requirements of this paragraph.
(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
p. Disclosure of ownership.
(2) The facility shall provide written notice to the department of inspections and appeals at the time of change, if a change occurs in:
1. Persons with an ownership or control interest.
2. The officers, directors, agents, or managing employees.
3. The corporation, association, or other company responsible for the management of the facility .
4. The facility 's administrator or director of nursing.
(3) The notice specified in subparagraph (2) above shall include the identity of each new individual or company.
This rule is intended to implement Iowa Code sections 249A.2, 249A.3(2) "a," and 249A.4.