Iowa Admin. Code r. 441-82.2 - Licensing and certification
In order to participate in the program, a facility shall be
licensed as an intermediate care facility for persons with an intellectual
disability by the
(1)
Governing body and
management.
a.
Governing
body. The facility shall identify an individual or individuals to
constitute the governing body of the facility. The governing body shall:
(1) Exercise general policy, budget, and
operating direction over the facility.
(2) Set the qualifications (in addition to
those already set by state law) for the administrator of the
facility.
(3) Appoint the
administrator of the facility.
b.
Compliance with federal, state,
and local laws. The facility shall be in compliance with all
applicable provisions of federal, state and local laws, regulations and codes
pertaining to health, safety, and sanitation.
c.
Client records.
(1) The facility shall develop and maintain a
record-keeping system that includes a separate record for each client and that
documents the clients' health care, active treatment, social information, and
protection of the client's rights.
(2) The facility shall keep confidential all
information contained in the clients' records, regardless of the form or
storage method of the records.
(3)
The facility shall develop and implement policies and procedures governing the
release of any client information, including consents necessary from the client
or parents (if the client is a minor) or legal guardian.
(4) Any individual who makes an entry in a
client's record shall make it legibly, date it, and sign it.
(5) The facility shall provide a legend to
explain any symbol or abbreviation used in a client's record.
(6) The facility shall provide each
identified residential living unit with appropriate aspects of each client's
record.
d.
Services provided under agreements with outside sources.
(1) If a service required under this rule is
not provided directly, the facility shall have a written agreement with an
outside program, resource, or service to furnish the necessary service,
including emergency and other health care.
(2) The agreement shall:
1. Contain the responsibilities, functions,
objectives, and other terms agreed to by both parties.
2. Provide that the facility is responsible
for ensuring that the outside services meet the standards for quality of
services contained in this rule.
(3) The facility shall ensure that outside
services meet the needs of each client.
(4) If living quarters are not provided in a
facility owned by the ICF/ID, the ICF/ID remains directly responsible for the
standards relating to physical environment that are specified in subrule
82.2(7), paragraphs"a" to "g," "j," and
"k."
e.
Disclosure of ownership. The facility shall supply to the
licensing agency full and complete information, and promptly report any changes
which would affect the current accuracy of the information, as to identify:
(1) Each person having a direct or indirect
ownership interest of 5 percent or more in the facility and the owner in whole
or in part of any property or assets (stock, mortgage, deed of trust, note or
other obligation) secured in whole or in part by the facility.
(2) Each officer and director of the
corporation, if the facility is organized as a corporation.
(3) Each partner, if the facility is
organized as a partnership.
(2)
Client protections.
a.
Protection of clients'
rights. The facility shall ensure the rights of all clients.
Therefore, the facility shall:
(1) Inform each
client, parent (if the client is a minor), or legal guardian of the client's
rights and the rules of the facility.
(2) Inform each client, parent (if the child
is a minor), or legal guardian, of the client's medical condition,
developmental and behavioral status, attendant risks of treatment, and of the
right to refuse treatment.
(3)
Allow and encourage individual clients to exercise their rights as clients of
the facility, and as citizens of the United States, including the right to file
complaints and the right to due process.
(4) Allow individual clients to manage their
financial affairs and teach them to do so to the extent of their
capabilities.
(5) Ensure that
clients are not subjected to physical, verbal, sexual, or psychological abuse
or punishment.
(6) Ensure that
clients are free from unnecessary drugs and physical restraints and are
provided active treatment to reduce dependency on drugs and physical
restraints.
(7) Provide each client
with the opportunity for personal privacy and ensure privacy during treatment
and care of personal needs.
(8)
Ensure that clients are not compelled to perform services for the facility and
ensure that clients who do work for the facility are compensated for their
efforts at prevailing wages and commensurate with their abilities.
(9) Ensure clients the opportunity to
communicate, associate and meet privately with individuals of their choice, and
to send and receive unopened mail.
(10) Ensure that clients have access to
telephones with privacy for incoming and outgoing local and long distance calls
except as contraindicated by factors identified within their individual program
plans.
(11) Ensure clients the
opportunity to participate in social, religious, and community group
activities.
(12) Ensure that
clients have the right to retain and use appropriate personal possessions and
clothing, and ensure that each client is dressed in the client's own clothing
each day.
(13) Permit a husband and
wife who both reside in the facility to share a room.
b.
Client finances.
(1) The facility shall establish and maintain
a system that ensures a full and complete accounting of clients' personal funds
entrusted to the facility on behalf of clients and precludes any commingling of
client funds with facility funds or with the funds of any person other than
another client.
(2) The client's
financial record shall be available on request to the client, parents (if the
client is a minor), or legal guardian.
c.
Communication with clients,
parents, and guardians. The facility shall:
(1) Promote participation of parents (if the
client is a minor) and legal guardians in the process of providing active
treatment to a client unless their participation is unobtainable or
inappropriate.
(2) Answer
communications from clients' families and friends promptly and
appropriately.
(3) Promote visits
by individuals with a relationship to the client (such as family, close
friends, legal guardians and advocates) at any reasonable hour, without prior
notice, consistent with the right of that client's and other clients' privacy,
unless the interdisciplinary team determines that the visit would not be
appropriate.
(4) Promote visits by
parents or guardians to any area of the facility that provides direct client
care services to the client, consistent with the right of that client's and
other clients' privacy.
(5) Promote
frequent and informal leaves from the facility for visits, trips, or
vacations.
(6) Notify promptly the
client's parents or guardian of any significant incidents or changes in the
client's condition including, but not limited to, serious illness, accident,
death, abuse, or unauthorized absence.
d.
Staff treatment of
clients.
(1) The facility shall
develop and implement written policies and procedures that prohibit
mistreatment, neglect or abuse of the client.
1. Staff of the facility shall not use
physical, verbal, sexual or psychological abuse or punishment.
2. Staff shall not punish a client by
withholding food or hydration that contributes to a nutritionally adequate
diet.
3. The facility shall
prohibit the employment of individuals with a conviction or prior employment
history of child or client abuse, neglect or mistreatment.
(2) The facility shall ensure that all
allegations of mistreatment, neglect or abuse, as well as injuries of unknown
source, are reported immediately to the administrator orto other officials 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 shall
be reported to the administrator or designated representative or to other
officials in accordance with state law within five working days of the
incident, and, if the alleged violation is verified, appropriate corrective
action shall be taken.
(3)
Facility staffing.
a.
Qualified intellectual disability
professional. Each client's active treatment program shall be
integrated, coordinated and monitored by a qualified intellectual disability
professional who has at least one year of experience working directly with
persons with an intellectual disability or other developmental disabilities and
is one of the following:
(1) A doctor of
medicine or osteopathy.
(2) A
registered nurse.
(3) An individual
who holds at least a bachelor's degree in a professional category specified in
82.2(3)"b"(5).
b.
Professional program
services.
(1) Each client shall
receive the professional program services needed to implement the active
treatment program defined by each client's individual program plan.
Professional program staff shall work directly with clients and with
paraprofessional, nonprofessional and other professional program staff who work
with clients.
(2) The facility
shall have available enough qualified professional staff to carry out and
monitor the various professional interventions in accordance with the stated
goals and objectives of every individual program plan.
(3) Professional program staff shall
participate as members of the interdisciplinary team in relevant aspects of the
active treatment process.
(4)
Professional program staff shall participate in ongoing staff development and
training in both formal and informal settings with other professional,
paraprofessional, and nonprofessional staff members.
(5) Professional program staff shall be
licensed, certified, or registered, as applicable, to provide professional
services by the state in which the staff practices. Those professional program
staff who do not fall under the jurisdiction of state licensure, certification,
or registration requirements shall meet the following qualifications:
1. To be designated as an occupational
therapist, an individual shall be eligible for certification as an occupational
therapist by the American Occupational Therapy Association or another
comparable body.
2. To be
designated as an occupational therapy assistant, an individual shall be
eligible for certification as an occupational therapy assistant by the American
Occupational Therapy Association or another comparable body.
3. To be designated as a physical therapist,
an individual shall be eligible for certification as a physical therapist by
the American Physical Therapy Association or another comparable body.
4. To be designated as a physical therapy
assistant, an individual shall be eligible for registration as a physical
therapy assistant by the American Physical Therapy Association orbe a graduate
of a two-year college-level program approved by the American Physical Therapy
Association or another comparable body.
5. To be designated as a psychologist, an
individual shall have at least a master's degree in psychology from an
accredited school.
6. To be
designated as a social worker, an individual shall hold a graduate degree from
a school of social work accredited or approved by the Council on Social Work
Education or another comparable body or hold a bachelor of social work degree
from a college or university accredited or approved by the Council on Social
Work Education or another comparable body.
7. To be designated as a speech-language
pathologist or audiologist, an individual shall be eligible for a Certificate
of Clinical Competence in Speech-Language Pathology or Audiology granted by the
American Speech-Language Hearing Association or another comparable body or meet
the educational requirements for certification and be in the process of
accumulating the supervised experience required for certification.
8. To be designated as a professional
recreation staff member, an individual shall have a bachelor's degree in
recreation or in a specialty area such as art, dance, music or physical
education.
9. To be designated as a
professional dietitian, an individual shall be eligible for registration by the
Academy of Nutrition and Dietetics.
10. To be designated as a human services
professional, an individual shall have at least a bachelor's degree in a human
services field (including, but not limited to, sociology, special education,
rehabilitation counseling or psychology).
(6) If the client's individual program plan
is being successfully implemented by facility staff, professional program staff
meeting the qualifications of 82.2(3)"b"(5) are not required
except for qualified intellectual disability professionals who must meet the
requirements set forth in 82.2(3)"a."
c.
Facility staffing.
(1) The facility shall not depend upon
clients or volunteers to perform direct care services for the
facility.
(2) There shall be
responsible direct care staff on duty and awake on a 24-hour basis, when
clients are present, to take prompt, appropriate action in case of injury,
illness, fire or other emergency, in each defined residential living unit
housing: clients for whom a physician has ordered a medical care plan; clients
who are aggressive, assaultive or security risks; more than 16 clients; or
fewer than 16 clients within a multi-unit building.
(3) There shall be a responsible direct care
staff person on duty on a 24-hour basis, when clients are present, to respond
to injuries and symptoms of illness, and to handle emergencies, in each defined
residential living unit housing: clients for whom a physician has not ordered a
medical care plan; clients who are not aggressive, assaultive or security
risks; and 16 or fewer clients.
(4)
The facility shall provide sufficient support staff so that direct care staff
are not required to perform support services to the extent that these duties
interfere with the exercise of their primary direct client care
duties.
d.
Direct
care (residential living unit) staff.
(1) The facility shall provide sufficient
direct care staff to manage and supervise clients in accordance with their
individual program plans.
(2)
Direct care staff are defined as the present on-duty staff calculated over all
shifts in a 24-hour period for each defined residential living unit.
(3) Direct care staff shall be provided by
the facility in the following minimum ratios of direct care staff to clients:
1. For each defined residential living unit
serving children under the age of 12, severely and profoundly intellectually
disabled clients, clients with severe physical disabilities, or clients who are
aggressive, assaultive, or security risks, or who manifest severely hyperactive
or psychotic-like behavior, the staff-to-client ratio is 1 to 3.2.
2. For each defined residential living unit
serving moderately intellectually disabled clients, the staff-to-client ratio
is 1 to 4.
3. For each defined
residential living unit serving clients who function within the range of mild
intellectual disability, the staff-to-client ratio is 1 to 6.4.
4. When there are no clients present in the
living unit, a responsible staff member must be available by
telephone.
e.
Staff training program.
(1)
The facility shall provide each employee with initial and continuing training
that enables the employee to perform the employee's duties effectively,
efficiently, and competently.
(2)
For employees who work with clients, training shall focus on skills and
competencies directed toward clients' developmental, behavioral, and health
needs.
(3) Staff shall be able to
demonstrate the skills and techniques necessary to administer interventions to
manage the inappropriate behavior of clients.
(4) Staff shall be able to demonstrate the
skills and techniques necessary to implement the individual program plans for
each client for whom they are responsible.
(4)
Active treatment
services.
a.
Active
treatment.
(1) Each client shall
receive a continuous active treatment program, which includes aggressive,
consistent implementation of a program of specialized and generic training,
treatment, health services and related services described in this paragraph,
that is directed toward: the acquisition of the behaviors necessary for the
client to function with as much self-determination and independence as
possible; and the prevention or deceleration of regression or loss of current
optimal functional status.
(2)
Active treatment does not include services to maintain generally independent
clients who are able to function with little supervision or in the absence of a
continuous active treatment program.
b.
Admissions, transfers, and
discharge.
(1) Clients who are
admitted by the facility shall be in need of and receiving active treatment
services.
(2) Admission decisions
shall be based on a preliminary evaluation of the client that is conducted or
updated by the facility or by outside sources.
(3) A preliminary evaluation shall contain
background information as well as currently valid assessments of functional
developmental, behavioral, social, health and nutritional status to determine
if the facility can provide for the client's needs and if the client is likely
to benefit from placement in the facility.
(4) If a client is to be either transferred
or discharged, the facility shall have documentation in the client's record
that the client was transferred or discharged for good cause and shall provide
a reasonable time to prepare the client and the client's parents or guardian
for the transfer or discharge (except in emergencies).
(5) At the time of the discharge, the
facility shall develop a final summary of the client's developmental,
behavioral, social, health and nutritional status and, with the consent of the
client, parents (if the client is a minor) or legal guardian, provide a copy to
authorized persons and agencies, and shall provide a post-discharge plan of
care that will assist the client to adjust to the new living
environment.
c.
Individual program plan.
(1)
Each client shall have an individual program plan developed by an
interdisciplinary team that represents the professions, disciplines or service
areas that are relevant to identifying the client's needs, as described by the
comprehensive functional assessments required in
82.2(4)"c"(3), and designing programs that meet the client's
needs.
(2) Appropriate facility
staff shall participate in interdisciplinary team meetings. Participation by
other agencies serving the client is encouraged. For those clients enrolled
with a managed care organization , the client's case manager shall participate
as appropriate and as allowed by the client. Participation by the client, the
client's parents (if the client is a minor), or the client's legal guardian is
required unless that participation is unobtainable or inappropriate.
(3) Within 30 days after admission, the
interdisciplinary team shall perform accurate assessments or reassessments as
needed to supplement the preliminary evaluation conducted prior to admission.
The comprehensive functional assessment shall take into consideration the
client's age (for example, child, young adult, elderly person) and the
implications for active treatment at each stage, as applicable, and shall:
1. Identify the presenting problems and
disabilities and, where possible, their causes.
2. Identify the client's specific
developmental strengths.
3.
Identify the client's specific developmental and behavioral management
needs.
4. Identify the client's
need for services without regard to the actual availability of the services
needed.
5. Include physical
development and health, nutritional status, sensorimotor development, affective
development, speech and language development, auditory functioning, cognitive
development, social development, adaptive behaviors or independent living
skills necessary for the client to be able to function in the community, and
vocational skills as applicable.
(4) Within 30 days after admission, the
interdisciplinary team shall prepare for each client an individual program plan
that states the specific objectives necessary to meet the client's needs, as
identified by the comprehensive assessment required by
82.2(4)"c"(3), and the planned sequence for dealing with those
objectives. These objectives shall:
1. Be
stated separately, in terms of a single behavioral outcome.
2. Be assigned projected completion
dates.
3. Be expressed in
behavioral terms that provide measurable indices of performance.
4. Be organized to reflect a developmental
progression appropriate to the individual.
5. Be assigned priorities.
(5) Each written training program
designed to implement the objectives in the individual program plan shall
specify:
1. The methods to be used.
2. The schedule for use of the
method.
3. The person responsible
for the program.
4. The type of
data and frequency of data collection necessary to be able to assess progress
toward the desired objectives.
5.
The inappropriate client behaviors, if applicable.
6. Provision for the appropriate expression
of behavior and the replacement of inappropriate behavior, if applicable, with
behavior that is adaptive or appropriate.
(6) The individual program plan shall also:
1. Describe relevant interventions to support
the individual toward independence.
2. Identify the location where program
strategy information (which shall be accessible to any person responsible for
implementation) can be found.
3.
Include, for those clients who lack them, training in personal skills essential
for privacy and independence (including, but not limited to, toilet training,
personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming,
and communication of basic needs), until it has been demonstrated that the
client is developmentally incapable of acquiring them.
4. Identify mechanical supports, if needed,
to achieve proper body position, balance, or alignment. The plan shall specify
the reason for each support, the situations in which each is to be applied, and
a schedule for the use of each support.
5. Provide that clients who have multiple
disabling conditions spend a major portion of each waking day out of bed and
outside the bedroom area, moving about by various methods and devices whenever
possible.
6. Include opportunities
for client choice and self-management.
(7) A copy of each client's individual
program plan shall be made available to all relevant staff, including staff of
other agencies who work with the client, and to the client, parents (if the
client is a minor) or legal guardian.
d.
Program implementation.
(1) As soon as the interdisciplinary team has
formulated a client's individual program plan, each client shall receive a
continuous active treatment program consisting of needed interventions and
services in sufficient number and frequency to support the achievement of the
objectives identified in the individual program plan.
(2) The facility shall develop an active
treatment schedule that outlines the current active treatment program and that
is readily available for review by relevant staff.
(3) Except for those facets of the individual
program plan that must be implemented only by licensed personnel, each client's
individual program plan shall be implemented by all staff who work with the
client, including professional, paraprofessional and nonprofessional
staff.
e.
Program
documentation.
(1) Data relative to
accomplishment of the criteria specified in client individual program plan
objectives shall be documented in measurable terms.
(2) The facility shall document significant
events that are related to the client's individual program plan and assessments
and that contribute to an overall understanding of the client's ongoing level
and quality of functioning.
f.
Program monitoring and
change.
(1) The individual program
plan shall be reviewed at least by the qualified intellectual disability
professional and revised as necessary, including, but not limited to,
situations in which the client:
1. Has
successfully completed an objective or objectives identified in the individual
program plan.
2. Is regressing or
losing skills already gained.
3. Is
failing to progress toward identified objectives after reasonable efforts have
been made.
4. Is being considered
for training toward new objectives.
(2) At least annually, the comprehensive
functional assessment of each client shall be reviewed by the interdisciplinary
team for relevancy and updated as needed, and the individual program plan shall
be revised, as appropriate, repeating the process set forth in
82.2(4)"c."
(3)
The facility shall designate and use a specially constituted committee or
committees consisting of members of facility staff, parents, legal guardians,
clients (as appropriate), qualified persons who have either experience or
training in contemporary practices to change inappropriate client behavior, and
persons with no ownership or controlling interest in the facility to:
1. Review, approve, and monitor individual
programs designed to manage inappropriate behavior and other programs that, in
the opinion of the committee, involve risks to client protection and
rights.
2. Ensure that these
programs are conducted only with the written informed consent of the client,
parent (if the client is a minor), or legal guardian.
3. Review, monitor and make suggestions to
the facility about its practices and programs as they relate to drug usage,
physical restraints, time-out rooms, application of painful or noxious stimuli,
control of inappropriate behavior, protection of client rights and funds, and
any other area that the committee believes needs to be
addressed.
(4) The
provisions of 82.2(4)"f"(3) may be modified only if, in the
judgment of the department of inspections and appeals, court decrees, state law
or regulations provide for equivalent client protection and
consultation.
(5)
Client behavior and facility
practices.
a.
Facility
practices-conduct toward clients.
(1) The facility shall develop and implement
written policies and procedures for the management of conduct between staff and
clients. These policies and procedures shall:
1. Promote the growth, development, and
independence of the client.
2.
Address the extent to which client choice will be accommodated in daily
decision making, emphasizing self-determination and self-management, to the
extent possible.
3. Specify client
conduct to be allowed or not allowed.
4. Be available to all staff, clients,
parents of minor children, and legal guardians.
(2) To the extent possible, clients shall
participate in the formulation of these policies and procedures.
(3) Clients shall not discipline other
clients, except as part of an organized system of self-government, as set forth
in facility policy.
b.
Management of inappropriate client behavior.
(1) The facility shall develop and implement
written policies and procedures that govern the management of inappropriate
client behavior. These policies and procedures shall be consistent with the
provisions of 82.2(5)"a." These procedures shall:
1. Specify all facility-approved
interventions to manage inappropriate client behavior.
2. Designate these interventions on a
hierarchy to be implemented ranging from most positive or least intrusive to
least positive or most intrusive.
3. Ensure, prior to the use of more
restrictive techniques, that the client's record documents that programs
incorporating the use of less intrusive or more positive techniques have been
tried systematically and have been demonstrated to be ineffective.
4. Address the use of time-out rooms, the use
of physical restraints, the use of drugs to manage inappropriate behavior, the
application of painful or noxious stimuli, the staff members who may authorize
the use of specified interventions, and a mechanism for monitoring and
controlling the use of these interventions.
(2) Interventions to manage inappropriate
client behavior shall be employed with sufficient safeguards and supervision to
ensure that the safety, welfare and civil and human rights of clients are
adequately protected.
(3)
Techniques to manage inappropriate client behavior shall never be used for
disciplinary purposes, for the convenience of staff or as a substitute for an
active treatment program.
(4) The
use of systematic interventions to manage inappropriate client behavior shall
be incorporated into the client's individual program plan, in accordance with
82.2(4)"c"(4) and (5).
(5) Standing or as-needed programs to control
inappropriate behavior are not permitted.
c.
Time-out rooms.
(1) A client may be placed in a room from
which egress is prevented only if the following conditions are met:
1. The placement is a part of an approved
systematic time-out program as required by
82.2(5)"b."
2. The
client is under the direct constant visual supervision of designated
staff.
3. The door to the room is
held shut by staff or by a mechanism requiring constant physical pressure from
a staff member to keep the mechanism engaged.
(2) Placement of a client in a time-out room
shall not exceed one hour.
(3)
Clients placed in time-out rooms shall be protected from hazardous conditions
including, but not limited to, presence of sharp corners and objects, uncovered
light fixtures, unprotected electrical outlets.
(4) A record of time-out activities shall be
kept.
d.
Physical
restraints.
(1) The facility may
employ physical restraint only:
1. As an
integral part of an individual program plan that is intended to lead to less
restrictive means of managing and eliminating the behavior for which the
restraint is applied.
2. As an
emergency measure, but only if absolutely necessary to protect the client or
others from injury.
3. As a
health-related protection prescribed by a physician, but only if absolutely
necessary during the conduct of a specific medical or surgical procedure, or
only if absolutely necessary for client protection during the time that a
medical condition exists.
(2) Authorizations to use or extend
restraints as an emergency shall be in effect no longer than 12 consecutive
hours and shall be obtained as soon as the client is restrained or
stable.
(3) The facility shall not
issue orders for restraint on a standing or as-needed basis.
(4) A client placed in restraint shall be
checked at least every 30 minutes by staff trained in the use of restraints,
shall be released from the restraint as quickly as possible, and a record of
these checks and usage shall be kept.
(5) Restraints shall be designated and used
so as not to cause physical injury to the client and so as to cause the least
possible discomfort.
(6)
Opportunity for motion and exercise shall be provided for a period of not less
than ten minutes during each two-hour period in which restraint is employed,
and a record of the activity shall be kept.
(7) Barred enclosures shall not be more than
three feet in height and shall not have tops.
e.
Drug usage.
(1) The facility shall not use drugs in doses
that interfere with the individual client's daily living activities.
(2) Drugs used for control of inappropriate
behavior shall be approved by the interdisciplinary team and be used only as an
integral part of the client's individual program plan that is directed
specifically toward the reduction and eventual elimination of the behaviors for
which the drugs are employed.
(3)
Drugs used for control of inappropriate behavior shall not be used until it can
be justified that the harmful effects of the behavior clearly outweigh the
potentially harmful effects of the drugs.
(4) Drugs used for control of inappropriate
behavior shall be monitored closely, in conjunction with the physician and the
drug regimen review requirement at 82.2(6)"j," for desired
responses and adverse consequences by facility staff, and shall be gradually
withdrawn at least annually in a carefully monitored program conducted in
conjunction with the interdisciplinary team, unless clinical evidence justifies
that this is contraindicated.
(6)
Health care services.
a.
Physician services.
(1) The facility shall ensure the
availability of physician services 24 hours a day.
(2) The physician shall develop, in
coordination with licensed nursing personnel, a medical care plan of treatment
for a client if the physician determines that an individual client requires
24-hour licensed nursing care. This plan shall be integrated in the individual
program plan.
(3) The facility
shall provide or obtain preventive and general medical care as well as annual
physical examinations of each client that at a minimum include the following:
1. Evaluation of vision and
hearing.
2. Immunizations, using as
a guide the recommendations of the Public Health Service Advisory Committee on
Immunization Practices or of the Committee on the Control of Infectious
Diseases of the American Academy of Pediatrics.
3. Routine screening laboratory examinations
as determined necessary by the physician, and special studies when
needed.
4. Tuberculosis control,
appropriate to the facility's population, and in accordance with the
recommendations of the American College of Chest Physicians or the section of
diseases of the chest of the American Academy of Pediatrics, or both.
(4) To the extent permitted by
state law, the facility may utilize physician assistants and nurse
practitioners to provide physician services as described in this
subrule.
b.
Physician participation in the individual program plan. A
physician shall participate in:
(1) The
establishment of each newly admitted client's initial individual program
plan.
(2) If appropriate,
physicians shall participate in the review and update of an individual program
plan as part of the interdisciplinary team process either in person or through
written report to the interdisciplinary team.
c.
Nursing services. The
facility shall provide clients with nursing services in accordance with their
needs. These services shall include:
(1)
Participation as appropriate in the development, review, and update of an
individual program plan as part of the interdisciplinary team
process.
(2) The development, with
a physician, of a medical care plan of treatment for a client when the
physician has determined that an individual client requires such a
plan.
(3) For those clients
certified as not needing a medical care plan, a review of their health status
which shall:
1. Be by a direct physical
examination.
2. Be by a licensed
nurse.
3. Be on a quarterly or more
frequent basis depending on client need.
4. Be recorded in the client's
record.
5. Result in any necessary
action including referral to a physician to address client health
problems.
(4) Other
nursing care as prescribed by the physician or as identified by client
needs.
(5) Implementing, with other
members of the interdisciplinary team, appropriate protective and preventive
health measures that include, but are not limited to:
1. Training clients and staff as needed in
appropriate health and hygiene methods.
2. Control of communicable diseases and
infections, including the instruction of other personnel in methods of
infection control.
3. Training
direct care staff in detecting signs and symptoms of illness or dysfunction,
first aid for accidents or illness, and basic skills required to meet the
health needs of the clients.
d.
Nursing staff.
(1) Nurses providing services in the facility
shall have a current license to practice in the state.
(2) The facility shall employ or arrange for
licensed nursing services sufficient to care for clients' health needs
including those clients with medical care plans.
(3) The facility shall utilize registered
nurses as appropriate and required by state law to perform the health services
specified in this subrule.
(4) If
the facility utilizes only licensed practical or vocational nurses to provide
health services, it shall have a formal arrangement with a registered nurse to
be available for verbal or on-site consultation with the licensed practical or
vocational nurse.
(5) Nonlicensed
nursing personnel who work with clients under a medical care plan shall do so
under the supervision of licensed persons.
e.
Dental services.
(1) The facility shall provide or make
arrangements for comprehensive diagnostic and treatment services for each
client from qualified personnel, including licensed dentists and dental
hygienists, either through organized dental services in-house or through
arrangement.
(2) If appropriate,
dental professionals shall participate in the development, review and update of
an individual program plan as part of the interdisciplinary process either in
person or through written report to the interdisciplinary team.
(3) The facility shall provide education and
training in the maintenance of oral health.
f.
Comprehensive dental diagnostic
services. Comprehensive dental diagnostic services include:
(1) A complete extraoral and intraoral
examination, using all diagnostic aids necessary to properly evaluate the
client's oral condition, not later than one month after admission to the
facility unless the examination was completed within 12 months prior to
admission.
(2) Periodic examination
and diagnosis performed at least annually, including radiographs when indicated
and detection of manifestations of systemic disease.
(3) A review of the results of examination
and entry of the results in the client's dental record.
g.
Comprehensive dental
treatment. The facility shall ensure comprehensive dental treatment
services that include:
(1) The availability
for emergency dental treatment on a 24-hour-a-day basis by a licensed
dentist.
(2) Dental care needed for
relief of pain and infections, restoration of teeth and maintenance of dental
health.
h.
Documentation of dental services.
(1) If the facility maintains an in-house
dental service, the facility shall keep a permanent dental record for each
client, with a dental summary maintained in the client's living unit.
(2) If the facility does not maintain an
in-house dental service, the facility shall obtain a dental summary of the
results of dental visits and maintain the summary in the client's living
unit.
i.
Pharmacy
services. The facility shall provide or make arrangements for the
provision of routine and emergency drugs and biologicals to its clients. Drugs
and biologicals may be obtained from community or contract pharmacists or the
facility may maintain a licensed pharmacy.
j.
Drug regimen review.
(1) A pharmacist with input from the
interdisciplinary team shall review the drug regimen of each client at least
quarterly.
(2) The pharmacist shall
report any irregularities in clients' drug regimens to the prescribing
physician and interdisciplinary team.
(3) The pharmacist shall prepare a record of
each client's drug regimen reviews and the facility shall maintain that
record.
(4) An individual
medication administration record shall be maintained for each client.
(5) As appropriate, the pharmacist shall
participate in the development, implementation, and review of each client's
individual program plan either in person or through written report to the
interdisciplinary team.
k.
Drug administration. The
facility shall have an organized system for drug administration that identifies
each drug up to the point of administration. The system shall ensure that:
(1) All drugs are administered in compliance
with the physician's orders.
(2)
All drugs, including those that are self-administered, are administered without
error.
(3) Unlicensed personnel are
allowed to administer drugs only if state law permits.
(4) Clients are taught how to administer
their own medications if the interdisciplinary team determines that
self-administration of medications is an appropriate objective, and if the
physician does not specify otherwise.
(5) The client's physician is informed of the
interdisciplinary team's decision that self-administration of medications is an
objective for the client.
(6) No
client self-administers medications until the client demonstrates the
competency to do so.
(7) Drugs used
by clients while not under the direct care of the facility are packaged and
labeled in accordance with state law.
(8) Drug administration errors and adverse
drug reactions are recorded and reported immediately to a physician.
l.
Drug storage and record
keeping.
(1) The facility shall
store drugs under proper conditions of sanitation, temperature, light,
humidity, and security.
(2) The
facility shall keep all drugs and biologicals locked except when being prepared
for administration. Only authorized persons may have access to the keys to the
drug storage area. Clients who have been trained to self-administer drugs in
accordance with 82.2(6)"k"(4) may have access to keys to their
individual drug supply.
(3) The
facility shall maintain records of the receipt and disposition of all
controlled drugs.
(4) The facility
shall, on a sample basis, periodically reconcile the receipt and disposition of
all controlled drugs in Schedules II through IV (drugs subject to the
Comprehensive Drug Abuse Prevention and Control Act of 1970,
21 U.S.C.
801 et seq.).
(5) If the facility maintains a licensed
pharmacy, the facility shall comply with the regulations for controlled
drugs.
m.
Drug
labeling.
(1) Labeling of drugs and
biologicals shall be based on currently accepted professional principles and
practices, and shall include the appropriate accessory and cautionary
instructions, as well as the expiration date, if applicable.
(2) The facility shall remove from use
outdated drugs and drug containers with worn, illegible, or missing
labels.
(3) Drugs and biologicals
packaged in containers designated for a particular client shall be immediately
removed from the client's current medication supply if discontinued by the
physician.
n.
Laboratory services.
(1) For
purposes of this subrule, "laboratory" means an entity for the microbiological,
serological, chemical, hematological, radiobioassay, cytological,
immunohematological, pathological or other examination of materials derived
from the human body, for the purpose of providing information for the
diagnosis, prevention, or treatment of any disease or assessment of a medical
condition.
(2) If a facility
chooses to provide laboratory services, the laboratory shall meet the
management requirements specified in
42 CFR
493.1407 as amended to March 29, 2022, and
provide personnel to direct and conduct the laboratory services.
The laboratory director shall be technically qualified to supervise the laboratory personnel and test performance and shall meet licensing or other qualification standards established by the state with respect to directors of clinical laboratories.
The laboratory director shall provide adequate technical supervision of the laboratory services and ensure that tests, examinations and procedures are properly performed, recorded and reported.
The laboratory director shall ensure that the staff has appropriate education, experience, and training to perform and report laboratory tests promptly and proficiently; is sufficient in number for the scope and complexity of the services provided; and receives in-service training appropriate to the type of complexity of the laboratory services offered.
The laboratory technologists shall be technically competent to perform test procedures and report test results promptly and proficiently.
(3) The
laboratory shall meet the proficiency testing requirements specified in
42 CFR
493.801 as amended to March 29,
2022.
(4) If the laboratory chooses
to refer specimens for testing to another laboratory, the referral laboratory
shall be an approved Medicare laboratory.
(7)
Physical environment.
a.
Client living
environment.
(1) The facility shall
not house clients of grossly different ages, developmental levels, and social
needs in close physical or social proximity unless the housing is planned to
promote the growth and development of all those housed together.
(2) The facility shall not segregate clients
solely on the basis of their physical disabilities. It shall integrate clients
who have ambulation deficits or who are deaf, hard of hearing, blind, or have
seizure disorders with others of comparable social and intellectual
development.
b.
Client bedrooms.
(1)
Bedrooms shall:
1. Be rooms that have at
least one outside wall.
2. Be
equipped with or located near toilet and bathing facilities.
3. Accommodate no more than four clients
unless granted a variance under 82.2(7)"b"(3).
4. Measure at least 60 square feet per client
in multiple-client bedrooms and at least 80 square feet in single-client
bedrooms.
5. In all facilities
initially certified or in buildings constructed or with major renovations or
conversions, have walls that extend from floor to ceiling.
(2) If a bedroom is below grade level, it
shall have a window that is usable as a second means of escape by the client
occupying the rooms and shall be no more than 44 inches measured to the
windowsill above the floor unless the facility is surveyed under the Health
Care Occupancy Chapter of the Life Safety Code, in which case the window must
be no more than 36 inches measured to the windowsill above the floor.
(3) The department of inspections and appeals
may grant a variance from the limit of four clients per room only if a
physician who is a member of the interdisciplinary team and who is a qualified
intellectual disability professional certifies that each client to be placed in
a bedroom housing more than four persons is so severely medically impaired as
to require direct and continuous monitoring during sleeping hours and documents
the reasons why housing in a room of only four or fewer persons would not be
medically feasible.
(4) The
facility shall provide each client with:
1. A
separate bed of proper size and height for the convenience of the
client.
2. A clean, comfortable
mattress.
3. Bedding appropriate to
the weather and climate.
4.
Functional furniture appropriate to the client's needs, and individual closet
space in the client's bedroom with clothes racks and shelves accessible to the
client.
c.
Storage space in bedroom. The facility shall provide:
(1) Space and equipment for daily out-of-bed
activity for all clients who are not yet mobile, except those who have a
short-term illness or those few clients for whom out-of-bed activity is a
threat to health and safety.
(2)
Suitable storage space, accessible to clients, for personal possessions such as
televisions, radios, prosthetic equipment and clothing.
d.
Client bathrooms. The
facility shall:
(1) Provide toilet and bathing
facilities appropriate in number, size, and design to meet the needs of the
clients.
(2) Provide for individual
privacy in toilets, bathtubs, and showers.
(3) In areas of the facility where clients
who have not been trained to regulate water temperature are exposed to hot
water, ensure that the temperature of the water does not exceed 110 degrees
Fahrenheit.
e.
Heating and ventilation.
(1)
Each client bedroom in the facility shall have at least one window to the
outside and direct outside ventilation by means of windows, air conditioning,
or mechanical ventilation.
(2) The
facility shall maintain the temperature and humidity within a normal comfort
range by heating, air conditioning or other means and ensure that the heating
apparatus does not constitute a burn or smoke hazard to clients.
f.
Floors. The
facility shall have:
(1) Floors that have a
resilient, nonabrasive, and slip-resistant surface.
(2) Nonabrasive carpeting, if the area used
by clients is carpeted and serves clients who lie on the floor or ambulate with
parts of their bodies, other than feet, touching the floor.
(3) Exposed floor surfaces and floor
coverings that promote mobility in areas used by clients, and promote
maintenance of sanitary conditions.
g.
Space and equipment. The
facility shall:
(1) Provide sufficient space
and equipment in dining, living, health services, recreation, and program areas
(including adequately equipped and sound treated areas for hearing and other
evaluations if they are conducted in the facility) to enable staff to provide
clients with needed services as required by this rule and as identified in each
client's individual program plan.
(2) Furnish, maintain in good repair, and
teach clients to use and to make informed choices about the use of dentures,
eyeglasses, hearing and other communications aids, braces, and other devices
identified by the interdisciplinary team as needed by the client.
(3) Provide adequate clean linen and dirty
linen storage areas.
h.
Emergency plan and procedures.
(1) The facility shall develop and implement
detailed written plans and procedures to meet all potential emergencies and
disasters such as fire, severe weather, and missing clients.
(2) The facility shall communicate,
periodically review, make the plan available, and provide training to the
staff.
i.
Evacuation drills.
(1) The
facility shall hold evacuation drills at least quarterly for each shift of
personnel and under varied conditions to ensure that all personnel on all
shifts are trained to perform assigned tasks; ensure that all personnel on all
shifts are familiar with the use of the facility's fire protection features;
and evaluate the effectiveness of emergency and disaster plans and
procedures.
(2) The facility shall
actually evacuate clients during at least one drill each year on each shift;
make special provisions for the evacuation of clients with physical
disabilities; file a report and evaluation on each evacuation drill; and
investigate all problems with evacuation drills, including accidents, and take
corrective action. During fire drills, clients may be evacuated to a safe area
in facilities certified under the Health Care Occupancies Chapter of the Life
Safety Code.
(3) Facilities shall
meet the requirements of 82.2(7)"i"(1) and (2) for any live-in
and relief staff they utilize.
j.
Fire protection.
(1) General.
1. Except as specified in
82.2(7)"i"(2), the facility shall meet the applicable
provisions of either the Health Care Occupancies Chapters or the Residential
Board and Care Occupancies Chapter of the Life Safety Code (LSC) of the
National Fire Protection Association, 1985 edition, which is incorporated by
reference.
2. The department of
inspections and appeals may apply a single chapter of the LSC to the entire
facility or may apply different chapters to different buildings or parts of
buildings as permitted by the LSC.
3. A facility that meets the LSC definition
of a residential board and care occupancy and that has 16 or fewer beds shall
have its evacuation capability evaluated in accordance with the Evacuation
Difficulty Index of the LSC (Appendix F).
(2) Exceptions.
1. For facilities that meet the LSC
definition of a health care occupancy, the Centers for Medicare and Medicaid
Services may waive, for a period it considers appropriate, specific provisions
of the LSC if the waiver would not adversely affect the health and safety of
the clients and rigid application of specific provisions would result in an
unreasonable hardship for the facility.
The
Compliance on November 28, 1982, with the 1967 edition of the LSC or compliance on April 18, 1986, with the 1981 edition of the LSC, with or without waivers, is considered to be compliance with this standard as long as the facility continues to remain in compliance with that edition of the code.
2. For facilities that
meet the LSC definition of a residential board and care occupancy and that have
more than 16 beds, the department of inspections and appeals may apply the
state's fire and safety code as specified above.
k.
Paint. The facility
shall:
(1) Use lead-free paint inside the
facility.
(2) Remove or cover
interior paint or plaster containing lead so that it is not accessible to
clients.
l.
Infection control.
(1) The
facility shall provide a sanitary environment to avoid sources and transmission
of infections. There shall be an active program for the prevention, control,
and investigation of infection and communicable diseases.
(2) The facility shall implement successful
corrective action in affected problem areas.
(3) The facility shall maintain a record of
incidents and corrective actions related to infections.
(4) The facility shall prohibit employees
with symptoms or signs of a communicable disease from direct contact with
clients and their food.
(8)
Dietetic services.
a.
Food and nutrition
services.
(1) Each client shall
receive a nourishing, well-balanced diet including modified and specially
prescribed diets.
(2) A qualified
dietitian shall be employed either full-time, part-time or on a consultant
basis at the facility's discretion.
(3) If a qualified dietitian is not employed
full-time, the facility shall designate a person to serve as the director of
food services.
(4) The client's
interdisciplinary team, including a qualified dietitian and physician, shall
prescribe all modified and special diets including those used as a part of a
program to manage inappropriate client behavior.
(5) Foods proposed for use as a primary
reinforcement of adaptive behavior are evaluated in light of the client's
nutritional status and needs.
(6)
Unless otherwise specified by medical needs, the diet shall be prepared at
least in accordance with the latest edition of the recommended dietary
allowances of the Food and Nutrition Board of the National Research Council,
National Academy of Sciences, adjusted for age, sex, disability and
activity.
b.
Meal
services.
(1) Each client shall
receive at least three meals daily, at regular times comparable to normal
mealtimes in the community with:
1. Not more
than 14 hours between a substantial evening meal and breakfast of the following
day, except on weekends and holidays when a nourishing snack is provided at
bedtime, 16 hours may elapse between a substantial evening meal and
breakfast.
2. Not less than 10
hours between breakfast and the evening meal of the same day, except as
provided under 82.2(8)"b"(1)"1."
(2) Food shall be served:
1. In appropriate quantity.
2. At appropriate temperature.
3. In a form consistent with the
developmental level of the client.
4. With appropriate utensils.
(3) Food served to clients
individually and uneaten shall be discarded.
c.
Menus.
(1) Menus shall:
1. Be prepared in advance.
2. Provide a variety of foods at each
meal.
3. Be different for the same
days of each week and adjusted for seasonal change.
4. Include the average portion sizes for menu
items.
(2) Menus for food
actually served shall be kept on file for 30 days.
d.
Dining areas and service.
The facility shall:
(1) Serve meals for all
clients, including persons with ambulation deficits, in dining areas, unless
otherwise specified by the interdisciplinary team or a physician.
(2) Provide table service for all clients who
can and will eat at a table, including clients in wheelchairs.
(3) Equip areas with tables, chairs, eating
utensils, and dishes designed to meet the developmental needs of each
client.
(4) Supervise and staff
dining rooms adequately to direct self-help dining procedure, to ensure that
each client receives enough food and to ensure that each client eats in a
manner consistent with the client's developmental level.
(5) Ensure that each client eats in an
upright position, unless otherwise specified by the interdisciplinary team or
physician.
This rule is intended to implement Iowa Code section 249A.12.
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.
No prior version found.