CHAPTER 77CONDITIONS OF PARTICIPATION FOR PROVIDERSOF MEDICAL AND REMEDIAL CARE[Prior to 7/1/83, Social Services[770] Ch 77][Prior to 2/11/87, Human Services[498]]44177.1(249A) Physicians. All physicians (doctors of medicine and osteopathy) licensed to practice in the state of Iowa are eligible to participate in the program. Physicians in other states are also eligible if duly licensed to practice in that state.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.2(249A) Retail pharmacies. Retail pharmacies are eligible to participate if they meet the requirements of this rule. 77.2(1) Licensure. Participating retail pharmacies must be licensed in the state of Iowa or duly licensed in another state. Out-of-state retail pharmacies delivering, dispensing, or distributing drugs by any method to an ultimate user physically located in Iowa must be duly licensed by Iowa as a nonresident pharmacy for that purpose. 77.2(2) Survey participation. As a condition of participation, retail pharmacies are required to make available drug acquisition cost invoice information, product availability information if known, dispensing cost information, and any other information deemed necessary by the department to assist in monitoring and revising reimbursement rates pursuant to 441—subrule 79.1(8) or for the efficient operation of the pharmacy benefit. a. A pharmacy shall produce and submit all requested information in the manner and format requested by the department or its designee at no cost to the department or its designee. b. A pharmacy shall submit information to the department or its designee within the time frame indicated following receipt of a request for information unless the department or its designee grants an extension upon written request of the pharmacy. c. Any dispensing or acquisition cost information submitted to the department that specifically identifies a pharmacy’s individual costs shall be held confidential.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0485C, 6310C44177.3(249A) Hospitals. 77.3(1) Qualifications. All hospitals licensed in the state of Iowa or in another state and certified as eligible to participate in Part A of the Medicare program (Title XVIII of the Social Security Act) are eligible to participate in the medical assistance program, subject to the additional requirements of this rule. 77.3(2) Referral to health home services provider. As a condition of participation in the medical assistance program, hospitals must establish procedures for referring to health home services providers any members who seek or need treatment in the hospital emergency department and who are eligible for health home services pursuant to 441—subrule 78.53(2). 77.3(3) Psychiatric bed tracking system. As a condition of participation in the medical assistance program, hospitals must establish procedures for participating in and updating the statewide psychiatric bed tracking system. a. Definitions.
"Adult beds" means the number of staffed and available psychiatric beds ready for admission to individuals 18 years of age to 60 years of age.
"Child beds" means the number of staffed and available psychiatric beds ready for admission to individuals up to the age of 18.
"Gender" means female or male.
"Geriatric beds" means the number of staffed and available psychiatric beds ready for admission to individuals 60 years of age and older.
"Hospital," for purposes of this subrule, means any licensed hospital providing inpatient psychiatric services and the state mental health institutes.
"Psychiatric bed tracking system" means a web-based electronic system managed by the department that can be searched to locate inpatient psychiatric services at an Iowa hospital.
b. Hospitals are required to participate in the psychiatric bed tracking system. c. Hospitals shall update the psychiatric bed tracking system, at a minimum, two times per day. The first update shall be entered between 12:00:01 a.m.and 9:59:59 a.m.each day; the second update shall be entered between 8:00:00 p.m.and 11:59:59 p.m.each day. d. Each update must include the number of child beds by gender, the number of adult beds by gender, and the number of geriatric beds by gender. e. Failure to comply with the psychiatric bed tracking reporting may result in sanctions in accordance with rule 441—79.2(249A).This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0198C, 3789C44177.4(249A) Dentists. All dentists licensed to practice in the state of Iowa are eligible to participate in the program. Dentists in other states are also eligible if duly licensed to practice in that state.Note: dental laboratories —Payment will not be made to a dental laboratory.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.5(249A) Podiatrists. All podiatrists licensed to practice in the state of Iowa are eligible to participate in the program. Podiatrists in other states are also eligible if duly licensed to practice in that state.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.6(249A) Optometrists. All optometrists licensed to practice in the state of Iowa are eligible to participate in the program. Optometrists in other states are also eligible if duly licensed to practice in that state.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.7(249A) Opticians. All opticians in the state of Iowa are eligible to participate in the program. Opticians in other states are also eligible to participate.Note: Opticians in states having licensing requirements for this professional group must be duly licensed in that state.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.8(249A) Chiropractors. All chiropractors licensed to practice in the state of Iowa are eligible to participate providing they have been determined eligible to participate in Title XVIII of the Social Security Act (Medicare) by the Social Security Administration. Chiropractors in other states are also eligible if duly licensed to practice in that state and determined eligible to participate in Title XVIII of the Social Security Act.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.9(249A) Home health agencies. Home health agencies are eligible to participate providing they are certified to participate in the Medicare program (Title XVIII of the Social Security Act) and, unless exempted under subrule 77.9(5), have submitted a surety bond as required by subrules 77.9(1) to 77.9(6). 77.9(1) Definitions. "Assets" includes any listing that identifies Medicaid members to whom home health services were furnished by a participating or formerly participating home health agency.
"Rider" means a notice issued by a surety that a change in the bond has occurred or will occur.
"Uncollected overpayment" means a Medicaid overpayment, including accrued interest, for which the home health agency is responsible that has not been recouped by the department within 60 days from the date of notification that an overpayment has been identified.
77.9(2) Parties to surety bonds. The surety bond shall name the home health agency as the principal, the Iowa department of human services as the obligee and the surety company (and its heirs, executors, administrators, successors and assignees, jointly and severally) as surety. The bond shall be issued by a company holding a current Certificate of Authority issued by the U.S. Department of the Treasury in accordance with 31 U.S.C. Sections 9304 to 9308 and 31 CFR Part 223 as amended to November 30, 1984, Part 224 as amended to May 29, 1996, and Part 225 as amended to September 12, 1974. The bond shall list the surety’s name, street address or post office box number, city, state and ZIP code. The company shall not have been determined by the department to be unauthorized in Iowa due to: a. Failure to furnish timely confirmation of the issuance of and the validity and accuracy of information appearing on a surety bond that a home health agency presents to the department that shows the surety company as surety on the bond. b. Failure to timely pay the department in full the amount requested, up to the face amount of the bond, upon presentation by the department to the surety company of a request for payment on a surety bond and of sufficient evidence to establish the surety company’s liability on the bond. c. Other good cause.The department shall give public notice of a determination that a surety company is unauthorized in Iowa and the effective date of the determination by publication of a notice in the newspaper of widest circulation in each city in Iowa with a population of 50,000 or more. A list of surety companies determined by the department to be unauthorized in Iowa shall be maintained and shall be available for public inspection by contacting the division of medical services of the department. The determination that a surety company is unauthorized in Iowa has effect only in Iowa and is not a debarment, suspension, or exclusion for the purposes of Federal Executive Order No.12549. 77.9(3) Surety company obligations. The bond shall guarantee payment to the department, up to the face amount of the bond, of the full amount of any uncollected overpayment, including accrued interest, based on payments made to the home health agency during the term of the bond. The bond shall provide that payment may be demanded from the surety after available administrative collection methods for collecting from the home health agency have been exhausted. 77.9(4) Surety bond requirements. Surety bonds secured by home health agencies participating in Medicaid shall comply with the following requirements: a. Effective dates and submission dates. (1) Home health agencies participating in the program on June 10, 1998, shall secure either an initial surety bond for the period January 1, 1998, through the end of the home health agency’s fiscal year or a continuous bond which remains in effect from year to year. (2) Home health agencies seeking to participate in Medicaid and Medicare for the first time after June 10, 1998, shall secure an initial surety bond for the period from Medicaid certification through the end of the home health agency’s fiscal year or a continuous bond which remains in effect from year to year. (3) Medicare-certified home health agencies seeking to participate in Medicaid for the first time after June 10, 1998, shall secure an initial surety bond for the period from Medicaid certification through the end of the home health agency’s fiscal year or a continuous bond which remains in effect from year to year. (4) Home health agencies seeking to participate in Medicaid after purchasing the assets of or an ownership interest in a participating or formerly participating agency shall secure an initial surety bond effective as of the date of purchase of the assets or the transfer of the ownership interest for the balance of the current fiscal year of the home health agency or a continuous bond which remains in effect from year to year. (5) Home health agencies which continue to participate in Medicaid after the period covered by an initial surety bond shall secure a surety bond for each subsequent fiscal year of the home health agency or a continuous bond which remains in effect from year to year. b. Amount of bond. Bonds for any period shall be in the amount of $50,000 or 15 percent of the home health agency’s annual Medicaid payments during the most recently completed state fiscal year, whichever is greater. After June 1, 2005, all bonds shall be in the amount of $50,000. At least 90 days before the start of each home health agency’s fiscal year, the department shall provide notice of the amount of the surety bond to be purchased and submitted to the Iowa Medicaid enterprise provider services unit. c. Other requirements. Surety bonds shall meet the following additional requirements. The bond shall: (1) Guarantee that upon written demand by the department to the surety for payment under the bond and the department’s furnishing to the surety sufficient evidence to establish the surety’s liability under the bond, the surety shall within 60 days pay the department the amount so demanded, up to the stated amount of the bond. (2) Provide that the surety’s liability for uncollected overpayments is based on overpayments determined during the term of the bond. (3) Provide that the surety’s liability to the department is not extinguished by any of the following:- Any action by the home health agency or the surety to terminate or limit the scope or term of the bond unless the surety furnishes the department with notice of the action not later than 10 days after the date of notice of the action by the home health agency to the surety and not later than 60 days before the effective date of the action by the surety.
- The surety’s failure to continue to meet the requirements in subrule 77.9(2) or the department’s determination that the surety company is an unauthorized surety under subrule 77.9(2).
- Termination of the home health agency’s provider agreement.
- Any action by the department to suspend, offset, or otherwise recover payments to the home health agency.
- Any action by the home health agency to cease operations, sell or transfer any assets or ownership interest, file for bankruptcy, or fail to pay the surety.
- Any fraud, misrepresentation, or negligence by the home health agency in obtaining the surety bond or by the surety (or the surety’s agent, if any) in issuing the surety bond; except that any fraud, misrepresentation, or negligence by the home health agency in identifying to the surety (or the surety’s agent) the amount of Medicaid payments upon which the amount of the surety bond is determined shall not cause the surety’s liability to the department to exceed the amount of the bond.
- The home health agency’s failure to exercise available appeal rights under Medicaid or assign appeal rights to the surety.
- The Joint Commission accreditation (TJC), or
- The Healthcare Facilities Accreditation Program (HFAP), or
- The Commission on Accreditation of Rehabilitation Facilities (CARF), or
- The Council on Accreditation (COA), or
- The Accreditation Association for Ambulatory Health Care (AAAHC), or
- Iowa Administrative Code 441—Chapter 24, “Accreditation of Providers of Services to Persons with Mental Illness, Intellectual Disabilities, or Developmental Disabilities.”
"Certified employment specialist" "CES" means a person who has demonstrated a sufficient level of knowledge and skill to provide integrated employment support services to a variety of client populations and has earned a CES certification through a nationally recognized accrediting body.
"Guardian" means a guardian appointed in probate or juvenile court.
"Individual placement and support" "IPS" means the evidence-based practice of supported employment that is guided by IPS practice principles outlined by the IPS Employment Center at Westat, and as measured by its most recently published 25-item supported employment fidelity scale available online at ipsworks.org/wp-content/uploads/2017/08/ips-fidelity-manual-3rd-edition_2-4-16.pdf. The IPS practice principles are:
- Focus on competitive employment: Agencies providing IPS services are committed to competitive employment as an attainable goal for people with behavioral health conditions seeking employment. Mainstream education and specialized training may enhance career paths.
- Zero exclusion criteria based on client choice: People are not excluded on the basis of readiness, diagnoses, symptoms, substance use history, psychiatric hospitalizations, homelessness, level of disability, or legal system involvement.
- Integration of rehabilitation and mental health services: IPS programs are closely integrated with mental health treatment teams.
- Attention to worker preferences: Services are based on each person’s preferences and choices, rather than providers’ judgments.
- Personalized benefits counseling: Employment specialists help people obtain personalized, understandable, and accurate information about their social security, Medicaid, and other government entitlements.
- Rapid job search: IPS programs use a rapid job search approach to help job seekers obtain jobs directly, rather than providing lengthy preemployment assessment, training, and counseling. If further education is part of their plan, IPS specialists assist in these activities as needed.
- Systematic job development: Employment specialists systematically visit employers, who are selected based on job seeker preferences, to learn about their business needs and hiring preferences.
- Time-unlimited and individualized support: Job supports are individualized and continue for as long as each worker wants and needs the support.
"Intensive residential service homes" or "intensive residential services" means intensive, community-based services provided 24 hours per day, 7 days per week, 365 days per year to individuals with a severe and persistent mental illness who have functional impairments and may also have multi-occurring conditions. Providers of intensive residential service homes are enrolled with Medicaid as providers of HCBS habilitation or HCBS intellectual disability waiver supported community living and meet additional criteria specified in 441—subrule 25.6(8).
"IPS 25-item supported employment fidelity scale" means the fidelity scale published by the IPS Employment Center at Westat, resulting in scores of exemplary fidelity, good fidelity, fair fidelity, or not supported employment.
"IPS implementation" means the process advocated by the IPS Employment Center at Westat, which consists of the following phases:
- Formation of IPS team steering group and one-day meeting with the IPS trainer and team members.
- Completion of the IPS Readiness Assessment developed by the IPS Employment Center at Westat and individual review with the IPS trainer.
- Completion of a one-day IPS kick-off team training with the IPS trainer and team members.
- Participation in individual team training and monthly consultations as follows:
- Two-and-a-half-day individual team training with the IPS trainer and team members.
- Virtual training by the IPS Employment Center at Westat for at least three people per team.
- Leadership training for two people per team at the IPS Employment Center at Westat.
- Virtual monthly technical assistance for two hours per month per team.
- Participation in the International Learning Collaborative, including:
- Participation in the International Learning Collaborative annual conference by two people per state.
- Virtual monthly technical assistance calls with the IPS Employment Center at Westat mentor assigned to the team.
- Participation in the prescribed data tracking and management activities.
- Completion of one baseline fidelity review per IPS team, with two IPS reviewers on site for two days per review.
- Evaluation and development of next steps, with an on-site half-day meeting for the IPS trainer and the team.
"IPS reviewer" means a person who is qualified to complete fidelity reviews of IPS services and is one of the following:
- A person who has provided IPS services or has supervised an IPS team in Iowa which has obtained a fidelity score of “good” or better, has completed the IPS Employment Center at Westat’s training to become an IPS reviewer, and has shadowed one or more IPS fidelity reviews;
- An existing IPS reviewer from a state which is a member of the IPS International Learning Collaborative;
- An IPS reviewer contracted directly from the IPS Employment Center at Westat;
- A CES with a bachelor’s degree who has completed the IPS Employment Center at Westat’s training to become an IPS reviewer and has shadowed one or more IPS fidelity reviews.
"IPS team" means, at a minimum, an IPS employment specialist, a behavioral health specialist, Iowa Vocational Rehabilitation Services (IVRS) counselor, and a case manager or care coordinator.
"IPS trainer" means a person who is qualified to provide training and technical assistance for IPS implementation and is one of the following:
- A person who has provided IPS services or has supervised an IPS team in Iowa which has obtained a fidelity score of “good” or better, and has completed the IPS Employment Center at Westat’s training to become an IPS trainer;
- An existing IPS trainer from a state which is a member of the IPS International Learning Collaborative;
- An IPS trainer contracted directly from the IPS Employment Center at Westat;
- A CES with a bachelor’s degree who has completed the IPS Employment Center at Westat’s training to become an IPS trainer.
"Major incident" means an occurrence involving a member during service provision that:
- Results in a physical injury to or by the member that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the member;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a member’s location being unknown by provider staff who are assigned protective oversight.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Member" means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
"Minor incident" means an occurrence involving a member during service provision that is not a major incident and that:
- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
"Prospective IPS team" means a group that is forming an IPS team to deliver IPS services but who has not yet completed implementation phase 4a.
"Provider-owned or controlled setting" means a setting where the HCBS provider owns the property where the member resides, leases the property from a third party, or has a direct or indirect financial relationship with the property owner that impacts either the care provided to or the financial conditions applicable to the member. The unit or dwelling is a specific physical space that can be owned, rented, or occupied under a legally enforceable agreement by the member receiving services, and the member has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the state, county, city, or other designated entity. For the settings in which landlord tenant laws do not apply, the state must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS member and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law.
"Provisionally approved IPS team" means a group that has (1) formed a team to deliver IPS services, (2) completed implementation phase 4a, and (3) begun to deliver IPS services.
77.25(2) Organization and staff. a. The prospective provider shall demonstrate the fiscal capacity to initiate and operate the specified programs on an ongoing basis. b. The provider shall complete child abuse, dependent adult abuse, and criminal background screenings pursuant to Iowa Code section 249A.29 before employing a person who will provide direct care. c. A person providing direct care shall be at least 16 years of age. d. A person providing direct care shall not be an immediate family member of the member. 77.25(3) Incident management and reporting. As a condition of participation in the medical assistance program, HCBS habilitation service providers must comply with the requirements of Iowa Code sections 232.69 and 235B.3 regarding the reporting of child abuse and dependent adult abuse and with the incident management and reporting requirements in this subrule. a. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the member’s file. b. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- The staff member’s supervisor.
- The member or the member’s legal guardian. Exception: Notification to the member is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The member’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the member involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other members or nonmembers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- The home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A); or
- The home- and community-based services brain injury waiver pursuant to rule 441—77.39(249A).
- The home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A); or
- The home- and community-based services brain injury waiver pursuant to rule 441—77.39(249A).
- The consumer’s name, birth date, age, and address and the telephone number of each parent, guardian or primary caregiver.
- An emergency medical care release.
- Emergency contact telephone numbers such as the number of the consumer’s physician and the parents, guardian, or primary caregiver.
- The consumer’s medical issues, including allergies.
- The consumer’s daily schedule which includes the consumer’s preferences in activities or foods or any other special concerns.
- Notifying the parent, guardian or primary caregiver of any injuries or illnesses that occur during respite provision. A parent’s, guardian’s or primary caregiver’s signature is required to verify receipt of notification.
- Requiring the parent, guardian or primary caregiver to notify the respite provider of any injuries or illnesses that occurred prior to respite provision.
- Documenting activities and times of respite. This documentation shall be made available to the parent, guardian or primary caregiver upon request.
- Ensuring the safety and privacy of the individual. Policies shall at a minimum address threat of fire, tornado, or flood and bomb threats.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- The consumer’s name, birth date, age, and address and the telephone number of the spouse, guardian or primary caregiver.
- An emergency medical care release.
- Emergency contact telephone numbers such as the number of the consumer’s physician and the spouse, guardian, or primary caregiver.
- The consumer’s medical issues, including allergies.
- The consumer’s daily schedule which includes the consumer’s preferences in activities or foods or any other special concerns.
- Notifying the spouse, guardian, or primary caregiver of any injuries or illnesses that occur during respite provision. A spouse’s, guardian’s or primary caregiver’s signature is required to verify receipt of notification.
- Requiring the spouse, guardian or primary caregiver to notify the respite provider of any injuries or illnesses that occurred prior to respite provision.
- Documenting activities and times of respite. This documentation shall be made available to the spouse, guardian or primary caregiver upon request.
- Ensuring the safety and privacy of the individual. Policies shall at a minimum address threat of fire, tornado, or flood and bomb threats.
- Meets the qualifications for case managers in 641—subrule 80.6(1); and
- Provides a current IDPH local public health services contract number.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- The consumer’s name, birth date, age, and address and the telephone number of each parent, guardian or primary caregiver.
- An emergency medical care release.
- Emergency contact telephone numbers such as the number of the consumer’s physician and the parents, guardian, or primary caregiver.
- The consumer’s medical issues, including allergies.
- The consumer’s daily schedule which includes the consumer’s preferences in activities or foods or any other special concerns.
- Notifying the parent, guardian or primary caregiver of any injuries or illnesses that occur during respite provision. A parent’s, guardian’s or primary caregiver’s signature is required to verify receipt of notification.
- Requiring the parent, guardian, or primary caregiver to notify the respite provider of any injuries or illnesses that occurred prior to respite provision.
- Documenting activities and times of respite. This documentation shall be made available to the parent, guardian or primary caregiver upon request.
- Ensuring the safety and privacy of the individual. Policies shall at a minimum address threat of fire, tornado, or flood and bomb threats.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff consumer’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- Implementation of necessary staff training and consumer input.
- Implementation of provider system changes to allow for flexibility in staff duties, services based on what each individual needs, and removal of housing as part of the service.
- The quantity of services currently available in the county is insufficient to meet the need;
- The quantity of affordable rental housing in the county is insufficient to meet the need; or
- Approval will result in a reduction in the size or quantity of larger congregate settings.
- The consumer’s name, birth date, age, and address and the telephone number of each parent, guardian or primary caregiver.
- An emergency medical care release.
- Emergency contact telephone numbers such as the number of the consumer’s physician and the parents, guardian, or primary caregiver.
- The consumer’s medical issues, including allergies.
- The consumer’s daily schedule which includes the consumer’s preferences in activities or foods or any other special concerns.
- Notifying the parent, guardian or primary caregiver of any injuries or illnesses that occur during respite provision. A parent’s, guardian’s or primary caregiver’s signature is required to verify receipt of notification.
- Requiring the parent, guardian or primary caregiver to notify the respite provider of any injuries or illnesses that occurred prior to respite provision.
- Documenting activities and times of respite. This documentation shall be made available to the parent, guardian or primary caregiver upon request.
- Ensuring the safety and privacy of the individual. Policies shall at a minimum address threat of fire, tornado, or flood and bomb threats.
- The agency must provide orientation training on the agency’s purpose, policies, and procedures within one month of hire or contracting for all employed and contracted treatment staff and must provide 24 hours of training during the first year of employment or contracting. The agency must also provide at least 12 hours of training per year after the first year of employment for all employed and contracted treatment staff. Annual training shall include, at a minimum, training on children’s intellectual disabilities and developmental disabilities services and children’s mental health issues. Identification and reporting of child abuse shall be covered in training at least every three years, in accordance with Iowa Code section 232.69.
- The agency must have standards for the rights and dignity of children that are age-appropriate. These standards shall include the following:
- Children, their families, and their legal representatives decide what personal information is shared and with whom.
- Children are a part of family and community life and perform varied social roles.
- Children have family connections, a social network, and varied relationships.
- Children develop and accomplish personal goals.
- Children are valued.
- Children live in positive environments.
- Children exercise their rights and responsibilities.
- Children make informed choices about how they spend their free time.
- Children choose their daily routine.
- The agency must use methods of self-evaluation by which:
- Past performance is reviewed.
- Current functioning is evaluated.
- Plans are made for the future based on the review and evaluation.
- The agency must have a governing body that receives and uses input from a wide range of local community interests and consumer representatives and provides oversight that ensures the provision of high-quality supports and services to children.
- Children, their parents, and their legal representatives must have the right to appeal the service provider’s application of policies or procedures or any staff person’s action that affects the consumer. The service provider shall distribute the policies for consumer appeals and procedures to children, their parents, and their legal representatives.
- Strengths and needs of the child.
- Goals to be achieved to meet the needs of the child.
- Objectives for each goal that are specific, measurable, and time-limited and include indicators of progress toward each goal.
- Specific service activities to be provided to achieve the objectives.
- The persons responsible for providing the services. When daily living and social skills development is provided in a group care setting, designation may be by job title.
- Date of service initiation and date of individual service plan development.
- Service goals describing how the child will be reunited with the child’s family and community.
- Service goals or objectives have been achieved.
- Progress toward goals and objectives is not being made.
- Changes have occurred in the identified service needs of the child, as listed on the Supports Intensity Scale® (SIS) assessment.
- The service plan is not consistent with the identified service needs of the child, as listed in the service plan.
- How the transition will occur.
- What physical change will need to take place in the living units.
- How children and their families will be involved in the transitioning process.
- How this transition will affect children’s social and educational environment.
- Initial certification. Providers eligible for initial certification by the department shall be issued an initial certification for 270 calendar days, effective on the date identified on the certificate of approval, based on documentation provided.
- Recertification. After the initial certification, recertification shall be based on an on-site review and shall be contingent upon demonstration of compliance with certification requirements.An exit conference shall be held with the provider to share preliminary findings of the recertification review. A review report shall be written and sent to the provider within 30 calendar days unless the parties mutually agree to extend that time frame.Recertification shall become effective on the date identified on the Certificate of Approval, Form 470-3410, and shall terminate one year from the month of issuance.Corrective actions may be required in connection with recertification and may be monitored through the assignment of follow-up monitoring either by written report, a plan of corrective actions and improvements, an on-site review, or the provision of technical assistance.
- Probational certification. Probational certification for 270 calendar days may be issued to a provider who cannot demonstrate compliance with all certification requirements on recertification review to give the provider time to establish and implement corrective actions and improvement activities.During the probational certification period, the department may require monitoring of the implementation of the corrective actions through on-site visits, written reports, or technical assistance.Probational certification shall not be renewed or extended and shall require a full on-site follow-up review to be completed. The provider must demonstrate compliance with all certification requirements at the time of the follow-up review in order to maintain certification.
- Immediate jeopardy. If, during the course of any review, a review team member encounters a situation that places a member in immediate jeopardy, the team member shall immediately notify the provider, the department, and other team members. “Immediate jeopardy” refers to circumstances where the life, health, or safety of a member will be severely jeopardized if the circumstances are not immediately corrected.The provider shall correct the situation within 24 to 48 hours. If the situation is not corrected within the prescribed time frame, the provider shall not be certified. The department shall immediately discontinue funding for that provider’s service. If this action is appealed and the member or legal guardian wants to maintain the provider’s services, funding can be reinstated. At that time the provider shall take appropriate action to ensure the life, health, and safety of the members deemed to be at risk. The case manager or department service worker shall notify the county or region in the event the county or region is funding a service that may assist the member in the situation.
- Abuse reporting. As a mandatory reporter, each review team member shall follow appropriate procedure in all cases where a condition reportable to child and adult protective services is observed.
- Extensions. The department shall establish the length of extensions on a case-by-case basis. The department may grant an extension to the period of certification for the following reasons:
- A delay in the department’s approval decision exists which is beyond the control of the provider or department.
- A request for an extension is received from a provider to permit the provider to prepare and obtain department approval of corrective actions.
- Revocation. The department may revoke the provider’s approval at any time for any of the following reasons:
- The findings of a site visit indicate that the provider has failed to implement the corrective actions submitted pursuant to paragraph 77.37(13)“e” and numbered paragraph 77.37(23)“f”(3)“4.”
- The provider has failed to provide information requested pursuant to paragraph 77.37(13)“f” and numbered paragraph 77.37(23)“f”(3)“4.”
- The provider refuses to allow the department to conduct a site visit pursuant to paragraph 77.37(13)“h” and subparagraph 77.37(23)“f”(3).
- There are instances of noncompliance with the standards that were not identified from information submitted on the application.
- Notice of intent to withdraw. An approved provider shall immediately notify the department, applicable county, the applicable mental health and developmental disabilities planning council, and other interested parties of a decision to withdraw as a provider of residential-based supported community living services.
- Technical assistance. Following certification, any provider may request technical assistance from the department regarding compliance with program requirements. The department may require that technical assistance be provided to a provider to assist in the implementation of any corrective action plan.
- Appeals. The provider can appeal any adverse action under 441—Chapter 7.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- The quantity of services currently available in the county is insufficient to meet the need;
- The quantity of affordable rental housing in the county is insufficient to meet the need; or
- Approval will result in a reduction in the size or quantity of larger congregate settings.
- The consumer’s name, birth date, age, and address and the telephone number of each parent, guardian or primary caregiver.
- An emergency medical care release.
- Emergency contact telephone numbers such as the number of the consumer’s physician and the parents, guardian, or primary caregiver.
- The consumer’s medical issues, including allergies.
- The consumer’s daily schedule which includes the consumer’s preferences in activities or foods or any other special concerns.
- Notifying the parent, guardian or primary caregiver of any injuries or illnesses that occur during respite provision. A parent’s, guardian’s or primary caregiver’s signature is required to verify receipt of notification.
- Requiring the parent, guardian or primary caregiver to notify the respite provider of any injuries or illnesses that occurred prior to respite provision.
- Documenting activities and times of respite. This documentation shall be made available to the parent, guardian or primary caregiver upon request.
- Ensuring the safety and privacy of the individual. Policies shall at a minimum address threat of fire, tornado, or flood and bomb threats.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
b. Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. c. Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident: (1) The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- Is in good standing under the infants and toddlers with disabilities program administered by the department of education, the department of public health, the department of human services, and the Iowa Child Health Specialty Clinics pursuant to the interagency agreement between these agencies under Subchapter III of the federal Individuals with Disabilities Education Act (IDEA); and
- Meets the following additional requirements.
- Consumers are valued.
- Consumers are a part of community life.
- Consumers develop meaningful goals.
- Consumers maintain physical and mental health.
- Consumers are safe.
- Consumers and their families have an impact on the services received.
"Major incident" means an occurrence involving a consumer during service provision that:
- Results in a physical injury to or by the consumer that requires a physician’s treatment or admission to a hospital;
- Results in the death of any person;
- Requires emergency mental health treatment for the consumer;
- Requires the intervention of law enforcement;
- Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
- Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
- Involves a consumer’s location being unknown by provider staff who are assigned protective oversight.
"Minor incident" means an occurrence involving a consumer during service provision that is not a major incident and that:
(2) Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the consumer’s file. (3) Notification procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident, the staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:- Results in the application of basic first aid;
- Results in bruising;
- Results in seizure activity;
- Results in injury to self, to others, or to property; or
- Constitutes a prescription medication error.
- The staff member’s supervisor.
- The consumer or the consumer’s legal guardian. Exception: Notification to the consumer is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
- The consumer’s case manager.
- By direct data entry into the Iowa Medicaid Provider Access System, or
- By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
- The name of the consumer involved.
- The date and time the incident occurred.
- A description of the incident.
- The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other waiver-eligible or non-waiver-eligible consumers who were present must be maintained by the use of initials or other means.
- The action that the provider staff took to manage the incident.
- The resolution of or follow-up to the incident.
- The date the report is made and the handwritten or electronic signature of the person making the report.
- Orientation regarding the agency’s mission, policies, and procedures; and
- Orientation regarding HCBS philosophy and outcomes for rights and dignity found in 77.36(1)“c” for the children’s mental health waiver.
- Serious emotional disturbance in children and provision of services to children with serious emotional disturbance;
- Confidentiality;
- Provision of medication according to agency policy and procedure;
- Identification and reporting of child abuse;
- Incident reporting;
- Documentation of service provision;
- Appropriate behavioral interventions; and
- Professional ethics.
- Orientation regarding the agency’s mission, policies, and procedures; and
- Orientation regarding HCBS philosophy and outcomes for rights and dignity found in 77.46(1)“c” for the children’s mental health waiver.
- Serious emotional disturbance in children and service provision to children with serious emotional disturbance;
- Confidentiality;
- Provision of medication according to agency policy and procedure;
- Identification and reporting of child abuse;
- Incident reporting;
- Documentation of service provision;
- Appropriate behavioral interventions; and
- Professional ethics.
- Orientation regarding the agency’s mission, policies, and procedures; and
- Orientation regarding HCBS philosophy and outcomes for rights and dignity for the children’s mental health waiver in 77.46(1)“c.”
- Serious emotional disturbance in children and provision of services to children with serious emotional disturbance;
- Confidentiality;
- Provision of medication according to agency policy and procedure;
- Identification and reporting of child abuse;
- Incident reporting;
- Documentation of service provision;
- Appropriate behavioral interventions; and
- Professional ethics.
"Chronic condition" means, for purposes of this rule, one of the conditions outlined in 441—subparagraph 78.53(3)“a”(1).
"Chronic condition health home" means a provider enrolled to deliver personalized, coordinated care for members with one chronic condition and at risk of developing another.
"Functional impairment" means the loss of functional capacity that (1) is episodic, recurrent, or continuous; (2) substantially interferes with or limits the achievement of or maintenance of one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills; and (3) substantially interferes with or limits the individual’s functional capacity with family, employment, school, or community. “Functional impairment” does not include difficulties resulting from temporary and expected responses to stressful events in a person’s environment. The level of functional impairment must be identified by the assessment completed by a mental health professional as defined in rule 441—24.1(225C).
"Health home" means a chronic condition health home or an integrated health home.
"Integrated health home" means a provider enrolled to integrate medical, social, and behavioral health care needs for adults with a serious mental illness and children with a serious emotional disturbance.
"Lead entity" means a managed care organization that supports and oversees the chronic condition health home and the integrated health home network.
"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
"Serious emotional disturbance" means the same as defined in rule 441—83.121(249A).
"Serious mental illness" means, for an adult, a persistent or chronic mental health, behavioral, or emotional disorder that (1) is specified within the most current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association or its most recent International Classification of Diseases, and (2) causes serious functional impairment and substantially interferes with or limits one or more major life activities, including functioning in the family, school, employment or community. “Serious mental illness” may co-occur with substance use disorder, developmental disabilities, neurodevelopmental disabilities or intellectual disabilities, but those diagnoses may not be the clinical focus for health home services.
77.47(2) Chronic condition health home provider qualifications. a. A chronic condition health home must be one of the following: (1) Physician(s). (2) Clinical practice or clinical group practice. (3) Rural health clinic. (4) Community health center. (5) Community mental health center accredited under 441—Chapter 24. (6) Federally qualified health clinic. b. A chronic condition health home may include multiple sites when those sites are identified as a single organization or medical group that shares policies, procedures, and electronic systems across all of the single organization’s or medical group’s practice sites. c. A chronic condition health home must achieve accreditation, recognition, or certification as a patient-centered medical home (PCMH) through a national accreditation or certification entity recognized by the department within the first year of operation and maintain the accreditation, recognition, or certification for the duration of enrollment as a health home. A chronic condition health home that fails to achieve accreditation, recognition, or certification within the first year of enrollment will have the chronic condition health home enrollment terminated unless granted an extension by the department. d. A chronic condition health home must complete a self-assessment when enrolling as a new health home and annually thereafter. e. A chronic condition health home must meet the requirements, qualifications, and standards outlined in the chronic condition health home state plan amendment. f. A chronic condition health home must participate in monthly, quarterly, and annual outcomes data collection and reporting. g. At a minimum, a chronic condition health home must fill the following roles: (1) Designated practitioner. The chronic condition health home must have at least one physician with an active Iowa license and credentialed with at least one managed care organization. If a chronic condition health home has multiple sites, a specific site may have a nurse practitioner or physician assistant, so long as the chronic condition health home has as least one physician. (2) Nurse care manager. The chronic condition health home must have at least one nurse care manager who is a registered nurse or has a bachelor of science in nursing with an active Iowa nursing license in accordance with rule 655—3.3(17A,147,152,272C). (3) Health coach. The chronic condition health home must have at least one trained health coach. 77.47(3) Integrated health home provider qualifications. a. An integrated health home must be one of the following: (1) Community mental health center accredited under 441—Chapter 24. (2) Licensed mental health service provider. (3) Licensed residential group care setting. (4) Licensed psychiatric medical institution for children (PMIC). (5) Provider accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) to provide behavioral health services. (6) Provider accredited by the Council on Accreditation for behavioral health or child, youth and family services. (7) Provider accredited by the Joint Commission for behavioral health care services. (8) Provider accredited under 441—Chapter 24 to deliver services to persons with mental illness. b. An integrated health home may include multiple sites when those sites are identified as a single organization or medical group that shares policies, procedures, and electronic systems across all of the single organization’s or medical group’s practice sites. c. An integrated health home must complete a self-assessment when enrolling as a new health home and annually thereafter. d. An integrated health home must meet the requirements, qualifications, and standards outlined in the integrated health home state plan amendment. e. An integrated health home must participate in monthly, quarterly, and annual outcomes data collection and reporting. f. At a minimum, an integrated health home must fill the following roles: (1) If serving adults: 1. Nurse care manager. The integrated health home must have a nurse care manager who is a registered nurse or has a bachelor of science in nursing with an active Iowa nursing license in accordance with rule 655—3.3(17A,147,152,272C). 2. Care coordinator. The integrated health home must have a care coordinator who has a bachelor of science in social work or a bachelor of science or bachelor of arts degree in a related field. 3. Trained peer support specialist. The integrated health home must have a peer support specialist who has completed a department-recognized training program and passed the competency examination within six months of hire. (2) If serving children: 1. Nurse care manager. The integrated health home must have a nurse care manager who is a registered nurse or has a bachelor of science in nursing with an active Iowa nursing license in accordance with rule 655—3.3(17A,147,152,272C). 2. Care coordinator. The integrated health home must have a care coordinator who has a bachelor of science in social work or a bachelor of science or bachelor of arts degree in a related field. 3. Family peer support specialist. The integrated health home must have a family peer support specialist who has completed a department-recognized training program and passed the competency examination within six months of hire. 77.47(4) Lead entity qualifications. a. A lead entity must meet the following requirements: (1) The lead entity must be licensed and in good standing in the state of Iowa as a health maintenance organization in accordance with 191—Chapter 40. (2) The lead entity must have a statewide integrated network of providers to serve members with serious mental illness and serious emotional disturbance. (3) The lead entity must complete a self-assessment at the time of enrollment and annually thereafter. (4) The lead entity must meet requirements, qualifications, and standards outlined in the state plan. (5) The lead entity must participate in monthly, quarterly, and annual outcomes data collection and reporting. b. At a minimum, a lead entity must fill the following roles: (1) Physician. The lead entity must have at least one physician to support the health home in meeting provider standards. The physician must have an active Iowa license to practice medicine in accordance with 653—Chapter 9 and be credentialed with at least one managed care organization. (2) Nurse care managers. The lead entity must have nurse care managers to support the health home in meeting provider standards. A nurse care manager must be a registered nurse or have a bachelor of science in nursing with an active Iowa nursing license in accordance with rule 655—3.3(17A,147,152,272C). (3) Social workers. The lead entity must have a care coordinator with a bachelor of science or bachelor of arts degree in social work or a related field, including sociology, counseling, psychology, or human services, to support the health home in meeting the provider standards and delivering health home services. (4) Behavioral health professionals. The lead entity must have a psychiatrist to support the health home in meeting provider standards and to deliver health home services. The psychiatrist must have an active Iowa license to practice medicine in accordance with 653—Chapter 9 and be credentialed with at least one managed care organization. 77.47(5) Health home general requirements. a. Whole person orientation. The health home is responsible for providing whole person care. (1) The health home must provide or take responsibility for appropriately arranging care with other qualified professionals for all the member’s health care needs. This includes care for all stages of life, including acute care, chronic care, preventive services, long-term care, and end-of-life care. (2) The health home must complete status reports to document the member’s housing, legal status, employment status, education, custody, and other social determinants of health, as applicable. (3) The health home must implement a formal screening tool to assess behavioral health, including mental health and substance abuse treatment needs, along with physical health care needs. (4) The health home must work with the lead entity or Iowa Medicaid to develop capacity to receive members redirected from emergency departments, engage in planning transitions in care with area hospitals, and follow up on hospital discharges, including psychiatric medical institutions for children. (5) The health home must provide bidirectional and integrated primary care and behavioral health services through use of a contract, memoranda of agreement, or other written agreements approved by the department. (6) The health home must, at the time of enrollment and reenrollment, provide letters of support from at least one area hospital and two area primary care practices that agree to collaborate with the health home on care coordination and hospital and emergency department notification. (7) The health home must advocate in the community on behalf of health home members, as needed. (8) The health home must be responsible for preventing fragmentation or duplication of services provided to members. b. Coordinated integrated care. The health home must provide coordinated integrated care. (1) The health home must ensure that the nurse care manager is responsible for oversight of the service, including assisting members with medication adherence, appointments, referral scheduling, tracking follow-up results from referrals, understanding health insurance coverage, reminders, transition of care, wellness education, health support or lifestyle modification, and behavior changes. (2) The health home must utilize member-level information, member profiles, and care coordination plans for high-risk individuals. (3) The health home must incorporate tools and evidence-based guidelines designed for identifying care opportunities across the age and diagnostic continuum, integrating clinical practices, and coordinating care with other providers. (4) The health home must conduct interventions as indicated based on the member’s level of risk. (5) The health home must communicate with the member, authorized representative, and the member’s family and caregivers in a culturally appropriate manner for the purposes of assessment of care decisions, including the identification of authorized representatives. (6) The health home must monitor, arrange, and evaluate appropriate evidence-based and evidence-informed preventive services. (7) The health home must coordinate or provide access to the following services: 1. Mental health. 2. Oral health. 3. Long-term care. 4. Chronic disease management. 5. Recovery services and social health services available in the community. 6. Behavior modification interventions aimed at supporting health management, including but not limited to obesity counseling, tobacco cessation, and health coaching. 7. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up. 8. Crisis services. (8) The health home must assess social, educational, housing, transportation, and vocational needs that may contribute to disease and present as barriers to self-management. (9) The health home must coordinate with community-based case managers, case managers, and service coordinators for members who receive service coordination activities. (10) The health home must maintain a system and written standards and protocols for tracking member referrals. c. Enhanced access. The health home must provide enhanced access for members and member caregivers, including access to health home services 24 hours per day, seven days per week. The health home must use email, text messaging, patient portals and other technology to communicate with members based on the member’s preferred method of communication. d. Emphasis on quality and safety. The health home must emphasize quality and safety in the delivery of health home services. (1) The health home must have an ongoing quality improvement plan to address gaps and identify opportunities for improvement. (2) The health home must participate in ongoing process improvement on clinical indicators and overall cost-effectiveness. (3) The health home must demonstrate continuing development of fundamental health home functionality through an assessment process applied by the department. (4) The health home must have strong, engaged organizational leadership that is personally committed to and capable of: 1. Leading the health home through the transformation process and sustaining transformed practice, and 2. Participating in learning activities including in-person sessions, webinars, and regularly scheduled meetings. (5) The health home must participate in or convene ad hoc or scheduled meetings with lead entities and the department to plan and discuss implementation of goals and objectives for practice transformation, with ongoing consideration of the unique practice needs for adult members with a serious mental illness and child members with a serious emotional disturbance and those members’ families. (6) The health home must participate in Centers for Medicare and Medicaid Services (CMS)- and department-required evaluation activities. (7) The health home must submit information as requested by the department. (8) The health home must maintain compliance with all of the terms and conditions of the integrated health home or chronic condition health home provider agreement. (9) The health home must use an interoperable patient registry and certified electronic health record within a timeline approved by the lead entity or the department to input clinical information, track and measure care of members, automate care reminders, and produce exception reports for care planning. (10) The health home must complete web-based member enrollment, disenrollment, members’ consent to release of information, and health risk questionnaires for all members. (11) The health home must use a certified electronic health record to support clinical decision-making within the practice workflow and establish a plan to meaningfully use health information in accordance with the federal law. (12) The health home must implement state-required disease management programs based on population-specific disease burdens. The health home may choose to identify and operate additional disease management programs at any time. e. Case management. The integrated health home must provide case management services as defined in and required by 441—Chapter 90 to eligible members in an integrated health home. Requirements in 441—Chapter 90 are the minimum criteria for intensive care management for members enrolled in the 1915(i) Habilitation Program or the 1915(c) Children’s Mental Health Waiver. f. Policies and procedures. The health home must have policies and processes in place to ensure compliance with federal and state requirements, including but not limited to statutes, rules and regulations, and sub-regulatory guidance. The health home must maintain documentation of its policies and processes and make those policies and processes readily available to any state or federal officials upon request. g. Report on quality measures. A health home must collect and report quality data to the lead entity and the department as specified by the department. h. Health home termination. If the health home intends to stop providing health home services, the health home must provide notice of termination a minimum of 60 days prior to the date of termination by submitting Form 470-5465, Provider Request to Terminate Enrollment, to the department. The health home must notify members of termination 60 days prior to the termination date and provide for a seamless transition of enrollees to other health home providers.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 6310C44177.48(249A) Speech-language pathologists. Speech-language pathologists who are enrolled in the Medicare program are eligible to participate in Medicaid. Speech-language pathologists who are not enrolled in the Medicare program are eligible to participate in Medicaid if they are licensed and in independent practice, as an individual or as a group. 77.48(1) Speech-language pathologists in another state are eligible to participate if they are licensed in that state and meet the Medicare criteria for enrollment. 77.48(2) Speech-language pathologists who provide services to Medicaid members who are also Medicare beneficiaries must be enrolled in the Medicare program.This rule is intended to implement Iowa Code section 249A.4 and 2012 Iowa Acts, Senate File 2158.Related ARC(s): 0360C44177.49(249A) Physician assistants. All physician assistants licensed to practice in the state of Iowa are eligible for participation in the program. Physician assistants duly licensed to practice in other states are also eligible for participation. This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0580C, 5418C44177.50(249A) Ordering and referring providers. A provider who provides services, including orders and referrals, to a Medicaid member shall be enrolled as a Medicaid provider as a condition of payment eligibility for services rendered to that Medicaid member. A provider who does not individually bill for services rendered due to, for example, payment arrangements with a facility or supervising provider, shall also be required to enroll. Enrollment will be for the purpose of ordering or referring items and providing professional services to Medicaid members and will not affect the provider’s payment arrangements with such facilities or supervising providers.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 0580C44177.51(249A) Child care medical services. Child care centers are eligible to participate in the medical assistance program when they comply with the standards of 441—Chapter 109. A child care center in another state is eligible to participate when duly licensed in that state. The provider of child care medical services implements a comprehensive protocol of care that is developed in conjunction with the parent or guardian and specifies the medical, nursing, psychosocial, developmental therapies and personal care required by the medically dependent or technologically dependent child served. Nursing services must be provided.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 1698C, 2361C, 6310C44177.52(249A) Community-based neurobehavioral rehabilitation services. 77.52(1) Definitions. "Assessment" means the review of the current functioning of the member using the service in regard to the member’s situation, needs, strengths, abilities, desires, and goals.
"Brain injury" means a diagnosis in accordance with rule 441—83.81(249A).
"Health care" means the services provided by trained and licensed health care professionals to restore or maintain the member’s health.
"Intermittent community-based neurobehavioral rehabilitation services" means services provided to a Medicaid member on an as-needed basis to support the member and the member’s family or caregivers to assist the member to increase adaptive behaviors, decrease maladaptive behaviors, and adapt and accommodate to challenging behaviors to support the member to remain in the member’s own home and community.
"Member" means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
"Neurobehavioral rehabilitation" refers to a specialized category of neurorehabilitation provided by a multidisciplinary team that has been trained in, and delivers, services individually designed to address cognitive, medical, behavioral and psychosocial challenges, as well as the physical manifestations of acquired brain injury. Services concurrently work to optimize functioning at personal, family and community levels by supporting the increase of adaptive behaviors, decrease of maladaptive behaviors and adaptation and accommodation to challenging behaviors to support a member to maximize the member’s independence in activities of daily living and ability to live in the member’s home and community.
"Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals for eligible members.
"Standardized assessment" means a valid, reliable, and comprehensive functional assessment tool(s) or process, or both, approved by the department for use in the assessment of a member’s needs.
77.52(2) Eligible providers. The following agencies may provide community-based neurobehavioral rehabilitation residential and intermittent services: a. An organization that is accredited by a department-approved, nationally recognized accreditation organization as a specialty brain injury rehabilitation service provider. b. Agencies not accredited by a department-approved, nationally recognized accreditation organization as a specialty brain injury rehabilitation service provider that have applied for accreditation within the last 16 months to provide services may be enrolled. However, an organization that has not received accreditation within 16 months after application shall no longer be a qualified provider. 77.52(3) Provider standards. All community-based neurobehavioral rehabilitation service providers shall meet the following criteria: a. The organization meets the outcome-based standards for community-based neurobehavioral rehabilitation service providers as follows: (1) The organization shall provide high-quality supports and services to members. (2) The organization shall have a defined mission commensurate with members’ needs, desires, and abilities. (3) The organization shall be fiscally sound and shall establish and maintain fiscal accountability. (4) The program administrator shall be a certified brain injury specialist trainer (CBIST) through the Academy of Certified Brain Injury Specialists or a certified brain injury specialist under the direct supervision of a CBIST or a qualified brain injury professional as defined in rule 441—83.81(249A) with additional certification as approved by the department. The administrator shall be present in the assigned location for 25 hours per week. In the event of an absence from the assigned location exceeding four weeks, the organization shall designate a qualified replacement to act as administrator for the duration of the assigned administrator’s absence. (5) A minimum of 75 percent of the organization’s administrative and direct care personnel shall meet one of the following criteria:- Have a bachelor’s degree in a human services-related field;
- Have an associate’s degree in human services with two years of experience working with individuals with brain injury;
- Be an individual who is in the process of seeking a degree in the human services field with two years of experience working with individuals with brain injury; or
- Be a certified brain injury specialist (CBIS) certified through the Academy for the Certification of Brain Injury Specialists (ACBIS) or have other nationally recognized brain injury certification as approved by the department.
- Promotion of a program structure and support for persons served so they can re-learn or regain skills for community inclusion and access.
- Compensatory strategies to assist in managing ADLS (activities of daily living).
- Quality of life issues.
- Behavioral supports and identification of antecedent triggers.
- Health and medication management.
- Dietary and nutritional programming.
- Assistance with identifying and utilizing assistive technology.
- Substance abuse and addiction issues.
- Self-management and self-interaction skills.
- Flexibility in programming to meet members’ individual needs.
- Teaching adaptive and compensatory strategies to address cognitive, behavioral, physical, psychosocial and medical needs.
- Community accessibility and safety.
- Household maintenance.
- Service support to the member’s family or support system related to the member’s neurobehavioral care.
- Restraint, including chemical restraint, manual restraint or mechanical restraint;
- Alarms added to a member’s natural environment including doors, windows, refrigerators, cabinets, and other home appliances and fixtures;
- Exclusionary time out;
- Intensive staffing for control of behavior;
- Limited access or contingency access to preferred items or activities naturally available in the member’s environment;
- Reprimand;
- Response cost; and
- Use of psychotropic medications to control the occurrence of an unwanted behavior.
"Coinsurance" means a percentage of costs of a covered health care service that has to be paid.
"Copayment" means a fixed amount a member pays for a covered health care service.
"Deductible" means the amount paid for covered health care services before the insurance plan will effect payment.
"Medicare cost sharing" means the Medicare member’s responsibility for a Medicare-covered service. “Medicare cost sharing” includes coinsurance, copayments, and deductibles.
"Qualified Medicare beneficiary" "QMB" means an individual who has been determined eligible for the QMB program pursuant to 441—subrule 75.1(29). Under the QMB program, Medicaid pays the individual’s Medicare Part A and B premiums; coinsurance; copayment; and deductible (except for Part D).
This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3494C44177.54(249A) Health insurance premium payment (HIPP) providers. Any provider not enrolled as an Iowa Medicaid provider for the general Medicaid population may enroll to be a HIPP provider. A HIPP provider may bill the department for the HIPP-eligible member’s out-of-pocket cost-sharing obligations. Reimbursement is limited to in-network coinsurance, copayments, and deductibles of the HIPP-eligible member’s health insurance paid for through the HIPP program.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3494C44177.55(249A) Crisis response services. 77.55(1) Definitions. The terms used in this rule shall have the same meaning as set out in 441—Chapter 24, Division II. 77.55(2) Eligible providers. Agencies which are accredited under the mental health service provider standards established by the mental health and disability services commission, set forth in 441—Chapter 24, Division II, are eligible to participate in the program by providing crisis response services, crisis stabilization community-based services, and crisis stabilization residential services. 77.55(3) Provider standards. All providers of crisis response services, crisis stabilization community-based services, and crisis stabilization residential services shall meet the standards criteria as set forth in 441—Chapter 24, Division II.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3551C44177.56(249A) Subacute mental health services. 77.56(1) Definitions. The terms used in this rule shall have the same meaning as set out in Iowa Code section 135G.1. 77.56(2) Subacute mental health services. Subacute mental health services are intended to be short-term, intensive, recovery-oriented services designed to stabilize an individual who is experiencing a decreased level of functioning due to a mental health condition. 77.56(3) Eligible provider. Subacute mental health care facilities which are licensed by the department of inspections and appeals in accordance with 481—Chapter 71 are eligible to participate in the program by providing subacute mental health services. 77.56(4) Provider standards. All providers of subacute mental health services shall meet the standards criteria as set forth in 481—Chapter 71.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 3551C44177.57(249A) Pharmacists. An authorized pharmacist licensed to practice in the state of Iowa is eligible to participate in the program. This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 5175CRelated ARC(s): 7741B, 7936B, 9314B, 9440B, 9487B, 9649B, 0191C, 0198C, 0358C, 0360C, 0359C, 0485C, 0545C, 0580C, 0757C, 0838C, 0848C, 1071C, 1051C, 1149C, 1445C, 1638C, 1698C, 1807C, 2165C, 2361C, 2341C, 2471C, 2930C, 3184C, 3494C, 3551C, 3789C, 3874C, 4165C, 4792C, 5175C, 5307C, 5361C, 5418C, 5809C, 5889C, 6310C, 6388C