CHAPTER 177
IN-HOME HEALTH RELATED CARE
[Prior to 7/1/83, Social Services[770] Ch 148]
[Previously appeared as Ch 148—renumbered IAB 2/29/84]
[Prior to 2/11/87, Human Services [498]]
441—177.1(249) In-home health related care. In-home health related care is a program of nursing care in an individual’s own home to provide personal services to an individual because such individual’s state of physical or mental health prevents independent self-care.
441—177.2(249) Own home. Own home means an individual’s house, apartment, or other living arrangement intended for single or family residential use.
441—177.3(249) Service criteria. The client shall require health care services that would require the supervision of a professional registered nurse working under the certification of a physician.
	177.3(1) Skilled services may include but not be limited to:
	a. 	Gavage feedings of individuals unable to eat solid foods.
	b. 	Intravenous therapy administered only by a registered nurse.
	c. 	Intramuscular injections required more than once or twice a week, excluding diabetes.
	d. 	Catheterizations, continuing care of indwelling catheters with supervision of irrigations and changing of Foley catheter when required.
	e. 	Inhalation therapy.
	f. 	Care of decubiti and other ulcerated areas, noting and reporting to physician.
	g. 	Rehabilitation services including, but not limited to: bowel and bladder training, range of motion exercises, ambulation training, restorative nursing services, reteaching the activity of daily living, respiratory care and breathing programs, reality orientation, reminiscing therapy, remotivation and behavior modification.
	h. 	Tracheotomy care.
	i. 	Colostomy care until the individual is capable of maintaining the colostomy personally.
	j. 	Care of medical conditions out of control which includes brittle diabetes and terminal conditions.
	k. 	Postsurgical nursing care, but only for short time periods, and primarily for individuals with complications following surgery, or with the need for frequent dressing changes.
	l. 	Monitoring medications needed for close supervision of medications because of fluctuating physical or psychological conditions, i.e., hypertensives, digitalis preparations, narcotics.
	m. 	Diets which are therapeutic and require evaluation at frequent intervals.
	n. 	Vital signs which is the recording and reporting of change in vital signs to the attending physician.
	177.3(2) Personal care services may include but not be limited to:
	a. 	Supervision on a 24-hour basis for physical or emotional needs.
	b. 	Helping client with bath, shampoo, oral hygiene.
	c. 	Helping client with toileting.
	d. 	Helping client in and out of bed and with ambulation.
	e. 	Helping client to reestablish activities of daily living.
	f. 	Assisting with oral medications ordinarily self-administered and ordered by the physician.
	g. 	Performing incidental household services which are essential to the client’s health care at home and are necessary to prevent or postpone institutionalization.
441—177.4(249) Eligibility.
	177.4(1) Eligible individual.
	a. 	The individual shall be eligible for supplemental security income in every respect except for income.
	b. 	The physician’s certification shall include a statement of the specific health care services and that the services can be provided in the individual’s own home. The certification shall be given on Form 470-0673, Physician’s Report, or on a similar plan of care form presently used by public health agencies.
	c. 	The individual shall live in the individual’s own home.
	d. 	The client shall require and be receiving qualified health care services. Qualified health care services are health care services supervised by a registered nurse and approved by a physician.
	177.4(2) Relationship to other programs. In-home health related care shall be provided only when other existing programs cannot meet the client’s need.
	177.4(3) Maximum costs. The maximum cost of service shall be $480.55. The provider shall accept the payment made and shall make no additional charges to the recipient or others.
	177.4(4) Service plan. A complete service plan shall be prepared which includes the services needed, the plan for providing these services, and the health care plan defined in rule 177.6(249).
	177.4(5) Certification procedure. The approval of the case plan by the service area manager or designee shall constitute certification and approval for payment.
	177.4(6) Temporary absence from home. The client will remain eligible and payment will be made for services for a period not to exceed 15 days in any calendar month when the client is absent from the home for a temporary period. Payment will not be authorized for over 15 days for any continuous absence whether or not the absence extends into a succeeding month or months.
	177.4(7) Income for adults. The countable income of the individual and spouse living in the home shall be limited to $480.55 per month if one needs care or $961.10 if both need care, after the following disregards from gross income:
	a. 	The amount of the basic supplemental security income standard for an individual or a couple, as applicable.
	b. 	When income is earned, $65.00 plus one-half of any remaining income.
	c. 	The amount of the supplemental security income standard for a dependent plus any established unmet medical needs, for each dependent living in the home. Any income of the dependent shall be applied to the dependent’s needs before making this disregard.
	d. 	The amount of the established medical needs of the ineligible spouse which are not otherwise met.
	e. 	The amount of the established medical needs of the applicant or recipient which are not otherwise met and would not be met if the individual were eligible for the medical assistance program.
	f. 	Rescinded, effective 7/1/84.
	177.4(8) Income for children.
	a. 	All income received by the parents in the home shall be deemed to the child with the following disregards:
	(1)	The amount of the basic supplemental security income standard for an individual when there is one parent in the home or for a couple when there are two parents in the home.
	(2)	The amount of the basic supplemental security income standard for a dependent for each ineligible child in the home.
	(3)	The amount of the unmet medical needs of the parents and ineligible dependents.
	(4)	When all income is earned, an additional basic supplemental security income standard for an individual in a one-parent home or for a couple in a two-parent home.
	(5)	When the income is both earned and unearned, $65.00 plus one-half of the remainder of the earned income.
	b. 	The countable income of the child shall be limited to $480.55 per month after the following disregards from gross income:
	(1)	The amount of the basic supplemental security income standard for an individual.
	(2)	The amount of the established medical needs of the child which are not otherwise met and would not be met if the child were eligible for the medical assistance program.
	(3)	One-third of the child support payments received from an absent parent.
	c. 	Rescinded, effective 7/1/84.
	177.4(9) Payment. The client or the person legally designated to handle the client’s finances shall be the sole payee for payments made under the program and shall be responsible for making payment to the provider except when the client payee becomes incapacitated or dies while receiving service.
	a. 	The department shall have the authority to issue one payment to a provider on behalf of a client payee who becomes incapacitated or dies while receiving service.
	b. 	When continuation of an incapacitated client payee in the program is appropriate, the department shall assist the client and the client’s family to legally designate a person to handle the client’s finances. Guardians, conservators, protective or representative payees, or persons holding power of attorney are considered to be legally designated.
	c. 	Payment for the program shall be approved effective as of the date of application or the date all eligibility requirements are met and qualified health care services are provided, whichever is later, notwithstanding 42 U.S.C. 1382(c)(7).
	177.4(10) Application. Application for in-home health-related care shall be made on Form 470-2927 or 470-2927(S), Health Services Application. An eligibility determination shall be completed within 30 days from the date of the application, unless one or more of the following conditions exist:
	a. 	An application has been filed and is pending for federal supplemental security income benefits.
	b. 	The application is pending because the department has not received information, which is beyond the control of the client or the department.
	c. 	The application is pending due to the disability determination process performed through the department.
	d. 	The application is pending because Form 470-0636, Provider Agreement, has not been completed and completion is beyond control of the client. When Form 470-0636 cannot be completed due to the client’s failure to locate a provider, applications shall not be held pending beyond 60 days from the date of application.
[ARC 7549B, IAB 2/11/09, effective 4/1/09]
441—177.5(249) Providers of health care services.
	177.5(1) Age. The provider shall be at least 18 years of age.
	177.5(2) Health assessment. The provider shall obtain certification that the provider is physically and emotionally capable of providing assistance to another person who may have physical and emotional limitations.
	a. 	The certification shall be based on an examination performed by a physician or advanced registered nurse practitioner or by a physician assistant who is working under the direction of a physician. If the provider works for an agency, the practitioner performing the examination may not be employed by the same agency.
	b. 	The practitioner conducting the examination shall indicate the certification by signing Form 470-0672, Provider Health Assessment.
	c. 	The certification shall be submitted to the department service worker:
	(1)	Before the provider agreement is signed, and
	(2)	Annually thereafter.
	177.5(3) Qualifications. The provider shall be qualified by training and experience to carry out the health care plan as specified in rule 177.4(4).
	177.5(4) Relative. The provider may be related to the client, so long as the provider is not a member of the family as defined in rule 441—130.1(234).
[ARC 8912B, IAB 6/30/10, effective 9/1/10]
441—177.6(249) Health care plan. The nurse shall complete the health care plan with the physician’s approval. The health care plan shall include the specific types of services required, the method of providing those services, and the expected duration of services.
	177.6(1) Transfer from medical facility. When the client is being transferred from a medical hospital or long-term care facility, the service worker shall obtain a transfer document describing the client’s current care plan, to be provided to the nurse supervising the in-home care plan.
	177.6(2) Medical records.
	a. 	Medical records shall include, whenever appropriate, transfer forms, physician’s certification and orders, interdisciplinary case plan, interdisciplinary progress notes, drug administration records, treatment records, and incident reports. The nurse shall be responsible for ensuring that record requirements are met.
	b. 	Medical records shall be located in the nurse’s case file, with a copy of the interdisciplinary plan of care and physician’s plan of service in the service worker’s file, and all other records available to the service worker. Upon termination of the in-home care plan, the records shall be maintained in the county office of the department of human services, or in the office of the public health nurse and available to the service worker, for five years or until completion of an audit.
	c. 	The client or legal representative shall have the right to view the client’s medical records.
	177.6(3) Review. The continuing need for in-home health care services shall be reviewed:
	a. 	At a minimum of every 60 days by the physician, including a written recertification of continuing appropriateness of the plan;
	b. 	At a minimum of every six months by the service worker, including a review of the total care plan;
	c. 	At a minimum of every 60 days by the nurse who shall review the nursing plan; or
	d. 	More frequently if required by the physician, the service worker, or the nurse.
	177.6(4) Annual physical. The client shall obtain a physical examination report annually and shall be under the regular supervision of a physician.
[ARC 7549B, IAB 2/11/09, effective 4/1/09]
441—177.7(249) Client participation.
	177.7(1) All income remaining after the disregards in 177.4(7) and 177.4(8) shall be considered income available for services and shall be used for service costs before payment for in-home health care begins.
	177.7(2) First month. When the first month of service is less than a full month, there is no client participation for that month. Payment will be made for the actual days of service provided according to the agreed-upon rate.
441—177.8(249) Determination of reasonable charges. Payment will be made only for reasonable charges for in-home health care services as determined by the service worker. Reasonableness shall be determined by:
	177.8(1) Community standards. The prevailing community standards for cost of care for similar services.
	177.8(2) Services at no charge. The availability of service providers at no cost to the department.
441—177.9(249) Written agreements.
	177.9(1) Independent contractor. The provider shall be an independent contractor and shall in no sense be an agent, employee or servant of the state of Iowa, the Iowa department of human services, any of its employees, or of its clients.
	177.9(2) Liability coverage. All professional health care providers shall have adequate liability coverage consistent with their responsibilities, as the department of human services assumes no responsibility for, or liability for, individuals providing care.
	177.9(3) Provider agreement. The client and the provider shall enter into an agreement, using Form 470-0636, Provider Agreement, prior to the provision of service. Any reduction to the state supplemental assistance program shall be applied to the maximum amount paid by the department of human services as stated in the Provider Agreement by using Form 470-1999, Amendment to Provider Agreement.
441—177.10(249) Emergency services. Written instructions for dealing with emergency situations shall be completed by the nurse and maintained in the client’s home and in the county department of human services office. The instructions shall include:
	177.10(1) Persons to notify. The name and telephone number of the client’s physician, the nurse, responsible family members or other significant persons, and the service worker.
	177.10(2) Hospital. Information as to which hospital to utilize.
	177.10(3) Ambulance. Information as to which ambulance service or other emergency transportation to utilize.
441—177.11(249) Termination. Termination of in-home health related care shall occur under the following conditions.
	177.11(1) Request. Upon the request of the client or legal representative.
	177.11(2) Care unnecessary. When the client becomes sufficiently self-sustaining to remain in the client’s own home with services that can be provided by existing community agencies as determined by the service worker.
	177.11(3) Additional care necessary. When the physical or mental condition of the client requires more care than can be provided in the client’s own home as determined by the service worker.
	177.11(4) Excessive costs. When the cost of care exceeds the maximum established in 177.4(3).
	177.11(5) Other services utilized. When the service worker determines that other services can be utilized to better meet the client’s needs.
	177.11(6) Terms of provider agreement not met. When it has been determined by the service worker that the terms of the provider agreement have not been met by the client or the provider, the state supplementary assistance payment may be terminated.
[ARC 7549B, IAB 2/11/09, effective 4/1/09]
These rules are intended to implement Iowa Code section 249.3(2)“a”(2).
[Filed emergency 10/7/76—published 11/3/76, effective 11/1/76]
[Filed emergency 12/17/76—published 1/12/77, effective 12/17/76]
[Filed 2/25/77, Notice 11/3/76—published 3/23/77, effective 4/27/77]
[Filed emergency 5/24/77—published 6/15/77, effective 7/1/77]
[Filed 10/24/77, Notice 9/7/77—published 11/16/77, effective 12/21/77]
[Filed 5/24/78, Notice 3/22/78—published 6/14/78, effective 7/19/78]
[Filed 12/19/80, Notice 10/29/80—published 1/7/81, effective 2/11/81]
[Filed 6/30/81, Notice 4/29/81—published 7/22/81, effective 9/1/81]
[Filed emergency 10/7/83—published 10/26/83, effective 11/1/83]
[Filed without Notice 10/7/83—published 10/26/83, effective 12/1/83]
[Filed 11/18/83, Notice 10/12/83—published 12/7/83, effective 2/1/84]
[Filed emergency 2/10/84—published 2/29/84, effective 2/10/84]
[Filed emergency 6/15/84—published 7/4/84, effective 7/1/84]
[Filed emergency 8/31/84—published 9/26/84, effective 10/1/84]
[Filed emergency 10/1/85—published 10/23/85, effective 11/1/85]
[Filed without Notice 10/1/85—published 10/23/85, effective 12/1/85]
[Filed 12/2/85, Notice 10/23/85—published 12/18/85, effective 2/1/86]
[Filed emergency 6/26/86—published 7/16/86, effective 7/1/86]
[Filed 6/20/86, Notice 4/23/86—published 7/16/86, effective 9/1/86]
[Filed emergency 1/15/87—published 2/11/87, effective 1/15/87]
[Filed emergency 6/9/88—published 6/29/88, effective 7/1/88]
[Filed emergency 6/9/89—published 6/28/89, effective 7/1/89]
[Filed 7/14/89, Notice 4/19/89—published 8/9/89, effective 10/1/89]
[Filed 8/17/89, Notice 6/28/89—published 9/6/89, effective 11/1/89]
[Filed emergency 6/20/90—published 7/11/90, effective 7/1/90]
[Filed 8/16/90, Notice 7/11/90—published 9/5/90, effective 11/1/90]
[Filed 12/11/91, Notice 10/16/91—published 1/8/92, effective 3/1/92]1
[Filed emergency 4/15/92—published 5/13/92, effective 4/16/92]
[Filed 5/14/92, Notice 3/18/92—published 6/10/92, effective 8/1/92]
[Filed emergency 6/16/94—published 7/6/94, effective 7/1/94]
[Filed 6/16/94, Notice 4/13/94—published 7/6/94, effective 9/1/94]
[Filed 8/12/94, Notice 7/6/94—published 8/31/94, effective 11/1/94]
[Filed emergency 6/7/95—published 7/5/95, effective 7/1/95]
[Filed 8/10/95, Notice 7/5/95—published 8/30/95, effective 11/1/95]
[Filed 3/13/96, Notice 1/17/96—published 4/10/96, effective 6/1/96]
[Filed emergency 6/13/96—published 7/3/96, effective 7/1/96]
[Filed 8/15/96, Notice 7/3/96—published 9/11/96, effective 11/1/96]
[Filed emergency 3/12/97—published 4/9/97, effective 4/1/97]
[Filed 4/11/97, Notice 2/12/97—published 5/7/97, effective 7/1/97]
[Filed 5/14/97, Notice 4/9/97—published 6/4/97, effective 8/1/97]
[Filed emergency 12/9/98—published 12/30/98, effective 1/1/99]
[Filed 2/10/99, Notice 12/30/98—published 3/10/99, effective 4/15/99]
[Filed emergency 12/8/99—published 12/29/99, effective 1/1/00]
[Filed 2/9/00, Notice 12/29/99—published 3/8/00, effective 5/1/00]
[Filed emergency 7/13/00—published 8/9/00, effective 8/1/00]
[Filed 11/8/00, Notice 8/9/00—published 11/29/00, effective 2/1/01]
[Filed emergency 4/11/01—published 5/2/01, effective 5/1/01]
[Filed 6/13/01, Notice 5/2/01—published 7/11/01, effective 9/1/01]
[Filed emergency 7/11/01—published 8/8/01, effective 8/1/01]
[Filed 9/11/01, Notice 7/11/01—published 10/3/01, effective 12/1/01]
[Filed 10/10/01, Notices 8/8/01, 8/22/01—published 10/31/01, effective 1/1/02]
[Filed emergency 12/12/02—published 1/8/03, effective 1/1/03]
[Filed 11/19/03, Notice 10/1/03—published 12/10/03, effective 2/1/04]
[Filed emergency 11/16/05—published 12/7/05, effective 12/1/05]
[Filed ARC 7549B (Notice ARC 7371B, IAB 11/19/08), IAB 2/11/09, effective 4/1/09]
[Filed ARC 8912B (Notice ARC 8690B, IAB 4/21/10), IAB 6/30/10, effective 9/1/10]
1	Effective date of 3/1/92 delayed until adjournment of the 1992 General Assembly by the Administrative Rules Review Committee at its meeting held February 3, 1992.