CHAPTER 68
ELDER GROUP HOMES
481—68.1(231B) Definitions. In addition to the definitions in 481—Chapter 67 and Iowa Code chapter 231B, the following definitions apply.
“Applicable requirements” means Iowa Code chapter 231B, this chapter and 481—Chapter 67 and includes any other applicable administrative rules and provisions of the Iowa Code.
“Change of ownership” means the purchase, transfer, assignment or lease of a certified elder group home and includes a change in the management company responsible for the day-to-day operation of the program, if the management company is ultimately responsible for any enforcement action taken by the department.
“Committee” means a resident advocate committee established by 321—Chapter 9.
“Elder” means a person 60 years of age or older.
“Elder group home” or “EGH” means a single-family residence that is operated by a person who is providing room, board, and personal care and may provide health-related services to three through five elders who are not related to the person providing the service within the third degree of consanguinity or affinity and that is staffed by an on-site manager 24 hours per day seven days per week.
“Household occupant” means a tenant and all others who reside in the EGH.
“In the proximate area” means located within a five minutes or less response time.
“Maximal assistance with activities of daily living” means routine total dependence on staff for the performance of a minimum of four activities of daily living for a period that exceeds 21 days.
“Medically unstable” means that a tenant has a condition or conditions:
	1.	Indicating physiological frailty as determined by the program’s staff in consultation with a physician or physician extender;
	2.	Resulting in two or more significant hospitalizations within a consecutive three-month period for more than observation; and
	3.	Requiring supervision by a registered nurse more than once a week of the tenant for more than 21 days.
For example, a tenant who has a condition such as congestive heart failure which results in two or more significant hospitalizations during a quarter and which requires that the tenant receive frequent supervision may be considered medically unstable.
“On-site manager” means the person on duty responsible for direct supervision or provision of tenant care. The on-site manager may be any household occupant over 18 years of age, except a tenant, who is qualified to perform the necessary duties.
“Personal care provider” means an individual who, in return for remuneration, assists with the essential activities of daily living which the tenant can perform personally only with difficulty.
“Program” means an elder group home.
“Unmanageable incontinence” means a condition that requires staff provision of total care for an incontinent tenant who lacks the ability to assist in bladder or bowel continence care.
“Unmanageable verbal abuse” means repeated verbalizations against tenants or staff that persist despite all interventions and that negatively affect the program. “Unmanageable verbal abuse” includes but is not limited to threats, frequent use of profane language, or unwelcome sexually oriented remarks.
“Usable floor space” means open floor space that is not under fixtures, furniture or other barriers and is available for walking or wheelchair use.
[ARC 8175B, IAB 9/23/09, effective 1/1/10; ARC 1927C, IAB 4/1/15, effective 5/6/15]
481—68.2(231B) Program certification and posting requirements.
	68.2(1) Certification requirements. A program may obtain certification by meeting all applicable requirements. For the purpose of these rules, certification is equivalent to licensure.
	68.2(2) Posting requirements. A program’s current certificate shall be visibly displayed within the designated operation area of the program. In addition, the latest monitoring report, state fire marshal report, and food establishment inspections report issued pursuant to Iowa Code chapter 137F shall be made available to the public by the program upon request.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.3(231B) Certification—application process.
	68.3(1) The applicant shall complete an application packet obtained from the department. Application materials may be obtained from the health facilities division Web site at https://dia-hfd.iowa.gov/DIA_HFD/Home.do; by mail from the Department of Inspections and Appeals, Adult Services Bureau, Lucas State Office Building, Third Floor, 321 E. 12th Street, Des Moines, Iowa 50319-0083; or by telephone at (515)281-6325.
	68.3(2) The applicant shall submit one copy of the completed application and all supporting documentation to the department at the above address at least 90 calendar days prior to the expected date of beginning operation.
	68.3(3) The appropriate fee as stated in Iowa Code section 231B.17 shall accompany each application and be payable by check or money order to the Department of Inspections and Appeals. Fees are nonrefundable.
	68.3(4) The department shall consider the application when all supporting documents and fees are received.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.4(231B) Certification—application content. An application for certification or recertification of an EGH shall include the following:
	68.4(1) A list that includes the names, addresses, and percentage of stock, shares, partnership or other equity interest of all officers, members of the board of directors and trustees, as well as stockholders, partners or any individuals who have greater than a 10 percent equity interest in each of the following, as applicable:
	a. 	The real estate owner or lessor;
	b. 	The lessee; and
	c. 	The management company responsible for the day-to-day operation of the program.
The program shall notify the department of any changes in the list no later than ten working days after the effective date of the change.
	68.4(2) A statement disclosing whether the individuals listed in subrule 68.4(1) have been convicted of a felony or an aggravated or serious misdemeanor or found to be in violation of the child abuse or dependent adult abuse laws of any state.
	68.4(3) A statement disclosing whether any of the individuals listed in subrule 68.4(1) have or have had an ownership interest in an assisted living program, adult day services program, elder group home, home health agency, licensed health care facility as defined in Iowa Code section 135C.1, or licensed hospital as defined in Iowa Code section 135B.1, which has been closed in any state due to removal of program, agency, or facility licensure or certification or due to involuntary termination from participation in either the Medicaid or Medicare program; or have been found to have failed to provide adequate protection or services to prevent abuse or neglect of residents, patients, tenants or participants.
	68.4(4) The policy and procedure for evaluation of each tenant. A copy of the evaluation tool or tools to be used to identify the functional, cognitive and health status of each tenant shall be included.
	68.4(5) The policy and procedure for service plans.
	68.4(6) The policy and procedure for addressing medication needs of tenants.
	68.4(7) The policy and procedure for accidents and emergency response.
	68.4(8) The policies and procedures for food service, including those relating to staffing, nutrition, menu planning, therapeutic diets, and food preparation, service and storage.
	68.4(9) The policy and procedure for transportation.
	68.4(10) The policy and procedure for staffing and training.
	68.4(11) The policy and procedure for emergencies, including natural disasters. The policy and procedure shall include an evacuation plan and procedures for notifying legal representatives in emergency situations as applicable.
	68.4(12) The policy and procedure for managing risk and upholding tenant autonomy when tenant decision making results in poor outcomes for the tenant or others.
	68.4(13) The policy and procedure for reporting incidents including dependent adult abuse as required in rule 481—67.2(231B,231C,231D).
	68.4(14) The tenant occupancy agreement and all attachments.
	68.4(15) If the program contracts for personal care or health-related care services from a certified home health agency, a mental health center or a licensed health care facility, a copy of that entity’s current license or certification.
	68.4(16) A copy of the state license for the entity that provides food service, whether the entity is the program or an outside entity or a combination of both.
	68.4(17) The fee set forth in Iowa Code section 231B.17.
[ARC 8175B, IAB 9/23/09, effective 1/1/10; ARC 1927C, IAB 4/1/15, effective 5/6/15]
481—68.5(231B) Initial certification process.
	68.5(1) Upon receipt of all completed documentation, including state fire marshal approval and structural and evacuation review approval, the department shall determine whether or not the proposed program meets applicable requirements.
	68.5(2) If, based upon the review of the complete application including all required supporting documents, the department determines the proposed program meets the requirements for certification, a provisional certification shall be issued to the program to begin operation and accept tenants.
	68.5(3) Within 180 calendar days following issuance of provisional certification, the department shall conduct a monitoring to determine the program’s compliance with applicable requirements.
	68.5(4) If a regulatory insufficiency is identified as a result of the monitoring, the process in rule 481—67.10(17A,231B,231C,231D) shall be followed.
	68.5(5) The department shall make a final certification decision based on the results of the monitoring and review of an acceptable plan of correction.
	68.5(6) The department shall notify the program of a final certification decision within 10 working days following the finalization of the monitoring report or receipt of an acceptable plan of correction, whichever is applicable.
	68.5(7) If the decision is to continue certification, the department shall issue a full two-year certification effective from the date of the original provisional certification.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.6(231B) Expiration of program certification.
	68.6(1) Unless conditionally issued, suspended or revoked, certification of a program shall expire at the end of the time period specified on the certificate.
	68.6(2) The department shall send recertification application materials to each program at least 120 calendar days prior to expiration of the program’s certification.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.7(231B) Recertification process. To obtain recertification, a program shall:
	68.7(1) Submit one copy of the completed application, including the information required in rule 481—68.4(231B), associated documentation, and the recertification fee as listed in Iowa Code section 231B.17 to the department at the address stated in subrule 68.3(1) at least 90 calendar days prior to the expiration of the program’s certification. The program need not submit policies and procedures that have been previously submitted to the department and remain unchanged. The program shall provide a list of the policies and procedures that have been previously submitted and are not being resubmitted.
	68.7(2) Submit additional documentation that each of the following has been inspected and found to be maintained in conformance with the manufacturer’s recommendations and nationally recognized standards: heating system, cooling system, water heater, electrical system, plumbing, sewage system, artificial lighting, and ventilation system; and, if located on site, garbage disposal, kitchen appliances, washing machines and dryers, and elevators.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.8(231B) Notification of recertification.
	68.8(1) The department shall review the application and associated documentation and fees. If the application is incomplete, the department shall contact the program to request the additional information. After all finalized documentation is received, including state fire marshal approval, the department shall determine the program’s compliance with applicable requirements.
	68.8(2) The department shall conduct a monitoring of the program between 60 and 90 days prior to expiration of the program’s certification.
	68.8(3) If a regulatory insufficiency is identified as a result of the monitoring, the process in rule 481—67.10(17A,231B,231C,231D) shall be followed.
	68.8(4) If no regulatory insufficiency is identified as a result of the monitoring, the department shall issue a report of the findings with the final recertification decision.
	68.8(5) If the decision is to recertify, the department shall issue the program a two-year certification effective from the date of the expiration of the previous certification.
	68.8(6) If the decision is to deny recertification, the department shall issue a notice of denial and provide the program the opportunity for a hearing pursuant to rule 481—67.13(17A,231B,231C,231D).
	68.8(7) If the department is unable to recertify a program through no fault of the program, the department shall issue to the program a time-limited extension of certification of no longer than one year.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.9(231B) Listing of all certified programs. The department shall maintain a list of all certified programs, which is available online at https://dia-hfd.iowa.gov/DIA_HFD/Home.do, under the “Entities Book” tab.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.10(231B) Change of ownership—notification to the department.
	68.10(1) Certification, unless conditionally issued, suspended or revoked, may be transferable. If the program’s certification has been conditionally issued, the department must approve a change of ownership prior to the transfer of the certification.
	68.10(2) In order to transfer certification, the applicant must:
	a. 	Meet the requirements of the rules, regulations and standards contained in Iowa Code chapter 231B and 481—Chapter 67 and this chapter; and
	b. 	At least 30 days prior to the change of ownership of the program, make application on forms provided by the department.
	68.10(3) The department may conduct a monitoring within 90 days following a change in the program’s ownership to ensure that the program complies with applicable requirements. If a regulatory insufficiency is found, the department shall take any necessary enforcement action authorized by applicable requirements.
[ARC 1927C, IAB 4/1/15, effective 5/6/15]
481—68.11(231B) Cessation of program operation.
	68.11(1) If a certified program ceases operation, which includes seeking decertification, at any time prior to expiration of the program’s certification, the program shall submit the certificate to the department. The program shall provide, at least 90 days in advance of cessation, which includes seeking decertification, unless there is some type of emergency, written notification to the department and the tenant advocate of the date on which the program will cease operation, which includes seeking decertification.
	68.11(2) If a certified program plans to cease operation, which includes seeking decertification, at the time the program’s certification expires, the program shall provide written notice of this fact to the department and the tenant advocate at least 90 days prior to expiration of the certification.
	68.11(3) At the time a program decides to cease operation, which includes seeking decertification, the program shall submit a plan to the department and make arrangements for the safe and orderly transfer or transition of all tenants within the 90-day period specified by subrule 68.11(2).
	68.11(4) The department may conduct a monitoring during the 90-day period to ensure the safety of tenants during the transfer process or transition process.
	68.11(5) The department may conduct an on-site visit to verify that the program has ceased operation as a certified program in accordance with the notice provided by the program.
	68.11(6) When a program ceases operation, which includes seeking decertification, tenant advocates shall be allowed by the program to privately meet with tenants to provide education and service options.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.12(231B) Occupancy agreement.
	68.12(1) The occupancy agreement shall be in 12-point type or larger, shall be written in plain language using commonly understood terms and shall be easy for the tenant or the tenant’s legal representative to understand.
	68.12(2) In addition to the requirements of Iowa Code section 231B.5, the written occupancy agreement shall include, but not be limited to, the following information in the body of the agreement or in the supporting documents and attachments:
	a. 	The telephone number for filing a complaint with the department.
	b. 	The telephone number for the office of the tenant advocate.
	c. 	The telephone number for reporting dependent adult abuse.
	d. 	A copy of the program’s statement on tenants’ rights.
	e. 	A statement that the program will notify the tenant at least 90 days in advance of any planned program cessation, which includes voluntary decertification, except in cases of emergency.
	f. 	A copy of the program’s admission and transfer criteria.
	68.12(3) The occupancy agreement shall be reviewed and updated as necessary to reflect any change in services or financial arrangements.
	68.12(4) A copy of the occupancy agreement shall be provided to the tenant or the tenant’s legal representative, if any, and a copy shall be kept by the program.
	68.12(5) A copy of the most current occupancy agreement shall be made available to the general public upon request. The basic marketing material shall include a statement that a copy of the occupancy agreement is available to all persons upon request.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.13(231B) Evaluation of tenant.
	68.13(1) Evaluation prior to occupancy. A program shall evaluate each prospective tenant’s functional, cognitive and health status prior to the tenant’s signing the occupancy agreement and becoming a household occupant to determine the tenant’s eligibility for the program, including whether the services needed are available. The cognitive evaluation shall utilize a scored, objective tool. When the score from the cognitive evaluation indicates moderate cognitive decline and risk, the Global Deterioration Scale shall be used at all subsequent intervals, if applicable. If the tenant subsequently returns to the tenant’s mildly cognitively impaired state, the program may discontinue the GDS and revert to a scored cognitive screening tool. The evaluation shall be conducted by a health care professional or human service professional.
	68.13(2) Evaluation within 30 days of occupancy and with significant change. A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy. A program shall also evaluate each tenant’s functional, cognitive and health status as needed with significant change, but not less than annually, to determine the tenant’s continued eligibility for the program and to determine any changes to services needed. The evaluation shall be conducted by a health care professional or human service professional. A licensed practical nurse may complete the evaluation via nurse delegation when the tenant has not exhibited a significant change.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.14(231B) Criteria for admission and retention of tenants.
	68.14(1) Persons who may not be admitted or retained. A program shall not knowingly admit or retain a tenant who:
	a. 	Is bed-bound; or
	b. 	Requires routine, one-person assistance with standing, transfer or evacuation; or
	c. 	Is dangerous to self or other tenants or staff, including but not limited to a tenant who:
	(1)	Despite intervention chronically elopes, is sexually or physically aggressive or abusive, or displays unmanageable verbal abuse or aggression; or
	(2)	Displays behavior that places another tenant at risk; or
	d. 	Is in an acute stage of alcoholism, drug addiction, or uncontrolled mental illness; or
	e. 	Is under the age of 18; or
	f. 	Requires more than part-time or intermittent health-related care; or
	g. 	Has unmanageable incontinence on a routine basis despite an individualized toileting program; or
	h. 	Is medically unstable; or
	i. 	Requires maximal assistance with activities of daily living; or
	j. 	Is physically or mentally unable to immediately and without aid of another travel a normal path to safety, including the ascent and descent of stairs from the tenant’s bedroom or bathroom.
	68.14(2) Disclosure of additional occupancy and transfer criteria. A program may have additional occupancy or transfer criteria if the criteria are disclosed in the written occupancy agreement prior to the tenant’s occupancy.
	68.14(3) Assistance with transfer from the program. A program shall provide assistance to a tenant and the tenant’s legal representative, if applicable, to ensure a safe and orderly transfer from the program when the tenant exceeds the program’s criteria for admission and retention.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.15(231B) Involuntary transfer from the program.
	68.15(1) Program initiation of transfer. If a program initiates the involuntary transfer of a tenant and the action is not the result of a monitoring, including a complaint investigation or program-reported incident investigation, by the department and if the tenant or tenant’s legal representative contests the transfer, the following procedures shall apply:
	a. 	The program shall notify the tenant or tenant’s legal representative, in accordance with the occupancy agreement, of the need to transfer the tenant and of the reason for the transfer and shall include the contact information for the tenant advocate.
	b. 	The program shall immediately provide to the tenant advocate, by certified mail, a copy of the notification and notify the tenant’s treating physician, if any.
	c. 	Pursuant to statute, the tenant advocate shall offer the notified tenant or tenant’s legal representative assistance with the program’s internal appeal process. The tenant or tenant’s legal representative is not required to accept the assistance of the tenant advocate.
	d. 	If, following the internal appeal process, the program upholds the transfer decision, the tenant or tenant’s legal representative may utilize other remedies authorized by law to contest the transfer.
	68.15(2) Transfer pursuant to results of monitoring or complaint or program-reported incident investigation by the department.  If one or more tenants are identified as exceeding the admission and retention criteria for tenants and need to be transferred as a result of a monitoring or a complaint or program-reported incident investigation conducted by the department, the following procedures shall apply:
	a. 	Notification of the program. Within 20 working days of the monitoring or complaint or program-reported incident investigation, the department shall notify the program, in writing, of the identification of any tenant who exceeds admission and retention criteria.
	b. 	Notification of others. Each identified tenant, the tenant’s legal representative, if applicable, and other providers of services to the tenant shall be notified of their opportunity to provide responses including: specific input, written comment, information, and documentation directly addressing any agreement or disagreement with the identification. All responses shall be provided to the department within 10 days of receipt of the notice.
	c. 	Program agreement with the department’s finding. If the program agrees with the department’s finding and the program begins involuntary transfer proceedings, the program’s internal appeal process in subrule 68.15(1) shall be utilized for appeals.
	d. 	Program disagreement with the department’s finding. If the program does not agree with the department’s finding that the tenant exceeds admission and retention criteria, the program may collect and submit all responses to the department, including those from other interested parties. In the program’s response, the program shall identify the tenant, list the known responses from others, and note the program’s agreement or disagreement with the responses from others. The program’s response shall be submitted to the department within 10 working days of the receipt of the notice. Submission of a response does not eliminate the applicable requirements including submission of a plan of correction under 481—subrule 67.10(5). Other persons may also submit information directly to the department.
	(1)	Consideration of response. Within 10 working days of receipt of the program’s response for each identified tenant, the department shall consider the response and make a final finding regarding the continued retention of a tenant.
	(2)	Amending the regulatory insufficiency. If the department’s determination is to amend the regulatory insufficiency based on the response, the department shall modify the report of findings.
	(3)	Retaining regulatory insufficiency. If the department retains the regulatory insufficiency, the department shall review the plan of correction in accordance with this chapter and 481—Chapter 67. The department shall notify the program of the opportunity to appeal the report findings as they relate to the admission and retention decision. In addition, the department shall provide to the tenant or the tenant’s legal representative the contact information for the tenant advocate. A copy of the final report shall also be sent to the tenant advocate.
	(4)	Effect of the filing of an appeal. If an appeal is filed, the tenant who exceeds admission and retention criteria shall be allowed to continue living in the EGH until all administrative appeals have been exhausted. Appeals filed that relate to the tenant’s exceeding admission and retention criteria shall be heard within 30 days of receipt, and appropriate services to meet the tenant’s needs shall be provided during that period of time.
	(5)	Request for waiver of criteria for retention of a tenant in a program. To allow a tenant to remain in the program, the program may request a waiver of criteria for retention of a tenant pursuant to rule 481—67.7(231B,231C,231D) from the department within 10 working days of the receipt of the report.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.16(231B) Tenant documents.
	68.16(1) Documentation for each tenant shall be maintained by the program and shall include:
	a. 	An occupancy record including the tenant’s name, birth date, and home address; identification numbers; date of beginning participation; name, address and telephone number of health professional(s); diagnosis; and names, addresses and telephone numbers of family members, friends or other designated people to contact in the event of illness or an emergency;
	b. 	Application forms;
	c. 	The initial evaluations and updates;
	d. 	A nutritional assessment as necessary;
	e. 	The initial individual service plan and updates;
	f. 	Signed authorizations for permission to release medical information, photographs, or other media information as necessary;
	g. 	A signed authorization for the tenant to receive emergency medical care as necessary;
	h. 	A signed managed risk policy and signed managed risk consensus agreements, if any;
	i. 	When any personal or health-related care is delegated to the program, the medical information sheet; documentation of health professionals’ orders, such as those for treatment, therapy, and medication; and nurses’ notes written by exception;
	j. 	Medication lists, which shall be maintained in conformance with 481—subrule 67.5(4);
	k. 	Advance health care directives as applicable;
	l. 	A complete copy of the tenant’s occupancy agreement, including any updates;
	m. 	A written acknowledgment that the tenant or the tenant’s legal representative, if applicable, has been fully informed of the tenant’s rights;
	n. 	A copy of guardianship, durable power of attorney for health care, power of attorney, or conservatorship or other documentation of a legal representative;
	o. 	Incident reports involving the tenant, including but not limited to those related to medication errors, accidents, falls, and elopements (such reports shall be maintained by the program but need not be included in the tenant’s medical record);
	p. 	A copy of waivers of admission or retention criteria, if any;
	q. 	When the tenant is unable to advocate on the tenant’s own behalf or the tenant has multiple service providers, including hospice care providers, accurate documentation of the completion of routine personal or health-related care is required on task sheets. If tasks are doctor-ordered, the tasks shall be part of the medication administration records (MARs); and
	r. 	Authorizations for the release of information, if any.
	68.16(2) The program records relating to a tenant shall be retained for a minimum of three years after the transfer or death of the tenant.
	68.16(3) All records shall be protected from loss, damage and unauthorized use.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.17(231B) Service plans.
	68.17(1) A service plan shall be developed for each tenant based on the evaluations conducted in accordance with subrules 68.13(1) and 68.13(2) and shall be designed to meet the specific service needs of the individual tenant. The service plan shall subsequently be updated at least annually and whenever changes are needed.
	68.17(2) Prior to the tenant’s signing the occupancy agreement and becoming a household occupant, a preliminary service plan shall be developed by a health care professional or human service professional in consultation with the tenant and, at the tenant’s request, with other individuals identified by the tenant, and, if applicable, with the tenant’s legal representative. All persons who develop the plan and the tenant or the tenant’s legal representative shall sign the plan.
	68.17(3) When a tenant needs personal care or health-related care, the service plan shall be updated within 30 days of the tenant’s occupancy and as needed with significant change, but not less than annually.
	a. 	If a significant change triggers the review and update of the service plan, the updated service plan shall be signed and dated by all parties.
	b. 	If a significant change does not exist, the program may, after nurse review, add minor discretionary changes to the service plan without a comprehensive evaluation and without obtaining signatures on the service plan.
	c. 	If a significant change relates to a recurring or chronic condition, a previous evaluation and service plan of the recurring condition may be utilized without new signatures being obtained. For example, with chronic exacerbation of a urinary tract infection, nurse review is adequate to institute the previously written evaluation and service plan.
	68.17(4) The service plan shall be individualized and shall indicate, at a minimum:
	a. 	The tenant’s identified needs and preferences for assistance;
	b. 	Any services and care to be provided pursuant to the occupancy agreement;
	c. 	The service provider(s), if other than the program, including but not limited to providers of hospice care, home health care, occupational therapy, and physical therapy; and
	d. 	Preferences, if any, of the tenant or the tenant’s legal representative for nursing facility care, if the need for nursing facility care presents itself during the elder group home occupancy.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.18(231B) Nurse review. If a tenant does not receive personal or health-related care, but an observed significant change in the tenant’s condition occurs, a nurse review shall be conducted. If a tenant receives personal or health-related care, the program shall provide for a registered nurse or a licensed practical nurse via nurse delegation:
	68.18(1) To monitor, at least every 90 days, or after a significant change in the tenant’s condition, any tenant who receives program-administered prescription medications for adverse reactions to the medications and to make appropriate interventions or referrals, and to ensure that the prescription medication orders are current and that the prescription medications are administered consistent with such orders; and
	68.18(2) To ensure that health care professionals’ orders are current for tenants who receive health care professional-directed care from the program; and
	68.18(3) To assess and document the health status of each tenant, to make recommendations and referrals as appropriate, and to monitor progress relating to previous recommendations at least every 90 days and whenever there are changes in the tenant’s health status; and
	68.18(4) To provide the program with written documentation of the activities under the service plan, as set forth in rule 481—68.17(231B), showing the time, date and signature.
Note: Refer to Table A at the end of this chapter. If the program does not provide personal or health-related care to a tenant, nurse review is not required.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.19(231B) Staffing. In addition to the general staffing requirements in rule 481—67.9 (231B,231C,231D), the following requirements apply to staffing in programs.
	68.19(1) The program shall be staffed by an on-site manager 24 hours per day, seven days per week.
	68.19(2) Personal care providers shall have completed, at minimum, a home care aide training program that meets the requirements and criteria established in 641—Chapter 80.
	68.19(3) The owner or management corporation of the program is responsible for ensuring that all personnel employed by or contracting with the program receive training appropriate to assigned tasks and target population.
	68.19(4) Personal care providers and nursing staff may be employed by the program or obtained through a contract with a home health agency or other service provider. Regardless of the source, the staff must meet all applicable requirements.
	68.19(5) The program shall notify the department in writing within ten business days of a change in the program’s manager.
[ARC 8175B, IAB 9/23/09, effective 1/1/10; ARC 1927C, IAB 4/1/15, effective 5/6/15]
481—68.20(231B) Managed risk policy and managed risk consensus agreements. The program shall have a managed risk policy. The managed risk policy shall be provided to the tenant along with the occupancy agreement. The managed risk policy shall include the following:
	68.20(1) An acknowledgment of the shared responsibility for identifying and meeting the needs of the tenant and the process for managing risk and for upholding tenant autonomy when tenant decision making results in poor outcomes for the tenant or others; and
	68.20(2) A consensus-based process to address specific risk situations. Program staff and the tenant shall participate in the process. The result of the consensus-based process may be a managed risk consensus agreement. The managed risk consensus agreement shall include the signature of the tenant and the signatures of all others who participated in the process. The managed risk consensus agreement shall be included in the tenant’s file.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.21(231B) Transportation. When transportation services are provided directly or under contract with the program:
	68.21(1) The vehicle shall be accessible and appropriate to the tenants who use it, with consideration for any physical disabilities and impairments.
	68.21(2) Every tenant transported shall have a seat in the vehicle, except for a tenant who remains in a wheelchair during transport.
	68.21(3) Vehicles shall have adequate seat belts and securing devices for ambulatory and wheelchair-using passengers.
	68.21(4) Wheelchairs shall be secured when the vehicle is in motion.
	68.21(5) During loading and unloading of a tenant, the driver shall be in the proximate area of the tenants in a vehicle.
	68.21(6) The driver shall have a valid and appropriate Iowa driver’s license or commercial driver’s license as required by law for the vehicle being utilized for transport. If the driver is licensed in another state, the license shall be valid and appropriate for the vehicle being utilized for transport. The driver shall meet any state or federal requirements for licensure or certification for the vehicle operated.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.22(231B) Identification of veteran’s benefit eligibility.
	68.22(1) Within 30 days of a tenant’s participation in an elder group home that receives reimbursement through the medical assistance program under Iowa Code chapter 249A, the program shall ask the tenant or the tenant’s personal representative whether the tenant is a veteran or whether the tenant is the spouse, widow, or dependent of a veteran and shall document the response.
	68.22(2) If the program determines that the tenant may be a veteran or the spouse, widow, or dependent of a veteran, the program shall report the tenant’s name along with the name of the veteran, if applicable, as well as the name of the contact person for this information, to the Iowa department of veterans affairs. When appropriate, the program may also report such information to the Iowa department of human services.
	68.22(3) If a tenant is eligible for benefits through the U.S. Department of Veterans Affairs or other third-party payor, the program first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.23(231B) Resident advocate committees. Resident advocate committees for EGHs shall be governed by 321—Chapter 9 unless otherwise required in this chapter.
	68.23(1) Committee placement. A resident advocate committee shall be established by the commission on aging for each program certified in accordance with this chapter.
	68.23(2) Committee visitations. The committee shall visit the program assigned to it within one month of the admission of the first tenant as well as a minimum of once and maximum of four times annually thereafter.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.24(231B) Life safety—emergency policies and procedures and structural safety requirements.
	68.24(1) The program shall submit to the department and follow written emergency policies and procedures, which shall include the following:
	a. 	An emergency plan, which shall include procedures for natural disasters (identify where the plan is located for easy reference);
	b. 	Fire safety procedures;
	c. 	Other general or personal emergency procedures;
	d. 	Provisions for amending or revising the emergency plan;
	e. 	Provisions for periodic training of all employees;
	f. 	Procedures for fire drills;
	g. 	Regulations regarding smoking;
	h. 	Monitoring and testing of smoke-control systems;
	i. 	Tenant evacuation procedures; and
	j. 	Procedures for reporting and documentation.
	68.24(2) The program’s structure and procedures and the facility in which a program is located shall meet the requirements adopted for elder group homes in administrative rules promulgated by the state fire marshal. Approval of the state fire marshal indicating that the building is in compliance with these requirements is necessary for certification of a program.
	68.24(3) The program shall have the means to control the maximum temperature of water at sources accessible by a tenant to prevent scalding and shall control the maximum water temperature for tenants with cognitive impairment or dementia or at a tenant’s request.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.25(231B) Structural standards.
	68.25(1) The EGH shall be safe, sanitary, well-ventilated, and properly lighted, heated, and cooled; and shall comply with all applicable state and local housing ordinances for family residences and with fire safety rules promulgated by the state fire marshal.
	68.25(2) In addition to meeting the requirements in subrule 68.25(1), the EGH shall meet the following standards:
	a. 	General.
	(1)	The home, furnishings and fixtures shall be clean, in good repair and appropriate for the tenants.
	(2)	Stairways shall have handrails of a circumference, length, texture, strength and stability that can reasonably be expected to provide tenant support.
	(3)	A functioning light shall be provided in each room, stairway and exit; all light bulbs shall be protected from breakage or removal with appropriate covers.
	(4)	The yard, fire exits and exterior steps shall be kept free of obstructions and shall be accessible and appropriate to the condition of the tenants.
	(5)	There shall be at least 150 square feet of common living space and sufficient furniture in the home to accommodate the recreational and socialization needs of all the tenants at one time; common space shall not be located in the basement or garage, unless such space was constructed for that purpose. Additional common living space may be required if wheelchairs, walkers or other durable medical equipment is to be accommodated. For an EGH constructed or remodeled after July 1, 2005, there shall be 300 square feet of usable floor space.
	(6)	Interior and exterior doorways used by tenants shall be wide enough to accommodate wheelchairs and walkers if tenants with impaired mobility are in residence.
	(7)	Hot and cold water at each tub, shower, and sink shall be in sufficient supply to meet the needs of the tenants and staff.
	(8)	Grab bars shall be present for each toilet, tub and shower. Access to toilet and bathing facilities shall be barrier-free. Toilet and bathing facilities shall provide individual privacy.
	(9)	A telephone shall be available and accessible for tenants’ use in a manner that allows for privacy for all calls.
	b. 	Safety.
	(1)	All combustion appliances shall be used and maintained properly and shall be inspected annually by a qualified technician for carbon monoxide emissions and any other hazards to health and safety;
	(2)	Extension cord wiring shall not be used in place of permanent electrical fixtures or outlets.
	c. 	Sanitation requirements.
	(1)	A public water supply shall be utilized if available. If a nonmunicipal water source is used, the owner or on-site manager must show documentation from the state laboratory that the water supply is potable and is tested as required by the rules of the environmental protection commission of the department of natural resources.
	(2)	Septic tanks or other nonmunicipal wastewater disposal systems shall be in good working order and shall comply with state and local regulations for wastewater treatment.
	(3)	Garbage and refuse shall be suitably stored and disposed of by a sanitation company providing service in the area.
	(4)	If laundry service is provided, soiled linens and clothing shall be stored in containers in an area separate from food storage, kitchen and dining areas.
	(5)	Sanitation for household pets and other domestic animals shall be adequate to prevent health and safety hazards.
	(6)	There shall be adequate control of insects and rodents.
	(7)	Reasonable and prudent precautions for infection control shall be taken, including washing hands and exposed portions of arms with soap and hot water immediately before engaging in food preparation and meal service and before and after providing personal care.
	(8)	There shall be at least one toilet and one sink for every four household occupants. A minimum of one sink and toilet is required on each floor occupied by tenants. A sink shall be located near each toilet. For an EGH constructed or remodeled after July 1, 2005, there shall be at least one toilet and one sink for every two household occupants, with a minimum of one toilet and one sink on each floor occupied by tenants.
	(9)	At least one tub or shower is required for each six household occupants. For an EGH constructed or remodeled after July 1, 2005, there shall be at least one tub or one shower for every four household occupants.
	d. 	Bedroom requirements.
	(1)	Each tenant bedroom shall:
	1.	Have a door that opens directly to a hallway or common use area without passage through another bedroom or common bathroom;
	2.	Be adequately ventilated, heated, cooled and lighted;
	3.	Have at least 70 square feet of usable floor space, excluding any area where a sloped ceiling does not allow a person to stand upright. For an EGH constructed or remodeled after July 1, 2005, each tenant bedroom shall have at least 100 square feet of usable floor space;
	4.	Provide individual privacy and be occupied by one tenant, unless an alternative arrangement is agreed to in the occupancy agreement by the tenant or the tenant’s legal representative;
	5.	Be on ground level for tenants with impaired mobility;
	6.	Be in sufficiently close proximity to the on-site manager to ensure that tenants are able to alert the on-site manager to nighttime needs or emergencies, or be equipped with a call system.
	(2)	Owners, operators, on-site managers, their family members, and personal care providers shall not use as bedrooms areas that are designated as living areas or as tenant bedrooms;
	(3)	Common living space and tenant bedrooms shall not be used for storage areas.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
481—68.26(231B) Landlord and tenant Act. Iowa Code chapter 562A, the uniform residential landlord and tenant Act, shall apply to all EGHs under this chapter.
[ARC 8175B, IAB 9/23/09, effective 1/1/10]
These rules are intended to implement Iowa Code chapter 231B.
Table A

[Filed ARC 8175B (Notice ARC 7960B, IAB 7/15/09), IAB 9/23/09, effective 1/1/10]
[Filed ARC 1927C (Notice ARC 1860C, IAB 2/4/15), IAB 4/1/15, effective 5/6/15]