CHAPTER 71
SUBACUTE MENTAL HEALTH CARE FACILITIES
481—71.1(135G) Purpose—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.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.2(135G) Definitions. For the purpose of these rules, the following terms shall have the meanings indicated in this chapter. The definitions set out in Iowa Code section 135G.1 are adopted by reference in the rules.
“Administrator” means an individual who administers, manages, supervises, and is in general administrative charge of a subacute care facility, whether or not such individual has an ownership interest in the facility and whether or not the functions and duties are shared with one or more individuals.
“Assessment” means the evaluation of a person in psychiatric crisis in order to ascertain the person’s current and previous level of functioning, psychiatric and medical history, potential for dangerousness, current psychiatric and medical condition factors contributing to the crisis and support systems that are available.
“Distinct part” means a clearly identifiable area or section within a health care facility, consisting of at least a residential unit, wing, floor, or building containing contiguous rooms.
“Incident” means an unusual occurrence within a facility or on its premises affecting residents, visitors, or employees whether or not there is apparent injury or where hidden injury may have occurred.
“Medication” means any drug including over-the-counter substances ordered and administered under the direction of a physician, physician assistant or advanced registered nurse practitioner.
“Peer support” means services that are provided by individuals in recovery from serious mental illness and delivered to others who also have mental illness.
“Psychiatric care” means the provision of care to patients in a psychiatric unit of an acute care hospital; a freestanding psychiatric hospital; or a mental health clinic.
“Recovery” means a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
“Recovery principles” means the ten guiding principles of recovery outlined by the federal Substance Abuse and Mental Health Services Administration (www.samhsa.gov): hope, person-driven, many pathways, holistic, peer support, relational, culture, addresses trauma, strengths/responsibility, and respect.
“Responsible party” means the person who signs or cosigns the admission agreement required in rule 481—71.13(135G) or the resident’s guardian or conservator if one has been appointed. In the event that a resident does not have a guardian, conservator or other person signing the admission agreement, the term “responsible party” shall include the resident’s sponsoring agency, e.g., the department of human services, the U.S. Department of Veterans Affairs, a religious group, fraternal organization, or foundation that assumes responsibility and advocates for its client patients and pays for their health care.
“Restraint” means the application of physical force, use of a chemical agent, or a mechanical device for the purpose of restraining the free movement of an individual’s body to protect the individual or others from immediate harm. Restraint does not include briefly holding without undue force an individual to calm or comfort the individual or holding an individual’s hand to safely escort the individual from one area to another.
“Restricted means of egress” means an exit door alarm system for safety of the residents and the public.
“Seclusion” means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.3(135G) Application for licensure.
	71.3(1) Initial application and licensing. In order to obtain an initial license for a subacute care facility, the applicant must meet all the requirements of the rules, regulations, and standards contained in Iowa Code chapter 135G and in this chapter and must make application at least 30 days prior to the proposed licensure date of the subacute care facility on forms provided by the department. The applicant must:
	a. 	Submit a résumé of care with a narrative which includes the following information:
	(1)	The purpose of the facility.
	(2)	A description of the target population and limitations on resident eligibility.
	(3)	Identification and description of the services the facility will provide, which shall minimally include specific and measurable goals and objectives for each of the services to be made available by the facility and a description of the resources needed to provide each of the services, including staff, physical facilities and funds.
	(4)	A description of the human services system available in the area including, but not limited to, social, public health, visiting nurse, vocational training, and employment services, residential living arrangements, and services of private agencies.
	(5)	A description of working relationships with human services agencies when applicable, which shall include at a minimum:
	1.	A description of how the facility will coordinate with human services agencies to facilitate continuity of care and coordination of services to residents; and
	2.	A description of how the facility will coordinate with human services agencies to identify unnecessary duplication of services and plan for development and coordination of needed services;
	b. 	Submit a floor plan of each floor of the facility drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathrooms, the designation of the use to which each room will be put, and window and door location;
	c. 	Submit a photograph of the front and side elevation of the facility;
	d. 	Submit the statutory fee for a subacute care facility license;
	e. 	Show evidence of a certificate signed by the state fire marshal or deputy state fire marshal, or the designee of either, certifying compliance with fire safety rules.
	71.3(2) Conversion from an intermediate care facility for persons with mental illness. An intermediate care facility for persons with mental illness may be converted to a subacute care facility pursuant to Iowa Code section 135G.4(2) if the facility:
	a. 	Provides written notice to the department that the facility has employed a full-time psychiatrist and desires to make the conversion; and
	b. 	Submits an application to the department.
	71.3(3) Renewal application or change of ownership. In order to obtain a renewal or change of the subacute care facility license, the applicant must:
	a. 	Submit to the department the completed application form 30 days prior to the annual license renewal or change of ownership date;
	b. 	Submit the statutory license fee for a subacute care facility with the application for renewal or change of ownership;
	c. 	Have an approved, current certificate signed by the state fire marshal or deputy state fire marshal, or the designee of either, certifying compliance with fire safety rules and regulations; and
	d. 	Submit appropriate changes in the résumé of care to reflect any changes in the resident care program or other services.
	71.3(4) Issuance of license. Licenses are issued to the person or governmental unit with responsibility for the operation of the facility and authority to comply with all applicable statutes, rules or regulations. The person or governmental unit must be the owner of the facility or, if the facility is leased, the lessee.
	71.3(5) Beds per facility. A single facility shall not be licensed for more than 16 beds.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 2068C, IAB 7/22/15, effective 8/26/15; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.4(135G) Licenses for distinct parts.
	71.4(1) Separate licenses may be issued for distinct parts of a health care facility which are clearly identifiable, include specifically designated rooms within the facility, and provide separate categories of care and services.
	71.4(2) The following requirements shall be met for a separate licensing of a distinct part:
	a. 	The distinct part shall serve only residents who require the category of care and services immediately available to the residents within that part;
	b. 	The distinct part shall meet all the standards, rules, and regulations pertaining to the category for which a license is being sought;
	c. 	A distinct part must be operationally and financially feasible.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.5(135G)  Waivers.
	71.5(1) Waivers from these rules may be granted by the director of the department if, in addition to the requirements of 481—Chapter 6:
	a. 	The need for a waiver has been established consistent with the résumé of care or the resident’s individual program plan; and
	b. 	There is no danger to the health, safety, welfare, or rights of any resident.
	71.5(2) The waiver will apply only to a subacute care facility.
	71.5(3) Waivers shall be reviewed by the department at the time of each licensure survey to verify whether the facility is still eligible for the waiver.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 5719C, IAB 6/16/21, effective 7/21/21]
481—71.6(135G) Provisional license.
	71.6(1) Provisional license procedure. The department may issue a provisional license to a subacute care facility pursuant to Iowa Code section 135G.8. The procedure for issuance of a provisional license shall be as follows:
	a. 	The department shall first issue to the facility a report which identifies the deficiency.
	b. 	Within 10 working days after receipt of the report, the facility shall provide the department with a written plan of correction.
	c. 	The department shall review the written plan of correction within 10 working days of receipt. The department may request additional information or revision to the plan, which shall be provided as requested.
	d. 	After accepting the written plan of correction, the department shall then issue a provisional license to the facility, which shall not exceed one year in duration.
	71.6(2) Written plan of correction. The written plan of correction shall contain:
	a. 	How the facility will correct the deficient practice;
	b. 	How the facility will act to protect residents;
	c. 	The measures the facility will take or the systems it will alter to ensure that the deficient practice does not recur; and
	d. 	The date when the plan of correction will be completed, not to exceed 30 days from the date of the department’s report.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.7(135G) General requirements.
	71.7(1) The license shall be displayed in the facility in a conspicuous place which is viewed by the public.
	71.7(2) The license shall be valid only for the premises and person named on the license and is not transferable.
	71.7(3) The posted license shall accurately reflect the current status of the subacute care facility’s license.
	71.7(4) A license shall expire one year after the date of issuance or as indicated on the license.
	71.7(5) There shall be no more beds added than are stipulated on the license.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.8(135G) Required notifications to the department.
	71.8(1) The department shall be notified:
	a. 	Thirty days in advance of any proposed change in the subacute care facility’s functional operation or the addition or deletion of required services;
	b. 	Thirty days before any addition, alteration, or new construction is begun in the subacute care facility or on the premises;
	c. 	Thirty days in advance of any closure of the subacute care facility;
	d. 	Within two weeks of any change in administrator;
	e. 	Within 30 days of the date on which any change in the category of license is sought;
	f. 	Within 30 days of any proposed change in the résumé of care for the subacute care facility.
	71.8(2) Prior to the purchase, transfer, assignment, or lease of a subacute care facility, the licensee shall:
	a. 	Inform the department of the pending sale, transfer, assignment, or lease of the facility; and
	b. 	Inform the department of the name and address of the prospective purchaser, transferee, assignee, or lessee at least 30 days before the sale, transfer, assignment, or lease is completed.
	71.8(3) Within 24 hours, or the next business day, by the most expeditious means available, the department shall be notified:
	a. 	Of any accident causing major injury. “Major injury” shall be defined as any injury which:
	(1)	Results in death; or
	(2)	Requires admission to a higher level of care for treatment, other than for observation; or
	(3)	Requires consultation with the attending physician, designee of the physician, physician assistant, or advanced registered nurse practitioner who determines, in writing, on a form designated by the department, that an injury is a “major injury” based upon the circumstances of the accident, the previous functional ability of the resident, and the resident’s prognosis;
	b. 	When a resident attempts suicide, regardless of injury;
	c. 	When damage to the facility is caused by a natural or other disaster;
	d. 	When a fire occurs in a facility and the fire requires the notification of emergency services, requires full or partial evacuation of the facility, or causes physical injury to a resident;
	e. 	When a defect or failure occurs in the fire sprinkler system for more than 10 hours or fire alarm system for more than 4 hours in a 24-hour period. (This reporting requirement is in addition to the requirement to notify the state fire marshal or the state fire marshal’s designee.)
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19; ARC 6974C, IAB 4/5/23, effective 5/10/23]
481—71.9(135G) Reports of dependent adult abuse. Reports of suspected dependent adult abuse shall be made to the department of human services.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.10(135G) Administrator.
	71.10(1) Administrator required. Each subacute care facility shall have one person in charge who is duly approved by the department or acting in a provisional capacity in accordance with these rules.
	71.10(2) Qualifications of an administrator. The administrator shall be at least 21 years of age and shall have a high school diploma or equivalent. In addition, the person shall meet at least one of the following conditions:
	a. 	Be a mental health professional, as defined in Iowa Code section 228.1(7), with at least one year of experience in an administrative capacity; or
	b. 	Have a four-year degree in human services, psychology, sociology, nursing, health care administration, public administration, or a related field and have a minimum of one year of experience in the field; or
	c. 	Have a master’s degree in human services, psychology, sociology, nursing, health care administration, public administration, or a related field; or
	d. 	Be a licensed nursing home administrator.
	71.10(3) Administrator—distinct part. If a subacute care facility is a distinct part of a licensed health care facility, the administrator of the facility as a whole may serve as the administrator of the subacute care facility.
	71.10(4) Provisional administrator. A provisional administrator may be appointed on a temporary basis by the subacute care facility licensee to assume the administrative responsibilities of the facility for a period not to exceed 12 months when the facility has, through no fault of its own, lost its administrator and has not been able to replace the administrator, provided the department has been notified and has approved the provisional administrator prior to the date of the administrator’s appointment. The provisional administrator must meet the requirements of subrule 71.10(2).
	71.10(5) Administrator—initial licensing of facility. A facility applying for an initial license shall not have a provisional administrator.
	71.10(6) Duties of administrator. An administrator shall:
	a. 	Be responsible for the implementation of procedures to support the policies established by the licensee;
	b. 	Select and direct competent personnel who provide services for the subacute care facility;
	c. 	Make a policies and procedures manual available to all staff;
	d. 	Be responsible for a monthly in-service educational program for all employees and maintain records of programs and participants;
	e. 	Make staff payroll records available for departmental review as needed;
	f. 	Furnish to the department within 30 days of the department’s request statistical information concerning the operation of the facility.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.11(135G) Administration.
	71.11(1) The licensee shall:
	a. 	Assume the responsibility for the overall operation of the subacute care facility;
	b. 	Be responsible for compliance with all applicable laws and with the rules of the department;
	c. 	Establish written policies, which shall be available for review, for the operation of the subacute care facility.
	71.11(2) The policy and procedures shall include:
	a. 	Personnel;
	b. 	Admission;
	c. 	Evaluation services;
	d. 	Treatment and discharge plan;
	e. 	Crisis intervention, including restraint and seclusion;
	f. 	Involuntary discharge or transfer;
	g. 	Medication management;
	h. 	Records;
	i. 	Resident rights.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.12(135G) Personnel.
	71.12(1) Staffing requirements. Availability of personnel must be sufficient to meet psychiatric and medical treatment needs of the residents served.
	71.12(2) Staffing shall include at minimum:
	a. 	Twenty-four-hour-per-day, seven-day-per-week availability of on-call psychiatrist or advanced registered nurse practitioner with at least one year of experience in psychiatric care;
	b. 	Twenty-four-hour-per-day, seven-day-per-week availability of on-call registered nurse with at least two years of experience in psychiatric care or a registered nurse with a bachelor of science in nursing (BSN) and at least one year of experience in psychiatric care;
	c. 	A mental health professional as defined in Iowa Code section 228.1(7);
	d. 	Direct care staff with at least one year of experience in a mental health care setting; and
	e. 	Social service staff at the bachelor level with at least one year of experience in a mental health care setting.
	71.12(3) Personnel policies and procedures shall include the following requirements:
	a. 	Written job descriptions for all employees or agreements for all consultants, which include duties and responsibilities, education, experience, or other requirements, and supervisory relationships.
	b. 	Annual performance evaluations of all employees and consultants which are dated and signed by the employee or consultant and the supervisor.
	c. 	Personnel records which are current, accurate, complete, and confidential to the extent allowed by law.
	(1)	The record shall contain documentation of how the employee’s or consultant’s education and experience are relevant to the position for which the employee or consultant was hired.
	(2)	The record shall contain documentation of criminal history, child abuse and dependent adult abuse record checks, which shall be conducted prior to employment.
	d. 	Roles, responsibilities, and limitations of student interns and volunteers.
	e. 	An orientation program for all newly hired employees and consultants that includes an introduction to the facility’s personnel policies and procedures and a discussion of the facility’s safety plan.
	f. 	Equal opportunity and affirmative action employment practices.
	g. 	Procedures to be used when disciplining an employee.
	h. 	Appropriate dress and personal hygiene for staff.
	i. 	An overview of recovery principles, person-centered planning and residents’ rights.
	71.12(4) The facility shall require regular health examinations for all personnel. Employees shall have a health examination within 12 months prior to beginning employment and regular examinations thereafter at least every four years. The examination shall include, at a minimum, the health status of the employee, including screening and testing for tuberculosis as described in 481—Chapter 59.
	a. 	No person shall be allowed to provide services in a facility if the person has a disease:
	(1)	Which is transmissible through required workplace contact;
	(2)	Which presents a significant risk of infecting others;
	(3)	Which presents a substantial possibility of harming others; and
	(4)	For which no reasonable accommodation can eliminate the risk.
	b. 	There shall be written policies for emergency medical care for employees in case of sudden illness or accident. These policies shall include the administrative individuals to be contacted.
	c. 	Health certificates for all employees shall be available for review by the department.
	71.12(5) Personnel record.
	a. 	A personnel record shall be kept for each employee.
	b. 	The record shall include the employee’s:
	(1)	Name and address,
	(2)	Social security number,
	(3)	Date of birth,
	(4)	Date of employment,
	(5)	References,
	(6)	Position in the facility,
	(7)	Job description,
	(8)	Documentation of experience and education,
	(9)	Criminal history, child abuse and dependent adult abuse background checks,
	(10)	Staff training records,
	(11)	Annual performance evaluation,
	(12)	Documentation of disciplinary action,
	(13)	Date and reason for discharge or resignation,
	(14)	Current physical examination.
	71.12(6) Orders for medications and treatments shall be correctly implemented by qualified personnel.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.13(135G) Admission, transfer, and discharge.
	71.13(1) General admission policies.
	a. 	A subacute care facility shall not admit or retain a resident who is in need of greater services than the facility can provide.
	b. 	Prior to admission of an applicant, the facility shall obtain sufficient information to determine if its program is appropriate and adequate to meet the individual’s needs.
	c. 	A subacute care facility shall admit only as many residents as indicated by the number of beds for which the facility is licensed.
	d. 	A subacute care facility shall adopt policies regarding the admission requirements outlined in subrule 71.13(2).
	71.13(2) Admission requirements.
	a. 	Eligibility for individualized subacute mental health services will be determined by the standardized preadmission screening utilized by the facility. The screening shall be conducted by a mental health professional as defined in Iowa Code section 228.1(7), a physician, a physician assistant, or an advanced registered nurse practitioner.
	b. 	In order to be admitted, the individual must:
	(1)	Be 18 years or older;
	(2)	During the past year, have had a diagnosable mental, behavioral or emotional disorder that meets the diagnostic criteria specified in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM);
	(3)	Demonstrate a high degree of impairment through significantly impaired mental, social, or educational functioning arising from the psychiatric condition or serious emotional disturbance;
	(4)	Demonstrate an impairment that severely limits the skills necessary to maintain an adequate level of functioning outside a treatment program and requires active treatment to obtain an adequate level of functioning;
	(5)	Demonstrate a low level of stability through any two of the following conditions:
	1.	The individual presents moderate to high risk of danger to self or others.
	2.	The individual lacks adequate skills or social support to address mental health symptoms.
	3.	The individual is medically stable but requires observation and care for stabilization of a mental health condition or impairment.
	71.13(3) Admission agreement. A subacute care facility shall provide an admission agreement to each resident upon admission to the facility. Each admission agreement shall include:
	a. 	Method of payment;
	b. 	Schedule of services and any additional fees;
	c. 	The facility’s policies regarding length of stay, discharge and transfer.
	71.13(4) Exclusion criteria.
	a. 	A subacute care facility shall not admit an individual into the facility if:
	(1)	The individual manifests behavioral or psychiatric symptoms that require acute care;
	(2)	The individual can be safely maintained and effectively treated with less intensive services in a community setting; or
	(3)	The symptoms of the individual do not meet admission criteria in subrule 71.13(2).
	b. 	An individual’s lack of adequate place of residence, placement, or housing is not reason to receive subacute mental health services.
	71.13(5) Continued stay criteria policies. By the tenth day following admission and every ten calendar days thereafter, the mental health professional shall conduct and document an assessment of the resident and determine if:
	a. 	The severity of the behavioral and emotional symptoms continues to require the subacute level of intervention and the DSM diagnosis remains the principal diagnosis.
	b. 	The prescribed interventions remain consistent with the intended treatment plan outcomes.
	c. 	There is documented evidence of active, individualized discharge planning.
	d. 	There is a reasonable likelihood of substantial benefit in the resident’s mental health condition as a result of active intervention of the 24-hour supervised program.
	e. 	Symptoms and behaviors that required admission are continuing.
	f. 	A less intensive level of care would be insufficient to stabilize the resident’s condition.
	g. 	New issues that meet the admission guidelines in subrule 71.13(2) have appeared.
	h. 	The resident requires further stabilization subsequent to acute care to treat active mental health symptoms such as psychosis, depression or mood disorder.
	71.13(6) Discharge criteria policies. A resident may be discharged from subacute level of care if:
	a. 	The resident’s treatment plan goals and objectives for subacute services have been met and a discharge plan to outpatient or other community-based services is in place.
	b. 	The resident’s physical condition necessitates transfer to a more intensive level of care.
	c. 	The resident is not making progress toward treatment goals and there is no reasonable expectation of progress at the subacute level of care.
	d. 	The resident becomes a danger to self, others, or facility structure and requires an emergency transfer to a higher level of care.
	e. 	The resident repeatedly refuses to participate in the resident’s treatment plan.
	71.13(7) Discharge or transfer.
	a. 	The facility shall give prior notification to the resident, as well as the resident’s next of kin, legal representative, attending physician or advanced registered nurse practitioner, and sponsoring agency, if any, prior to transfer or discharge of any resident.
	b. 	The subacute care facility shall make proper arrangements for the welfare of the resident prior to transfer or discharge in the event of an emergency or inability to reach the next of kin or legal representative.
	c. 	The facility shall make advance notification to the receiving facility prior to the transfer of any resident if the resident is to be transferred to another facility.
	(1)	Notification shall be made no less than 24 hours prior to transfer unless paragraph 71.13(6)“d” applies.
	(2)	Prior to the transfer or discharge of a resident to another health care facility, arrangements to provide for continuity of care shall be made with the facility to which the resident is being transferred.
	d. 	The appropriate record as set forth in subrule 71.20(1) shall accompany the resident when the resident is transferred or discharged.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 2068C, IAB 7/22/15, effective 8/26/15; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.14(135G) Treatment plan.
	71.14(1) A treatment plan must be developed with each resident. The plan must be based on initial and ongoing assessment of need, be designed to resolve the acute or crisis mental health symptoms or the imminent risk of acute or crisis mental health symptoms, and be completed within six hours of admission, or no later than 12 noon following admission if the resident is admitted between 8 p.m. and 6 a.m.
	71.14(2) The treatment plan must be documented in the resident’s record and must include the following:
	a. 	The resident’s name.
	b. 	The date the plan is developed.
	c. 	Standardized diagnostic formulations, including but not limited to the current Diagnostic and Statistical Manual (DSM) or the current International Statistical Classification of Diseases and Related Health Problems (ICD).
	d. 	Problems and strengths of the resident that are to be addressed.
	e. 	Observable and measurable individual objectives that relate to the specific problems identified.
	f. 	Interventions that address specific objectives, identification of staff responsible for interventions, and planned frequency of interventions.
	g. 	Signatures of mental health professionals responsible for developing the plan, including the qualified prescriber.
	h. 	Signatures of the resident and any parent, guardian, conservator, or legal custodian. Reasons for refusal to sign or inability to participate in treatment plan development must be documented.
	i. 	A projected discharge date and anticipated postdischarge needs, including documentation of resources needed in the community.
	j. 	Review of the treatment plan by the appropriate treatment staff at least daily and upon completion of the stated goals or objectives and documentation of the following:
	(1)	Progress toward each treatment objective, with revisions as indicated; and
	(2)	Status of discharge plans, including availability of resources needed by the resident in the community, with revisions as indicated.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.15(135G) Crisis intervention.
	71.15(1) There shall be written policies and procedures concerning crisis intervention. These policies and procedures shall be:
	a. 	Directed to maximizing the growth and development of the individual by incorporating a hierarchy of available alternative methods that emphasize positive approaches;
	b. 	Available in each program area and living unit;
	c. 	Available to individuals and their families; and
	d. 	Developed with the participation, as appropriate, of individuals served.
	71.15(2) An emergency safety intervention must be performed in a manner that is safe, proportionate, and appropriate to the severity of the behavior and to the individual’s chronological and developmental age, size, gender, physical, medical, and psychiatric condition and personal history, including any history of physical or sexual abuse.
[ARC 1740C, IAB 11/26/14, effective 12/31/14]
481—71.16(135G) Seclusion and restraint.
	71.16(1) Use of a seclusion room. Pursuant to Iowa Code section 135G.3(2), a seclusion room used by a subacute care facility must meet the conditions of 42 CFR § 483.364(b).
	a. 	A subacute care facility utilizing a seclusion room shall have written policies regarding its use. The policy shall:
	(1)	Specify the types of behavior that may result in seclusion room placement.
	(2)	Delineate the licensed personnel who may authorize use of the seclusion room.
	(3)	Require documentation of the time in the seclusion room, the reasons for use of the seclusion room, and the reasons for any extension of time beyond one hour. Under no circumstances shall the use of the seclusion room exceed four hours.
	(4)	Require notice to residents of the types of behavior that may result in seclusion room placement.
	b. 	A staff member shall always be in hearing distance of the seclusion room, and the resident shall be visually checked by the staff at least every 15 minutes. Every check shall be documented in writing.
	c. 	A seclusion room shall not be used for punishment, for the convenience of staff, or as a substitution for supervision. A seclusion room shall only be used when a less restrictive alternative has failed and:
	(1)	In an emergency to prevent injury to the resident or to others; or
	(2)	For crisis intervention.
	71.16(2) Use of restraints. There shall be written policies that define the use of restraint, designate the staff member who may authorize its use, and establish a mechanism for monitoring and controlling its use.
	a. 	Restraint shall not be used for punishment, for the convenience of staff, or as a substitution for supervision. Restraint shall only be used:
(1) In an emergency to prevent injury to the resident or to others; or
(2) For crisis intervention.
	b. 	Restraint must not result in harm or injury to the resident and must be used only to ensure the safety of the resident or others during an emergency situation until the emergency situation has ceased, even if the restraint order has not expired.
	c. 	The use of restraint should be selected only when other less restrictive measures have been found to be ineffective to protect the resident or others. The staff shall demonstrate effective treatment approaches and alternatives to the use of restraint.
	d. 	Under no circumstances shall a resident be allowed to actively or passively assist in the restraint of another resident.
	e. 	Staff trained in the use of emergency safety interventions must be physically present and continually assessing and monitoring the well-being of the resident and the safe use of restraint throughout the duration of the emergency situation.
	71.16(3) Orders for restraint or seclusion. An order for restraint or seclusion shall not be written as a standing order or on an as-needed basis.
	a. 	Each order for restraint or seclusion shall include:
	(1)	The name of the ordering physician, physician assistant or advanced registered nurse practitioner.
	(2)	The date and time the order is obtained.
	(3)	The emergency safety intervention ordered, including the length of time for which restraint or seclusion is authorized.
	b. 	Orders for restraint or seclusion must be by a physician, physician assistant or advanced registered nurse practitioner.
	(1)	Verbal orders must be received while the emergency safety intervention is being initiated by staff or immediately after the emergency safety situation ends and must be verified in writing in the resident’s record by the physician, physician assistant or advanced registered nurse practitioner.
	(2)	Once the one-time order for the specific resident in an emergency safety situation has expired, it may not be renewed on a planned, anticipated, or as-needed basis.
	71.16(4) Simultaneous use prohibited. Restraint and seclusion shall not be used simultaneously.
	71.16(5) Documentation of use of restraint or seclusion. Staff must document in the resident’s record and in a centralized tracking system any use of restraint or seclusion.
	a. 	Documentation must be completed by the end of the shift in which the intervention occurs or during the shift in which it ends.
	b. 	Documentation shall include:
	(1)	The order for restraint or seclusion.
	(2)	The time the emergency safety intervention began and ended.
	(3)	The emergency safety situation that required restraint or seclusion.
	(4)	The name of staff involved in the emergency safety intervention.
	(5)	The interventions used and their outcomes.
	(6)	The signature of the physician, physician assistant or advanced registered nurse practitioner.
	71.16(6) Meeting to process restraint or seclusion. As soon as reasonably possible after the restraint or seclusion of a resident has terminated, staff must meet to process the restraint or seclusion occurrence and document in writing the meeting.
	71.16(7) Multiple occasions of restraint or seclusion. A resident who requires restraint or seclusion on multiple occasions should be considered for a higher level of care.
	71.16(8) Staff training. The facility shall provide to the staff training by qualified professionals on physical restraint and seclusion theory and techniques.
	a. 	The facility shall keep a record of the training, including attendance, for review by the department.
	b. 	Only staff who have documented training in physical restraint and seclusion theory and techniques shall be authorized to assist with the seclusion or physical restraint of a resident.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.17(135G) Medication management.
	71.17(1) Medications must be ordered by qualified prescribers and administered by qualified personnel. For purposes of this subrule, “qualified personnel” means, at a minimum, a certified medication aide.
	71.17(2) Prescription medication must be legally dispensed and labeled according to state law.
	71.17(3) All medication errors, drug reactions and suspected drug overmedication must be documented and reported to the practitioner who prescribed the medication.
	71.17(4) All medications and other preparations intended for internal or external human use must be stored in medicine cabinets or drug rooms. When preservation of the medication or other preparation requires refrigeration, the facility must provide a means of securely refrigerating these items. Such cabinets or drug rooms must be kept securely locked when not in use, and the key must be in the possession of the supervising nurse or other authorized person.
	71.17(5) Schedule II drugs must be stored within two separately locked compartments at all times and accessible only to qualified personnel in charge of administering medication.
	71.17(6) Any unused portions of program-prescribed medication(s) must be either turned over to the resident with written authorization and directions by the qualified prescriber or returned to a pharmacy for proper disposition by the pharmacist.
	71.17(7) Whenever a resident brings the resident’s own prescribed medications into the facility, such medications must not be administered unless identified by a qualified prescriber or pharmacist and ordered by a qualified prescriber. If such medications cannot be administered, they must be packaged, sealed, and returned to an adult member of the resident’s immediate family or the legal guardian or securely stored and returned to the resident upon discharge. However, if previously prescribed medication would prove harmful to the resident, the medication may be withheld from the resident and disposed of in accordance with subrule 71.17(6). There must be documentation by the qualified prescriber in the resident’s clinical record citing the dangers or contraindications of the medication being withheld.
	71.17(8) All potent, poisonous, or caustic materials shall be stored separately from medications. All potent, poisonous, or caustic materials shall be plainly labeled and stored in a specific, well-illuminated cabinet, closet or storeroom and made accessible only to authorized personnel.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.18(135G) Dietary.
	71.18(1) Nutrition and menu planning.
	a. 	Menus shall be planned and followed to meet the nutritional needs of residents.
	b. 	Menus shall be planned and served to include foods and amounts necessary to meet federal dietary guidelines.
	c. 	At least three meals or their equivalent shall be served daily, at regular hours.
	71.18(2) Dietary storage, food preparation, and service. All food shall be handled, prepared, served and stored in compliance with the Food Code adopted pursuant to Iowa Code section 137F.2.
[ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.19(135G) Buildings, furnishings, and equipment.
	71.19(1) Buildings—general requirements.
	a. 	All windows shall be supplied with window treatments that are kept clean and in good repair.
	b. 	Whenever glass sliding doors or transparent panels are used, they shall be marked conspicuously.
	c. 	The facility shall meet the equivalent requirements of the appropriate group occupancy of the state fire code.
	71.19(2) Furnishings and equipment.
	a. 	All furnishings and equipment shall be durable, cleanable, and appropriate to their function.
	b. 	Upholstery materials shall be moisture- and soil-resistant as needed, except on furniture provided by the resident and the property of the resident.
	71.19(3) Dining area and common area. Every facility shall have a dining area and a common area easily accessible to all residents.
	a. 	A common area shall be maintained for the use of residents and their visitors and may be used for recreational activities. Common areas shall be suitably furnished.
	b. 	Dining areas shall be furnished with dining tables and chairs appropriate to the size and function of the facility. Dining areas and furnishings shall be kept clean and sanitary.
	71.19(4) Bedrooms.
	a. 	Each resident shall be provided with a twin-sized or larger bed, substantially constructed and in good repair. Rollaway beds, metal cots, or folding beds are not acceptable.
	b. 	Each bed shall be equipped with the following: casters or glides; clean springs in good repair; a clean, comfortable, well-constructed mattress approximately five inches thick and standard in size for the bed; and clean, comfortable pillows of average bed size.
	c. 	Each resident shall have a bedside table with a drawer to accommodate personal possessions.
	d. 	There shall be a comfortable chair, either a rocking chair or armchair, per resident bed. The resident’s personal wishes shall be considered.
	e. 	There shall be drawer space for each resident’s clothing. In a bedroom in which more than one resident resides, drawer space shall be assigned to each resident.
	f. 	Beds and other furnishings shall not obstruct free passage to and through doorways.
	g. 	Beds shall not be placed in such a manner that the side of the bed is against the radiator or in close proximity to it unless the radiator is covered so as to protect the resident from contact with it or from excessive heat.
	h. 	There shall be no more than two residents per room.
	71.19(5) Bath and toilet facilities.
	a. 	There shall be a minimum of one toilet and one sink for each four residents and one shower for each eight residents. For example, a facility with the maximum of 16 beds shall have four toilets and sinks and two showers.
	b. 	All sinks shall have paper towel dispensers and an available supply of soap.
	c. 	Toilet paper shall be readily available to residents.
	71.19(6) Heating. A centralized heating system shall be maintained in good working order and capable of maintaining a comfortable temperature for residents of the facility. Portable units or space heaters are prohibited from being used in the facility except in an emergency.
	71.19(7) Water supply.
	a. 	Private sources of water supply shall be tested annually and the report made available for review by the department upon request.
	b. 	A bacterially unsafe source of water supply shall be grounds for denial, suspension, or revocation of license.
	c. 	The department may require testing of private sources of water supply at its discretion in addition to the annual test. The facility shall supply reports of such tests as directed by the department.
	d. 	Hot and cold running water under pressure shall be available in the facility.
	e. 	Prior to construction of a new facility or new water source, private sources of water supply shall be surveyed and shall comply with the requirements of the department.
[ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.20(135G) Records.
	71.20(1) Resident record. The licensee shall keep a permanent record about each resident with all entries current, dated, and signed. The record shall include:
	a. 	Name and previous address of resident;
	b. 	Birth date, sex, and marital status of resident;
	c. 	Provisional or admitting diagnosis;
	d. 	A biopsychosocial history sufficient to provide data on the resident’s relevant past history, present situation, social support system, community resource contacts, and other information relevant to appropriate treatment and discharge planning;
	e. 	The name, telephone number and address of the licensed mental health professional completing the biopsychosocial history;
	f. 	Name, address and telephone number of next of kin or legal representative;
	g. 	Name, address and telephone number of the person to be notified in case of emergency;
	h. 	Pharmacy name, telephone number, and address;
	i. 	Written orders for treatment and medications, signed by a physician, physician assistant or advanced registered nurse practitioner;
	j. 	Any change in the resident’s condition;
	k. 	Notations describing the resident’s condition on admission, transfer, and discharge;
	l. 	A copy of instructions given to the resident, legal representative, or facility in the event of discharge or transfer;
	m. 	Individualized treatment and discharge or transfer plan pursuant to rule 481—71.14(135G);
	n. 	Progress notes, including any use of seclusion or restraint pursuant to rule 481—71.16(135G), recorded by the physician, physician assistant, advanced registered nurse practitioner or mental health professional and, when appropriate, others significantly involved in active treatment modalities. Progress notes must contain a concise assessment of the resident’s progress and recommendations for revising the treatment plan as indicated by the resident’s condition;
	o. 	The discharge summary, including a recapitulation of the resident’s hospitalization, recommendations for appropriate services concerning follow-up, and a brief summary of the resident’s condition on discharge.
	71.20(2) Confidentiality of resident records. The facility shall have policies and procedures providing that each resident shall be assured confidential treatment of all information, including information contained in electronic records.
	a. 	The facility shall limit access to any resident records to staff and consultants providing professional services to the resident. Information shall be made available to staff only to the extent that the information is relevant to the staff person’s responsibilities and duties. This restriction shall not preclude access by representatives of state or federal regulatory agencies.
	b. 	The resident, or the resident’s legal guardian, shall be entitled to examine all information and shall have the right to secure full copies of the record at reasonable cost upon request, unless the physician, physician assistant, advanced registered nurse practitioner or mental health professional determines the disclosure of the record or a section thereof is contraindicated, in which case the designated information will be redacted prior to making the record available to the resident. This determination and the reasons for it must be documented in the resident’s record.
	71.20(3) Incident records.
	a. 	Each subacute care facility shall maintain an incident record report and shall have available incident report forms.
	b. 	A report of every unusual occurrence shall be detailed on the printed incident report form.
	c. 	The person in charge at the time of the unusual occurrence shall oversee the preparation of and sign the incident report.
	d. 	A copy of the incident report shall be kept on file in the facility and shall be available for review and a part of administrative records.
	71.20(4) Retention of records.
	a. 	Records shall be retained in the facility for five years following termination of services to the resident, even when there is a change of ownership.
	b. 	When the facility ceases to operate, the resident’s record shall be released to the facility to which the resident is transferred. If no transfer occurs, the record shall be released to the individual’s physician or advanced registered nurse practitioner.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
481—71.21(135G) Residents’ rights in general.
	71.21(1) Policies and procedures. Each facility shall ensure that policies and procedures are written and implemented, include all of the following subrules, and govern all areas of service provided to staff and residents, their families or legal representatives. The policies and procedures shall be available to the public and shall be reviewed annually by the facility.
	71.21(2) Grievances. Written policies and procedures shall include a method for submission of grievances and recommendations by residents or their responsible parties and a method to ensure a response and disposition by the facility. The written grievance procedure shall ensure protection of the resident from any form of reprisal or intimidation and shall include:
	a. 	The name of an employee or an alternate staff person designated to be responsible for handling grievances and recommendations; and
	b. 	Methods to investigate and assess the validity of a grievance or recommendation, resolve grievances, and take action.
	71.21(3) Informed of rights and responsibilities. Policies and procedures shall include a provision that each resident shall be fully informed of the resident’s rights and responsibilities as a resident and of all rules governing resident conduct and responsibilities. This information must be provided upon admission.
	a. 	The facility shall inform residents about what they may expect from the facility and its staff and what is expected from residents.
	b. 	Residents’ rights and responsibilities shall be presented in language understandable to the resident. If the facility serves residents who are non-English-speaking or deaf or hard of hearing, steps shall be taken to translate the information into the person’s native language or sign language. In the case of visually impaired residents, either Braille or a recording shall be provided.
	c. 	A statement shall be signed by the resident and legal guardian, if applicable, indicating an understanding of these rights and responsibilities, and the statement shall be maintained in the record. A copy of the signed statement shall be given to the resident or legal guardian.
	71.21(4) Informed of health condition. Each resident or legal guardian shall be fully informed by a physician, physician assistant, advanced registered nurse practitioner or mental health professional of the resident’s health and medical condition unless medically contraindicated as documented by a physician, physician assistant, advanced registered nurse practitioner or mental health professional in the resident’s record.
	71.21(5) Posting of names. The facility shall post in a prominent area the name, telephone number, and address of the survey agency, the local law enforcement agency and the protection and advocacy agency designated to provide to residents another course of redress.
	71.21(6) Dignity preserved. Each resident shall be treated with consideration, respect, and full recognition of the resident’s dignity and individuality, including privacy in treatment and in care of personal needs.
	a. 	Corporal punishment, verbal abuse, or any other activity that would be damaging to an individual’s self-respect shall be prohibited by written policy.
	b. 	Medication shall not be used as punishment, for the convenience of staff, or as a substitute for a program.
	c. 	Staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of the individuality and dignity of human beings.
	d. 	Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door shall shield the resident from passersby. People not involved in the care of the residents shall not be present without the resident’s consent while the resident is being examined or treated.
	e. 	Staff shall knock and be acknowledged before entering a resident’s room unless the resident is not capable of a response. This requirement does not apply under emergency conditions.
	71.21(7) Communications. Each resident may communicate, associate, and meet privately with persons of the resident’s choice, unless to do so would infringe upon the rights of other residents. Each resident may send and receive personal mail unopened unless prohibited in the treatment plan, which requires explicit approval of the resident or legal guardian.
	71.21(8) Visiting hours. Subject to reasonable scheduling restrictions, visiting policies and procedures shall permit residents to receive visits from anyone they wish. Visiting hours shall be posted.
	a. 	Reasonable, regular visiting hours shall not be less than 12 hours per day and shall take into consideration the special circumstances of each visitor. A particular visitor(s) may be restricted by the facility for one of the following reasons:
	(1)	The resident refuses to see the visitor(s).
	(2)	The visit would not be in accordance with the treatment plan.
	(3)	The visitor’s behavior is unreasonably disruptive to the functioning of the facility.
	b. 	Reasons for denial of visitation shall be documented in the resident’s records.
	71.21(9) Privacy. Space shall be provided for residents to receive visitors in comfort and privacy.
	71.21(10) Telephone calls. Telephones shall be available and accessible for residents to make and receive calls with privacy. Residents who need help shall be assisted in using the telephone.
	71.21(11) Mail. Arrangements shall be made to provide assistance to residents who require help in reading or sending mail.
	71.21(12) Permission to leave premises. Residents shall be permitted to leave the facility and environs at reasonable times if permitted in writing by the physician, physician assistant, advanced registered nurse practitioner, mental health professional, or administrator.
	71.21(13) Resident activities. Each resident may participate in recreational activities as desired unless contraindicated for reasons documented in the resident’s record.
	71.21(14) Resident property. Each resident may retain and use personal clothing and possessions, as space permits, and cash and other financial instruments, provided that the use of such items is not otherwise prohibited.
	a. 	The personal property shall be kept in a secure location which is convenient to the resident.
	b. 	Residents shall be advised, prior to or at the time of admission, of the kinds and amounts of clothing and possessions permitted for personal use and whether the facility will accept responsibility for maintaining these items, e.g., cleaning and laundry.
	c. 	Any personal clothing or possessions retained by the facility for the resident shall be identified and recorded on admission and the record placed on the resident’s chart. The facility shall be responsible for secure storage of items, and the items shall be returned to the resident promptly upon request or upon discharge from the facility.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19; ARC 5711C, IAB 6/16/21, effective 7/21/21]
481—71.22(135G) Health and safety.
	71.22(1) Emergency care. Each facility shall have written policies and procedures for emergency medical and psychiatric treatment, which shall include immediate notification by the person in charge to the physician, physician assistant, advanced registered nurse practitioner or mental health professional of any accident, injury or adverse change in the resident’s condition. “Immediate” for purposes of this subrule means within 24 hours.
	71.22(2) First-aid kit. A first-aid emergency kit shall be available on each floor.
	71.22(3) Infection control. Each facility shall have a written and implemented infection control program.
	71.22(4) Safe environment. The licensee of a subacute care facility is responsible for the provision and maintenance of a safe environment for residents and personnel. The subacute care facility shall meet the fire and safety rules as promulgated by the state fire marshal or the state fire marshal’s designee.
	71.22(5) Disaster. The licensee shall have a written emergency plan to be followed in the event of fire, tornado, explosion, or other emergency.
	a. 	The plan shall be posted.
	b. 	Training shall be provided to ensure that all employees are knowledgeable of the emergency plan. The training shall be documented.
	71.22(6) Smoking. A subacute care facility shall follow the smokefree air Act, Iowa Code chapter 142D.
[ARC 1740C, IAB 11/26/14, effective 12/31/14; ARC 4431C, IAB 5/8/19, effective 6/12/19]
These rules are intended to implement Iowa Code chapter 135G.
[Filed ARC 1740C (Notice ARC 1615C, IAB 9/3/14), IAB 11/26/14, effective 12/31/14]
[Filed ARC 2068C (Notice ARC 1996C, IAB 5/27/15), IAB 7/22/15, effective 8/26/15]
[Filed ARC 4431C (Notice ARC 4328C, IAB 3/13/19), IAB 5/8/19, effective 6/12/19]
[Filed ARC 5711C (Notice ARC 5567C, IAB 4/21/21), IAB 6/16/21, effective 7/21/21]
[Filed ARC 5719C (Notice ARC 5560C, IAB 4/21/21), IAB 6/16/21, effective 7/21/21]
[Filed ARC 6974C (Notice ARC 6834C, IAB 1/25/23), IAB 4/5/23, effective 5/10/23]