CHAPTER 58
NURSING FACILITIES
[Prior to 7/15/87, Health Department[470] Ch 58]
481—58.1(135C) Definitions. For the purpose of these rules, the following terms shall have the meaning indicated in this chapter. The definitions set out in Iowa Code section 135C.1 shall be considered to be incorporated verbatim in the rules. The use of the words “shall” and “must” indicates those standards are mandatory. The use of the words “should” and “could” indicates those standards are recommended.
“Accommodation” means the provision of lodging, including sleeping, dining, and living areas.
“Administrator” means a person licensed pursuant to Iowa Code chapter 147 who administers, manages, supervises, and is in general administrative charge of a nursing facility, whether or not such individual has an ownership interest in such facility, and whether or not the functions and duties are shared with one or more individuals.
“Alcoholic” means a person in a state of dependency resulting from excessive or prolonged consumption of alcoholic beverages as defined in Iowa Code section 125.2.
“Ambulatory” means the condition of a person who immediately and without aid of another is physically or mentally capable of traveling a normal path to safety, including the ascent and descent of stairs.
“Basement” means that part of a building where the finish floor is more than 30 inches below the finish grade.
“Board” means the regular provision of meals.
“Chairfast” means capable of maintaining a sitting position but lacking the capacity of bearing own weight, even with the aid of a mechanical device or another individual.
“Communicable disease” means a disease caused by the presence of viruses or microbial agents within a person’s body, which agents may be transmitted either directly or indirectly to other persons.
“Department” means the state department of inspections and appeals.
“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.
“Drug addiction” means a state of dependency, as medically determined, resulting from excessive or prolonged use of drugs as defined in Iowa Code chapter 124.
“Medication” means any drug including over-the-counter substances ordered and administered under the direction of the physician.
“Nonambulatory” means the condition of a person who immediately and without aid of another is not physically or mentally capable of traveling a normal path to safety, including the ascent and descent of stairs.
“Nourishing snack” is defined as a verbal offering of items, single or in combination, from the basic food groups. Adequacy of the “nourishing snack” will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility.
“Person directed care environment” means the provision of care and services provided in a facility that promotes decision making and choices by the resident, enhances the primary caregiver’s capacity to respond to each resident’s needs, and promotes a homelike environment. Examples of a person directed care environment include, but are not limited to, the Green House concept, the Eden alternative, service houses and neighborhoods.
“Personal care” means assistance with the activities of daily living which the recipient can perform only with difficulty. Examples are assistance in getting in and out of bed, assistance with personal hygiene and bathing, assistance with dressing, meal assistance, and supervision over medications which can be self-administered.
“Potentially hazardous food” means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting the rapid and progressive growth of infectious or toxigenic microorganisms, the growth and toxin production of clostridium botulinum, or in raw shell eggs, the growth of salmonella enteritidis. Potentially hazardous food includes an animal food (a food of animal origin) that is raw or heat-treated; a food of plant origin that is heat-treated or consists of raw seed sprouts; cut melons; and garlic and oil mixtures that are not acidified or otherwise modified at a food processing plant in a way that results in mixtures that do not support growth of bacteria.
“Program of care” means all services being provided for a resident in a health care facility.
“Qualified mental retardation professional” means a psychologist, physician, registered nurse, educator, social worker, physical or occupational therapist, speech therapist or audiologist who meets the educational requirements for the profession, as required in the state of Iowa, and having one year’s experience working with the mentally retarded.
“Qualified nurse” means a registered nurse or a licensed practical nurse, as defined in Iowa Code chapter 152.
“Rate” means that daily fee charged for all residents equally and shall include the cost of all minimum services required in these rules and regulations.
“Responsible party” means the person who signs or cosigns the admission agreement required in 58.13(135C) 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, religious groups, fraternal organizations, or foundations that assume responsibility and advocate for their client patients and pay for their health care.
“Restraints” means any chemical, manual method or physical or mechanical device, material, or equipment attached to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.
“Substantial evening meal” is defined as an offering of three or more menu items at one time, one of which includes a high protein such as meat, fish, eggs or cheese. The meal would represent no less than 20 percent of the day’s total nutritional requirements.
481—58.2(135C) Variances. Variances from these rules may be granted by the director of the department of inspections and appeals for good and sufficient reason when the need for variance has been established; no danger to the health, safety, or welfare of any resident results; alternate means are employed or compensating circumstances exist and the variance will apply only to an individual nursing facility. Variances will be reviewed at the discretion of the director of the department of inspections and appeals.
	58.2(1) To request a variance, the licensee must:
	a. 	Apply for variance in writing on a form provided by the department;
	b. 	Cite the rule or rules from which a variance is desired;
	c. 	State why compliance with the rule or rules cannot be accomplished;
	d. 	Explain alternate arrangements or compensating circumstances which justify the variance;
	e. 	Demonstrate that the requested variance will not endanger the health, safety, or welfare of any resident.
	58.2(2) Upon receipt of a request for variance, the director of inspections and appeals will:
	a. 	Examine the rule from which variance is requested to determine that the request is necessary and reasonable;
	b. 	If the request meets the above criteria, evaluate the alternate arrangements or compensating circumstances against the requirement of the rules;
	c. 	Examine the effect of the requested variance on the health, safety, or welfare of the residents;
	d. 	Consult with the applicant if additional information is required.
	58.2(3) Based upon these studies, approval of the variance will be either granted or denied within 120 days of receipt.
481—58.3(135C) Application for licensure.
	58.3(1) Initial application and licensing. In order to obtain an initial nursing facility license, for a nursing facility which is currently licensed, the applicant must:
	a. 	Meet all of the rules, regulations, and standards contained in 481—Chapters 58 and 61. Applicable exceptions found in rule 481—61.2(135C) shall apply based on the construction date of the facility.
	b. 	Submit a letter of intent and a written résumé of the resident care program and other services provided for departmental review and approval;
	c. 	Make application at least 30 days prior to the change of ownership of the facility on forms provided by the department;
	d. 	Submit a floor plan of each floor of the nursing facility, drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathrooms, and designation of the use to which room will be put and window and door location;
	e. 	Submit a photograph of the front and side elevation of the nursing facility;
	f. 	Submit the statutory fee for a nursing facility license;
	g. 	Meet the requirements of a nursing facility for which licensure application is made;
	h. 	Comply with all other local statutes and ordinances in existence at the time of licensure;
	i. 	Have a certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations.
	58.3(2) In order to obtain an initial nursing facility license for a facility not currently licensed as a nursing facility, the applicant must:
	a. 	Meet all of the rules, regulations, and standards contained in 481—Chapters 58 and 61. Exceptions noted in 481—subrule 61.1(2) shall not apply;
	b. 	Submit a letter of intent and a written résumé of the resident care program and other services provided for departmental review and approval;
	c. 	Make application at least 30 days prior to the change of ownership of the facility on forms provided by the department;
	d. 	Submit a floor plan of each floor of the nursing facility, drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathrooms, and designation of the use to which room will be put and window and door locations;
	e. 	Submit a photograph of the front and side elevation of the nursing facility;
	f. 	Submit the statutory fee for a nursing facility license;
	g. 	Comply with all other local statutes and ordinances in existence at the time of licensure;
	h. 	Have a certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations.
	58.3(3) Renewal application. In order to obtain a renewal of the nursing facility license, the applicant must:
	a. 	Submit the completed application form 30 days prior to annual license renewal date of nursing facility license;
	b. 	Submit the statutory license fee for a nursing facility with the application for renewal;
	c. 	Have an approved current certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations;
	d. 	Submit appropriate changes in the résumé to reflect any changes in the resident care program or other services.
	58.3(4) Licenses are issued to the person or governmental unit which has 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.
481—58.4(135C) General requirements.
	58.4(1) The license shall be displayed in a conspicuous place in the facility which is viewed by the public. (III)
	58.4(2) The license shall be valid only in the possession of the licensee to whom it is issued.
	58.4(3) The posted license shall accurately reflect the current status of the nursing facility. (III)
	58.4(4) Licenses expire one year after the date of issuance or as indicated on the license.
	58.4(5) No nursing facility shall be licensed for more beds than have been approved by the health facilities construction review committee.
	58.4(6) Each citation or a copy of each citation issued by the department for a class I or class II violation shall be prominently posted by the facility in plain view of the residents, visitors, and persons inquiring about placement in the facility. The citation or copy of the citation shall remain posted until the violation is corrected to the satisfaction of the department. (III)
481—58.5(135C) Notifications required by the department. The department shall be notified:
	58.5(1) Within 48 hours, by letter, of any reduction or loss of nursing or dietary staff lasting more than seven days which places the staffing ratio below that required for licensing. No additional residents shall be admitted until the minimum staffing requirements are achieved; (III)
	58.5(2) Of any proposed change in the nursing facility’s functional operation or addition or deletion of required services; (III)
	58.5(3) Thirty days before addition, alteration, or new construction is begun in the nursing facility or on the premises; (III)
	58.5(4) Thirty days in advance of closure of the nursing facility; (III)
	58.5(5) Within two weeks of any change in administrator; (III)
	58.5(6) When any change in the category of license is sought; (III)
	58.5(7) Prior to the purchase, transfer, assignment, or lease of a nursing facility, the licensee shall:
	a. 	Inform the department of the pending sale, transfer, assignment, or lease of the facility; (III)
	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; (III)
	c. 	Submit a written authorization to the department permitting the department to release all information of whatever kind from the department’s files concerning the licensee’s nursing facility to the named prospective purchaser, transferee, assignee, or lessee. (III)
	58.5(8) Pursuant to the authorization submitted to the department by the licensee prior to the purchase, transfer, assignment, or lease of a nursing facility, the department shall upon request send or give copies of all recent licensure surveys and of any other pertinent information relating to the facility’s licensure status to the prospective purchaser, transferee, assignee, or lessee; costs for such copies shall be paid by the prospective purchaser.
481—58.6(135C) Witness fees. Rescinded IAB 3/30/94, effective 5/4/94. See 481—subrule 50.6(4).
481—58.7(135C) Licenses for distinct parts.
	58.7(1) Separate licenses may be issued for distinct parts of a health care facility which are clearly identifiable, containing contiguous rooms in a separate wing or building or on a separate floor of the facility and which provide care and services of separate categories.
	58.7(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 them within that part; (III)
	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;
	d. 	A separate staff with qualifications appropriate to the care and services being rendered must be regularly assigned and working in the distinct part under responsible management; (III)
	e. 	Separately licensed distinct parts may have certain services such as management, building maintenance, laundry, and dietary in common with each other.
481—58.8(135C) Administrator.
	58.8(1) Each nursing facility shall have one person in charge, duly licensed as a nursing home administrator or acting in a provisional capacity. (III)
	58.8(2) A licensed administrator may act as an administrator for not more than two nursing facilities.
	a. 	The distance between the two facilities shall be no greater than 50 miles. (II)
	b. 	The administrator shall spend the equivalent of three full eight-hour days per week in each facility. (II)
	c. 	The administrator may be responsible for no more than 150 beds in total if the administrator is an administrator of more than one facility. (II)
	58.8(3) The licensee may be the licensed nursing home administrator providing the licensee meets the requirements as set forth in these regulations and devotes the required time to administrative duties. Residency in the facility does not in itself meet the requirement. (III)
	58.8(4) A provisional administrator may be appointed on a temporary basis by the nursing facility licensee to assume the administrative duties when the facility, through no fault of its own, has lost its administrator and has been unable to replace the administrator provided that no facility licensed under Iowa Code chapter 135C shall be permitted to have a provisional administrator for more than 6 months in any 12-month period and further provided that:
	a. 	The department has been notified prior to the date of the administrator’s appointment; (III)
	b. 	The board of examiners for nursing home administrators has approved the administrator’s appointment and has confirmed such appointment in writing to the department. (III)
	58.8(5) In the absence of the administrator, a responsible person shall be designated in writing to the department to be in charge of the facility. (III) The person designated shall:
	a. 	Be knowledgeable of the operation of the facility; (III)
	b. 	Have access to records concerned with the operation of the facility; (III)
	c. 	Be capable of carrying out administrative duties and of assuming administrative responsibilities; (III)
	d. 	Be at least 18 years of age; (III)
	e. 	Be empowered to act on behalf of the licensee during the administrator’s absence concerning the health, safety, and welfare of the residents; (III)
	f. 	Have had training to carry out assignments and take care of emergencies and sudden illness of residents. (III)
	58.8(6) A licensed administrator in charge of two facilities shall employ an individual designated as a full-time assistant administrator for each facility. (III)
	58.8(7) An administrator of only one facility shall be considered as a full-time employee. Full-time employment is defined as 40 hours per week. (III)
481—58.9(135C) Administration.
	58.9(1) The licensee shall:
	a. 	Assume the responsibility for the overall operation of the nursing facility; (III)
	b. 	Be responsible for compliance with all applicable laws and with the rules of the department; (III)
	c. 	Establish written policies, which shall be available for review, for the operation of the nursing facility. (III)
	58.9(2) The administrator shall:
	a. 	Be responsible for the selection and direction of competent personnel to provide services for the resident care program; (III)
	b. 	Be responsible for the arrangement for all department heads to annually attend a minimum of ten contact hours of educational programs to increase skills and knowledge needed for the position; (III)
	c. 	Be responsible for a monthly in-service educational program for all employees and to maintain records of programs and participants; (III)
	d. 	Make available the nursing facility payroll records for departmental review as needed; (III)
	e. 	Be required to maintain a staffing pattern of all departments. These records must be maintained for six months and are to be made available for departmental review. (III)
481—58.10(135C) General policies.
	58.10(1) There shall be written personnel policies in facilities of more than 15 beds to include hours of work, and attendance at educational programs. (III)
	58.10(2) There shall be a written job description developed for each category of worker. The job description shall include title of job, job summary, qualifications (formal education and experience), skills needed, physical requirements, and responsibilities. (III)
	58.10(3) There shall be written personnel policies for each facility. Personnel policies shall include the following requirements:
	a. 	Employees shall have a physical examination and tuberculin test before employment; (I, II, III)
	b. 	Employees shall have a physical examination at least every four years, including an assessment of tuberculosis status. (I, II, III)
	58.10(4) Health certificates for all employees shall be available for review. (III)
	58.10(5) Rescinded IAB 10/19/88, effective 11/23/88.
	58.10(6) There shall be written policies for emergency medical care for employees and residents in case of sudden illness or accident which includes the individual to be contacted in case of emergency. (III)
	58.10(7) The facility shall have a written agreement with a hospital for the timely admission of a resident who, in the opinion of the attending physician, requires hospitalization. (III)
	58.10(8) Infection control program. Each facility shall have a written and implemented infection control and exposure control program with policies and procedures based on the guidelines issued by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. (I, II, III) CDC guidelines are available at http://www.cdc.gov/ncidod/dhqp/index.html.
	58.10(9) Infection control committee. Each facility shall establish an infection control committee of representative professional staff responsible for overall infection control in the facility. (III)
	a. 	The committee shall annually review and revise the infection control policies and procedures to monitor effectiveness and suggest improvement. (III)
	b. 	The committee shall meet at least quarterly, submit reports to the administrator, and maintain minutes in sufficient detail to document its proceedings and actions. (III)
	c. 	The committee shall monitor the health aspect and the environment of the facility. (III)
	58.10(10) There shall be written policies for resident care programs and services as outlined in these rules. (III)
	58.10(11) Prior to the removal of a deceased resident/patient from a facility, the funeral director or person responsible for transporting the body shall be notified by the facility staff of any special precautions that were followed by the facility having to do with the mode of transmission of a known or suspected communicable disease. (III)
481—58.11(135C) Personnel.
	58.11(1) General qualifications.
	a. 	No person with a current record of habitual alcohol intoxication or addiction to the use of drugs shall serve in a managerial role of a nursing facility. (II)
	b. 	No person under the influence of alcohol or intoxicating drugs shall be permitted to provide services in a nursing facility. (II)
	c. 	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, (I, II, III)
	(2)	Which presents a significant risk of infecting others, (I, II, III)
	(3)	Which presents a substantial possibility of harming others, and (I, II, III)
	(4)	For which no reasonable accommodation can eliminate the risk. (I, II, III)
Refer to Guidelines for Infection Control in Hospital Personnel, Centers for Disease Control, U.S. Department of Health and Human Services, PB85-923402 to determine (1), (2), (3) and (4).
	d. 	Reserved.
	e. 	Individuals with either physical or mental disabilities may be employed for specific duties, but only if that disability is unrelated to that individual’s ability to perform the duties of the job. (III)
	f. 	Persons employed in all departments, except the nursing department of a nursing facility shall be qualified through formal training or through prior experience to perform the type of work for which they have been employed. Prior experience means at least 240 hours of full-time employment in a field related to their duties. Persons may be hired in laundry, housekeeping, activities and dietary without experience or training if the facility institutes a formal in-service training program to fit the job description in question and documents such as having taken place within 30 days after the initial hiring of such untrained employees. (III)
	g. 	Rescinded, effective 7/14/82.
	h. 	The health services supervisor shall be a qualified nurse as defined in these regulations. (II)
	i. 	Those persons employed as nurse’s aides, orderlies, or attendants in a nursing facility who have not completed the state-approved 75-hour nurse’s aide program shall be required to participate in a structured on-the-job training program of 20 hours’ duration to be conducted prior to any resident contact, except that contact required by the training program. This educational program shall be in addition to facility orientation. Each individual shall demonstrate competencies covered by the curriculum. This shall be observed and documented by an R.N. and maintained in the personnel file. No aide shall work independently until this is accomplished, nor shall the aide’s hours count toward meeting the minimum hours of nursing care required by the department. The curriculum shall be approved by the department. An aide who has completed the state-approved 75-hour course may model skills to be learned.
Further, such personnel shall be enrolled in a state-approved 75-hour nurse’s aide program to be completed no later than six months from the date of employment. If the state-approved 75-hour program has been completed prior to employment, the on-the-job training program requirement is waived. The 20-hour course is in addition to the 75-hour course and is not a substitute in whole or in part. The 75-hour program, approved by the department, may be provided by the facility or academic institution.
Newly hired aides who have completed the state-approved 75-hour course shall demonstrate competencies taught in the 20-hour course upon hire. This shall be observed and documented by an R.N. and maintained in the personnel file.
All personnel administering medications must have completed the state-approved training program in medication administration. (II)
	j. 	There shall be an organized ongoing in-service educational and training program planned in advance for all personnel in all departments. (II, III)
	k. 	Nurse aides, orderlies or attendants in a nursing facility who have received training other than the Iowa state-approved program, must pass a challenge examination approved by the department of inspections and appeals. Evidence of prior formal training in a nursing aide, orderly, attendant, or other comparable program must be presented to the facility or institution conducting the challenge examination before the examination is given. The approved facility or institution, following department of inspections and appeals guidelines, shall make the determination of who is qualified to take the examination. Documentation of the challenge examinations administered shall be maintained.
	58.11(2) Nursing supervision and staffing.
	a. 	Rescinded IAB 8/7/91, effective 7/19/91.
	b. 	Where only part-time nurses are employed, one nurse shall be designated health service supervisor. (III)
	c. 	A qualified nurse shall be employed to relieve the supervising nurses, including charge nurses, on holidays, vacation, sick leave, days off, absences or emergencies. Pertinent information for contacting such relief person shall be posted at the nurse’s station. (III)
	d. 	When the health service supervisor serves as the administrator of a facility 50 beds and over, a qualified nurse must be employed to relieve the health service supervisor of nursing responsibilities. (III)
	e. 	The department may establish on an individual facility basis the numbers and qualifications of the staff required in the facility using as its criteria the services being offered and the needs of the residents. (III)
	f. 	Additional staffing, above the minimum ratio, may be required by the department commensurate with the needs of the individual residents. (III)
	g. 	The minimum hours of resident care personnel required for residents needing intermediate nursing care shall be 2.0 hours per resident day computed on a seven-day week. A minimum of 20 percent of this time shall be provided by qualified nurses. If the maximum medical assistance rate is reduced below the 74th percentile, the requirement will return to 1.7 hours per resident per day computed on a seven-day week. A minimum of 20 percent of this time shall be provided by qualified nurses. (II, III)
	h. 	The health service supervisor’s hours worked per week shall be included in computing the 20 percent requirement.
	i. 	A nursing facility of 75 beds or more shall have a qualified nurse on duty 24 hours per day, seven days a week. (II, III)
	j. 	In facilities under 75 beds, if the health service supervisor is a licensed practical nurse, the facility shall employ a registered nurse, for at least four hours each week for consultation, who must be on duty at the same time as the health service supervisor. (II, III)
	(1)	This shall be an on-site consultation and documentation shall be made of the visit. (III)
	(2)	The registered nurse-consultant shall have responsibilities clearly outlined in a written agreement with the facility. (III)
	(3)	Consultation shall include but not be limited to the following: counseling the health service supervisor in the management of the health services; (III) reviewing and evaluating the health services in determining that the needs of the residents are met; (II, III) conducting a review of medications at least monthly if the facility does not employ a registered nurse part-time. (II, III)
	k. 	Facilities with 75 or more beds must employ a health service supervisor who is a registered nurse. (II)
	l. 	There shall be at least two people who shall be capable of rendering nursing service, awake, dressed, and on duty at all times. (II)
	m. 	Physician’s orders shall be implemented by qualified personnel. (II, III)
	58.11(3) Personnel histories.
	a. 	Each health care facility shall submit a form specified by the department of public safety to the department of public safety, and receive the results of a criminal history check and dependent adult abuse record check before any person is employed in a health care facility. The health care facility shall submit a form specified by the department of human services to the department of human services to request a child abuse history check. For the purposes of this subrule, “employed in a facility” shall be defined as any individual who is paid, either by the health care facility or any other entity (i.e., temporary agency, private duty, Medicare/Medicaid or independent contractors), to provide direct or indirect treatment or services to residents in a health care facility. Direct treatment or services include those provided through person-to-person contact. Indirect treatment or services include those provided without person-to-person contact such as those provided by administration, dietary, laundry, and maintenance. Specifically excluded from the requirements of this subrule are individuals such as building contractors, repair workers or others who are in a facility for a very limited purpose, are not in the facility on a regular basis, and do not provide any treatment or services to the residents of the health care facility. (I, II, III)
	b. 	A person who has a criminal record or founded dependent adult abuse report cannot be employed in a health care facility unless the department of human services has evaluated the crime or founded abuse report and concluded that the crime or founded abuse report does not merit prohibition from employment. (I, II, III)
	c. 	Each health care facility shall ask each person seeking employment in a facility “Do you have a record of founded child or dependent adult abuse or have you ever been convicted of crime in this state or any other state?” The person shall also be informed that a criminal history and dependent adult abuse record check will be conducted. The person shall indicate, by signature, that the person has been informed that the record checks will be conducted. (I, II, III)
	d. 	If a person has a record of founded child abuse in Iowa or any other state, the person shall not be employed in a health care facility unless the department of human services has evaluated the crime or founded report and concluded that the report does not merit prohibition of employment. (I, II, III)
	e. 	Proof of dependent adult abuse and criminal history checks may be kept in files maintained by the temporary employee agencies and contractors. Facilities may require temporary agencies and contractors to provide a copy of the results of the dependent adult abuse and criminal history checks. (I, II, III)
481—58.12(135C) Admission, transfer, and discharge.
	58.12(1) General admission policies.
	a. 	No resident shall be admitted or retained in a nursing facility who is in need of greater services than the facility can provide. (II, III)
	b. 	No nursing facility shall admit more residents than the number of beds for which it is licensed, except guest rooms for visitors. (II, III)
	c. 	There shall be no more beds erected than is stipulated on the license. (II, III)
	d. 	There shall be no more beds erected in a room than its size and other characteristics will permit. (II, III)
	e. 	The admission of a resident to a nursing facility shall not give the facility or any employee of the facility the right to manage, use, or dispose of any property of the resident except with the written authorization of the resident or the resident’s legal representative. (III)
	f. 	The admission of a resident shall not grant the nursing facility the authority or responsibility to manage the personal affairs of the resident except as may be necessary for the safety of the resident and safe and orderly management of the facility as required by these rules. (III)
	g. 	A nursing facility shall provide for the safekeeping of personal effects, funds, and other property of its residents. The facility may require that items of exceptional value or which would convey unreasonable responsibilities to the licensee be removed from the premises of the facility for safekeeping. (III)
	h. 	Rescinded, effective 7/14/82.
	i. 	Funds or properties received by the nursing facility belonging to or due a resident, expendable for the resident’s account, shall be trust funds. (III)
	j. 	Infants and children under the age of 16 shall not be admitted to health care facilities for adults unless given prior written approval by the department. A distinct part of a health care facility, segregated from the adult section, may be established based on a program of care submitted by the licensee or applicant which is commensurate with the needs of the residents of the health care facility and has received the department’s review and approval. (III)
	k. 	No health care facility, and no owner, administrator, employee or representative thereof shall act as guardian, trustee, or conservator for any resident’s property, unless such resident is related to the person acting as guardian within the third degree of consanguinity.
	l. 	Within 30 days of a resident’s admission to a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249A, the facility shall ask the resident or the resident’s personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a potential veteran, the facility shall report the resident’s name along with the names of the resident’s spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veterans affairs. Where appropriate, the facility may also report such information to the Iowa department of human services.
If a resident is eligible for benefits through the United States Department of Veterans Affairs or other third-party payor, the facility first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A.
The provisions of this paragraph shall not apply to the admission of an individual as a resident to a state mental health institute for acute psychiatric care or to the admission of an individual to the Iowa Veterans Home. (II, III)
	58.12(2) Discharge or transfer.
	a. 	Prior notification shall be made to the resident, as well as the resident’s next of kin, legal representative, attending physician, and sponsoring agency, if any, prior to transfer or discharge of any resident. (III)
	b. 	Proper arrangements shall be made by the nursing facility 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. (III)
	c. 	The licensee shall not refuse to discharge or transfer a resident when the physician, family, resident, or legal representative requests such a discharge or transfer. (II, III)
	d. 	Advance notification will be made to the receiving facility prior to the transfer of any resident. (III)
	e. 	When a resident is transferred or discharged, the appropriate record as set forth in 58.15(2)“k” of these rules will accompany the resident. (II, III)
	f. 	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 sent. (II, III)
481—58.13(135C) Contracts. Each contract shall:
	58.13(1) State the base rate or scale per day or per month, the services included, and the method of payment; (III)
	58.13(2) Contain a complete schedule of all offered services for which a fee may be charged in addition to the base rate. Furthermore, the contract shall: (III)
	a. 	Stipulate that no further additional fees shall be charged for items not contained in complete schedule of services as set forth in 58.13(3); (III)
	b. 	State the method of payment of additional charges; (III)
	c. 	Contain an explanation of the method of assessment of such additional charges and an explanation of the method of periodic reassessment, if any, resulting in changing such additional charges; (III)
	d. 	State that additional fees may be charged to the resident for nonprescription drugs, other personal supplies, and services by a barber, beautician, etc.; (III)
	58.13(3) Contain an itemized list of those services, with the specific fee the resident will be charged and method of payment, as related to the resident’s current condition, based on the nursing assessment at the time of admission, which is determined in consultation with the administrator; (III)
	58.13(4) Include the total fee to be charged initially to the specific resident; (III)
	58.13(5) State the conditions whereby the facility may make adjustments to the facility’s overall fees for resident care as a result of changing costs. (III) Furthermore, the contract shall provide that the facility shall give:
	a. 	Written notification to the resident, or responsible party when appropriate, of changes in the overall rates of both base and additional charges at least 30 days prior to effective date of such changes; (III)
	b. 	Notification to the resident, or responsible party when appropriate, of changes in additional charges, based on a change in the resident’s condition. Notification must occur prior to the date such revised additional charges begin. If notification is given orally, subsequent written notification must also be given within a reasonable time, not to exceed one week, listing specifically the adjustments made; (III)
	58.13(6) State the terms of agreement in regard to refund of all advance payments in the event of transfer, death, voluntary or involuntary discharge; (III)
	58.13(7) State the terms of agreement concerning the holding and charging for a bed when a resident is hospitalized or leaves the facility temporarily for recreational or therapeutic reasons. The terms shall contain a provision that the bed will be held at the request of the resident or the resident’s responsible party.
	a. 	The facility shall ask the resident or responsible party if the resident wants the bed held. This request shall be made before the resident leaves or within 48 hours after the resident leaves. The inquiry and the response shall be documented. (II)
	b. 	The facility shall reserve the bed when requested for as long as payments are made in accordance with the contract. (II)
	58.13(8) State the conditions under which the involuntary discharge or transfer of a resident would be effected; (III)
	58.13(9) State the conditions of voluntary discharge or transfer; (III)
	58.13(10) Set forth any other matters deemed appropriate by the parties to the contract. No contract or any provision thereof shall be drawn or construed so as to relieve any health care facility of any requirement or obligation imposed upon it by this chapter or any standards or rules in force pursuant to this chapter; (III)
	58.13(11) Each party shall receive a copy of the signed contract. (III)
481—58.14(135C) Medical services.
	58.14(1) Each resident in a nursing facility shall designate a licensed physician who may be called when needed. Professional management of a resident’s care shall be the responsibility of the hospice program when:
	a. 	The resident is terminally ill, and
	b. 	The resident has elected to receive hospice services under the federal Medicare program from a Medicare-certified hospice program, and
	c. 	The facility and the hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of hospice care.
	58.14(2) Each resident admitted to a nursing facility shall have had a physical examination prior to admission. If the resident is admitted directly from a hospital, a copy of the hospital admission physical and discharge summary may be made part of the record in lieu of an additional physical examination. A record of the examination, signed by the physician, shall be a part of the resident’s record. (III)
	58.14(3) Arrangements shall be made to have a physician available to furnish medical care in case of emergency. (II, III)
	58.14(4) Rescinded, effective 7/14/82.
	58.14(5) The person in charge shall immediately notify the physician of any accident, injury, or adverse change in the resident’s condition. (I, II, III)
	58.14(6) A schedule listing the names and telephone numbers of the physicians shall be posted in each nursing station. (III)
	58.14(7) Residents shall be admitted to a nursing facility only on a written order signed by a physician certifying that the individual being admitted requires no greater degree of nursing care than the facility is licensed to provide. (III)
	58.14(8) Each resident shall be visited by or shall visit the resident’s physician at least twice a year. The year period shall be measured from the date of admission and is not to include preadmission physicals. Notwithstanding the provisions of 42 CFR 483.40, any required physician task or visit in a nursing facility may also be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant who is working in collaboration with a physician, as outlined in Table 1. (III)
In dually certified skilled nursing/nursing facilities, the advanced registered nurse practitioner, clinical nurse specialist, and physician assistant must follow the skilled nursing facility requirements for services for skilled nursing facility stays. For nursing facility stays in skilled nursing/nursing facilities, any required physician task or visit may be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant working in collaboration with the physician.
Nurse practitioners, clinical nurse specialists, and physician assistants may perform other tasks that are not reserved to the physician such as visits outside the normal schedule needed to address new symptoms or other changes in medical status.
Table 1: 	Authority for non-physician practitioners to perform visits, sign orders, and sign certifications/recertifications when permitted by state law*

 	Initial Comprehensive Visit/Orders	Other Required Visits<fo:wrapper font-size=".69em" baseline-shift=".33em">1</fo:wrapper>	Other Medically Necessary Visits and Orders<fo:wrapper font-size=".69em" baseline-shift=".33em">2</fo:wrapper>	Certification/
Recertification	
Skilled Nursing Facilities	
Nurse practitioner and clinical nurse specialist employed by the facility	May not perform/May not sign	May perform	May perform and sign	May not sign	
Nurse practitioner and clinical nurse specialist not a facility employee	May not perform/May not sign	May perform	May perform and sign	May sign subject to state requirements	
Physician assistant regardless of employer	May not perform/May not sign	May perform	May perform and sign	May not sign	
Nursing Facilities	
Nurse practitioner, clinical nurse specialist, and physician assistant employed by the facility	May not perform/May not sign	May not perform	May perform and sign	May sign subject to state requirements	
Nurse practitioner, clinical nurse specialist, and physician assistant not a facility employee	May perform/May sign	May perform	May perform and sign	May sign subject to state requirements	
*As permitted by state law governing the scope and practice of nurse practitioners, clinical nurse specialists, and physician assistants.
1 Other required visits include the skilled nursing resident monthly visits that may be alternated between physician and advanced registered nurse practitioners, clinical nurse specialists, or physician assistants after the initial comprehensive visit is completed.
2 Medically necessary visits may be performed prior to the initial comprehensive visit.
481—58.15(135C) Records.
	58.15(1) Resident admission record. The licensee shall keep a permanent record on all residents admitted to a nursing facility with all entries current, dated, and signed. This shall be a part of the resident clinical record. (III) The admission record form shall include:
	a. 	Name and previous address of resident; (III)
	b. 	Birth date, sex, and marital status of resident; (III)
	c. 	Church affiliation; (III)
	d. 	Physician’s name, telephone number, and address; (III)
	e. 	Dentist’s name, telephone number, and address; (III)
	f. 	Name, address, and telephone number of next of kin or legal representative; (III)
	g. 	Name, address, and telephone number of person to be notified in case of emergency; (III)
	h. 	Mortician’s name, telephone number, and address; (III)
	i. 	Pharmacist’s name, telephone number, and address. (III)
	58.15(2) Resident clinical record. There shall be a separate clinical record for each resident admitted to a nursing facility with all entries current, dated, and signed. (III) The resident clinical record shall include:
	a. 	Admission record; (III)
	b. 	Admission diagnosis; (III)
	c. 	Physical examination: The record of the admission physical examination and medical history shall portray the current medical status of the resident and shall include the resident’s name, sex, age, medical history, tuberculosis status, physical examination, diagnosis, statement of chief complaints, estimation of restoration potential and results of any diagnostic procedures. The report of the physical examination shall be signed by the physician. (III)
	d. 	Physician’s certification that the resident requires no greater degree of nursing care than the facility is licensed to provide; (III)
	e. 	Physician’s orders for medication, treatment, and diet in writing and signed by the physician quarterly; (III)
	f. 	Progress notes.
	(1)	Physician shall enter a progress note at the time of each visit; (III)
	(2)	Other professionals, i.e., dentists, social workers, physical therapists, pharmacists, and others shall enter a progress note at the time of each visit; (III)
	g. 	All laboratory, X-ray, and other diagnostic reports; (III)
	h. 	Nurse’s record including:
	(1)	Admitting notes including time and mode of transportation; room assignment; disposition of valuables; symptoms and complaints; general condition; vital signs; and weight; (II, III)
	(2)	Routine notes including physician’s visits; telephone calls to and from the physician; unusual incidents and accidents; change of condition; social interaction; and P.R.N. medications administered including time and reason administered, and resident’s reaction; (II, III)
	(3)	Discharge or transfer notes including time and mode of transportation; resident’s general condition; instructions given to resident or legal representative; list of medications and disposition; and completion of transfer form for continuity of care; (II, III)
	(4)	Death notes including notification of physician and family to include time, disposition of body, resident’s personal possessions and medications; and complete and accurate notes of resident’s vital signs and symptoms preceding death; (III)
	i. 	Medication record.
	(1)	An accurate record of all medications administered shall be maintained for each resident. (II, III)
	(2)	Schedule II drug records shall be kept in accordance with state and federal laws; (II, III)
	j. 	Death record. In the event of a resident’s death, notations in the resident’s record shall include the date and time of the resident’s death, the circumstances of the resident’s death, the disposition of the resident’s body, and the date and time that the resident’s family and physician were notified of the resident’s death; (III)
	k. 	Transfer form.
	(1)	The transfer form shall include identification data from the admission record, name of transferring institution, name of receiving institution, and date of transfer; (III)
	(2)	The nurse’s report shall include resident attitudes, behavior, interests, functional abilities (activities of daily living), unusual treatments, nursing care, problems, likes and dislikes, nutrition, current medications (when last given), and condition on transfer; (III)
	(3)	The physician’s report shall include reason for transfer, medications, treatment, diet, activities, significant laboratory and X-ray findings, and diagnosis and prognosis; (III)
	l. 	Consultation reports shall indicate services rendered by allied health professionals in the facility or in health-centered agencies such as dentists, physical therapists, podiatrists, oculists, and others. (III)
	58.15(3) Resident personal record. Personal records may be kept as a separate file by the facility.
	a. 	Personal records may include factual information regarding personal statistics, family and responsible relative resources, financial status, and other confidential information.
	b. 	Personal records shall be accessible to professional staff involved in planning for services to meet the needs of the resident. (III)
	c. 	When the resident’s records are closed, the information shall become a part of the final record. (III)
	d. 	Personal records shall include a duplicate copy of the contract(s). (III)
	58.15(4) Incident record.
	a. 	Each nursing facility shall maintain an incident record report and shall have available incident report forms. (III)
	b. 	Report of incidents shall be in detail on a printed incident report form. (III)
	c. 	The person in charge at the time of the incident shall prepare and sign the report. (III)
	d. 	The report shall cover all accidents where there is apparent injury or where hidden injury may have occurred. (III)
	e. 	The report shall cover all accidents or unusual occurrences within the facility or on the premises affecting residents, visitors, or employees. (III)
	f. 	A copy of the incident report shall be kept on file in the facility. (III)
	58.15(5) Retention of records.
	a. 	Records shall be retained in the facility for five years following termination of services. (III)
	b. 	Records shall be retained within the facility upon change of ownership. (III)
	c. 	Rescinded, effective 7/14/82.
	d. 	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. (III)
	58.15(6) Reports to the department. The licensee shall furnish statistical information concerning the operation of the facility to the department on request. (III)
	58.15(7) Personnel record.
	a. 	An employment record shall be kept for each employee, consisting of the following information: name and address of employee, social security number of employee, date of birth of employee, date of employment, experience and education, references, position in the home, criminal history and dependent adult abuse background checks, and date and reason for discharge or resignation. (III)
	b. 	The personnel records shall be made available for review upon request by the department. (III)
481—58.16(135C) Resident care and personal services.
	58.16(1) Beds shall be made daily and adjusted as necessary. A complete change of linen shall be made at least once a week and more often if necessary. (III)
	58.16(2) Residents shall receive sufficient supervision so that their personal cleanliness is maintained. (II, III)
	58.16(3) Residents shall have clean clothing as needed to present a neat appearance, to be free of odors, and to be comfortable. Clothing shall be based on resident choice and shall be appropriate to residents’ activities and to the weather. (III)
	58.16(4) Rescinded, effective 7/14/82.
	58.16(5) Residents shall be encouraged to leave their rooms and make use of the recreational room or living room of the facility. (III)
	58.16(6) Residents shall not be required to pass through another’s bedroom to reach a bathroom, living room, dining room, corridor, or other common areas of the facility. (III)
	58.16(7) Rescinded, effective 7/14/82.
	58.16(8) Uncontrollable residents shall be transferred or discharged from the facility in accordance with contract arrangements and requirements of Iowa Code chapter 135C. (II, III)
	58.16(9) Except for those who request differently, residents who are not bedfast shall be fully dressed each day to maintain self-esteem and promote the residents’ normal lifestyles. (III)
	58.16(10) Residents shall receive a bath of their choice, based on the facility’s accommodations, as needed to maintain proper hygiene. (II, III)
481—58.17 Rescinded, effective 7/14/82.
481—58.18(135C) Nursing care.
	58.18(1) Individual health care plans shall be based on resident treatment decisions, the nature of the illness or disability, treatment, and care prescribed. Goals shall be developed by each discipline providing service, treatment, and care. These plans shall be in writing, revised as necessary, and kept current. They shall be made available to all those rendering the services and for review by the department. (III)
	58.18(2) Residents shall be protected against hazards to themselves and others or the environment. (II, III)
	58.18(3) The facility shall provide resident and family education as an integral part of restorative and supportive care. (III)
	58.18(4) The facility shall provide prompt response from qualified staff for the resident’s use of the nurse call system. (II, III) (Prompt response being considered as no longer than 15 minutes.)
481—58.19(135C) Required nursing services for residents. The program plan for nursing facilities shall have the following required nursing services under the 24-hour direction of qualified nurses with ancillary coverage as set forth in these rules:
	58.19(1) Activities of daily living.
	a. 	Bathing; (II, III)
	b. 	Daily oral hygiene (denture care); (II, III)
	c. 	Routine shampoo; (II, III)
	d. 	Nail care; (III)
	e. 	Shaving; (III)
	f. 	Daily care and application of prostheses (glasses, hearing aids, glass eyes, limb prosthetics, braces, or other assistive devices); (II, III)
	g. 	Ambulation with equipment if applicable, or transferring, or positioning; (I, II, III)
	h. 	Daily routine range of motion; (II, III)
	i. 	Mobility (assistance with wheelchair, mechanical lift, or other means of locomotion); (I, II, III)
	j. 	Elimination.
	(1)	Assistance to and from the bathroom and perineal care; (II, III)
	(2)	Bedpan assistance; (II, III)
	(3)	Care for incontinent residents; (II, III)
	(4)	Bowel and bladder training programs including in-dwelling catheter care (i.e., insertion and irrigation), enema and suppository administration, and monitoring and recording of intake and output, including solid waste; (I, II, III)
	k. 	Colostomy care (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II, III)
	l. 	Ileostomy care (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II, III)
	m. 	All linens necessary; (III)
	n. 	Nutrition and meal service.
	(1)	Regular, therapeutic, modified diets, and snacks; (I, II, III)
	(2)	Mealtime preparation of resident; (II, III)
	(3)	Assistance to and from meals; (II, III)
	(4)	In-room meal service or tray service; (II, III)
	(5)	Assistance with food preparation and meal assistance including total assistance if needed; (II, III)
	(6)	Assistance with adaptive devices; (II, III)
	(7)	Enteral nutrition (to be performed by a registered nurse or licensed practical nurse only); (I, II, III)
	o. 	Promote initiation of self-care for elements of resident care; (II, III)
	p. 	Oral suctioning (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse). (I, II)
	58.19(2) Medication and treatment.
	a. 	Administration of all medications as ordered by the physician including oral, instillations, topical, injectable (to be injected by a registered nurse or licensed practical nurse only); (I, II)
	b. 	Wound care; (I, II)
	c. 	Blood glucose monitoring; (I, II)
	d. 	Vital signs, blood pressure, and weights; (I, II)
	e. 	Ambulation and transfer; (II, III)
	f. 	Provision of restraints; (I, II)
	g. 	Administration of oxygen (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II)
	h. 	Provision of all treatments; (I, II, III)
	i. 	Provision of emergency medical care, including arranging for transportation, in accordance with written policies and procedures of the facility; (I, II, III)
	j. 	Provision of accurate assessment and timely intervention for all residents who have an onset of adverse symptoms which represent a change in mental, emotional, or physical condition. (I, II, III)
481—58.20(135C) Duties of health service supervisor. Every nursing facility shall have a health service supervisor who shall:
	58.20(1) Direct the implementation of the physician’s orders; (I, II)
	58.20(2) Plan for and direct the nursing care, services, treatments, procedures, and other services in order that each resident’s needs and choices, where practicable, are met; (II, III)
	58.20(3) Review the health care needs and choices, where practicable, of each resident admitted to the facility and assist the attending physician in planning for the resident’s care; (II, III)
	58.20(4) Develop and implement a written health care plan in cooperation with, to the extent practicable, the resident, the resident’s family or the resident’s legal representative, and others in accordance with instructions of the attending physician as follows:
	a. 	The written health care plan, based on the assessment and reassessment of the resident’s health needs and choices, where practicable, is personalized for the individual resident and indicates care to be given, goals to be accomplished, and methods, approaches, and modifications necessary to achieve best results; (III)
	b. 	The health service supervisor is responsible for preparing, reviewing, supervising the implementation, and revising the written health care plan; (III)
	c. 	The health care plan is readily available for use by all personnel caring for the resident; (III)
	58.20(5) Initiate preventative and restorative nursing procedures for each resident so as to achieve and maintain the highest possible degree of function, self-care, and independence based on resident choice, where practicable; (II, III)
	58.20(6) Supervise health services personnel to ensure they perform the following restorative measures in their daily care of residents:
	a. 	Maintaining good bodily alignment and proper positioning; (II, III)
	b. 	Making every effort to keep the resident active except when contraindicated by physician’s orders, and encouraging residents to achieve independence in activities of daily living by teaching self-care, transfer, and ambulation activities; (III)
	c. 	Assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests as necessary; (III)
	d. 	Assisting residents to carry out prescribed therapy exercises between visits of the therapist; (III)
	e. 	Assisting residents with routine range of motion exercises; (III)
	58.20(7) Plan and conduct nursing staff orientation and in-service programs and provide for training of nurse’s aides; (III)
	58.20(8) Plan with the resident and the resident’s physician and family and health-related agencies for the care of the resident upon discharge; (III)
	58.20(9) Designate a responsible person to be in charge during absences; (III)
	58.20(10) Be responsible for all assignments and work schedules for all health services personnel to ensure that the health needs of the residents are met; (III)
	58.20(11) Ensure that all nurse’s notes are descriptive of the care rendered including the resident’s response; (III)
	58.20(12) Visit each resident routinely to be knowledgeable of the resident’s current condition; (III)
	58.20(13) Evaluate in writing the performance of each individual on the health care staff on at least an annual basis. This evaluation shall be available for review in the facility to the department; (III)
	58.20(14) Keep the administrator informed of the resident’s status; (III)
	58.20(15) Teach and coordinate rehabilitative health care including activities of daily living, promotion and maintenance of optimal physical and mental functioning; (III)
	58.20(16) Supervise serving of meals to ensure that individuals unable to assist themselves are promptly fed and that special eating adaptive devices are available as needed; (II, III)
	58.20(17) Make available a nursing procedure manual which shall include all procedures practiced in the facility; (III)
	58.20(18) Participate with the administrator in the formulation of written policies and procedures for resident services; (III)
	58.20(19) The person in charge shall immediately notify the family of any accident, injury, or adverse change in the resident’s condition requiring physician’s notification. (III)
481—58.21(135C) Drugs, storage, and handling.
	58.21(1) Drug storage for residents who are unable to take their own medications and require supervision shall meet the following requirements:
	a. 	A cabinet with a lock, convenient to nursing service, shall be provided and used for storage of all drugs, solutions, and prescriptions; (III)
	b. 	The drug storage cabinet shall be kept locked when not in use; (III)
	c. 	The medication cabinet key shall be in the possession of the person directly responsible for issuing medications; (II, III)
	d. 	Double-locked storage of Schedule II drugs shall not be required under single unit package drug distribution systems in which the quantity stored does not exceed a three-day supply and a missing dose can be readily detected. (II)
	58.21(2) Drugs for external use shall be stored separately from drugs for internal use. (III)
	58.21(3) Medications requiring refrigeration shall be kept in a refrigerator and separated from food and other items. A method for locking these medications shall be provided. (III)
	58.21(4) All potent, poisonous, or caustic materials shall be stored separately from drugs. They shall be plainly labeled and stored in a specific, well-illuminated cabinet, closet, or storeroom and made accessible only to authorized persons. (I, II)
	58.21(5) All flammable materials shall be specially stored and handled in accordance with applicable local and state fire regulations. (II)
	58.21(6) A properly trained person shall be charged with the responsibility of administering nonparenteral medications.
	a. 	The individual shall have knowledge of the purpose of the drugs, their dangers, and contraindications.
	b. 	This person shall be a licensed nurse or physician or shall have successfully completed a department-approved medication aide course or passed a department-approved medication aide challenge examination administered by an area community college.
	c. 	Prior to taking a department-approved medication aide course, the individual shall:
	(1)	Successfully complete an approved nurse aide course, nurse aide training and testing program or nurse aide competency examination.
	(2)	Be employed in the same facility for at least six consecutive months prior to the start of the medication aide course. This requirement is not subject to waiver.
	(3)	Have a letter of recommendation for admission to the medication aide course from the employing facility.
	d. 	A person who is a nursing student or a graduate nurse may take the challenge examination in place of taking a medication aide course. This individual shall do all of the following before taking the medication aide challenge examination:
	(1)	Complete a clinical or nursing theory course within six months before taking the challenge examination;
	(2)	Successfully complete a nursing program pharmacology course within one year before taking the challenge examination;
	(3)	Provide to the community college a written statement from the nursing program’s pharmacology or clinical instructor indicating the individual is competent in medication administration.
	(4)	Successfully complete a department-approved nurse aide competency evaluation.
	e. 	A person who has written documentation of certification as a medication aide in another state may become a medication aide in Iowa by successfully completing a department-approved nurse aide competency examination and a medication aide challenge examination.
The requirements of paragraph “c” of this subrule do not apply to this individual.
	58.21(7) Unless the unit dose system is used, the person assigned the responsibility of medication administration must complete the procedure by personally preparing the dose, observing the actual act of swallowing the oral medication, and charting the medication. (II) In facilities where the unit dose system is used, the person assigned the responsibility must complete the procedure by observing the actual act of swallowing the medication and charting the medication. Medications shall be prepared on the same shift of the same day that they are administered, (II) unless the unit dose system is used.
	58.21(8) An accurate written record of medications administered shall be made by the individual administering the medication. (III)
	58.21(9) Records shall be kept of all Schedule II drug medications received and dispensed in accordance with the controlled drug and substance Act. (III)
	58.21(10) Any unusual resident reaction shall be reported to the physician at once. (II)
	58.21(11) A policy shall be established by the facility in conjunction with a licensed pharmacist to govern the distribution of prescribed medications to residents who are on leave from the facility. (III)
	a. 	Medication may be issued to residents who will be on leave from a facility for less than 24 hours. Notwithstanding the prohibition against paper envelopes in 58.21(14)“a,” non-child-resistant containers may be used. Each container may hold only one medication. A label on each container shall indicate the date, the resident’s name, the facility, the medication, its strength, dose, and time of administration.
	b. 	Medication for residents on leave from a facility longer than 24 hours shall be obtained in accordance with requirements established by the Iowa board of pharmacy examiners.
	c. 	Medication distributed as above may be issued only by a nurse responsible for administering medication. (I, II, III)
	58.21(12) Emergency medications. A nursing facility shall provide emergency medications pursuant to the following requirements: (III)
	a. 	Prescription drugs as well as nonprescription items must be prescribed or approved by the physician, in consultation with the pharmacist, who provides emergency service to the facility; (III)
	b. 	The emergency medications shall be stored in an accessible place; (III)
	c. 	A list of the emergency medications and quantities of each item shall be maintained by the facility; (III)
	d. 	The container holding the emergency medications shall be closed with a seal which may be broken when drugs are required in an emergency or for inspection; (III)
	e. 	Any item removed from the emergency medications shall be replaced within 48 hours; (III)
	f. 	A permanent record shall be kept of each time the emergency medications are used; (III)
	g. 	The emergency medications shall be inspected by a pharmacist at least once every three months to determine the stability of items. (III)
	58.21(13) Drug handling.
	a. 	Bulk supplies of prescription drugs shall not be kept in a nursing facility unless a licensed pharmacy is established in the facility under the direct supervision and control of a pharmacist. (III)
	b. 	Inspection of drug storage condition shall be made by the health service supervisor and a registered pharmacist not less than once every three months. The inspection shall be verified by a report signed by the nurse and pharmacist and filed with the administrator. The report shall include, but not be limited to, certifying absence of the following: expired drugs, deteriorated drugs, improper labeling, drugs for which there is no current physician’s order, and drugs improperly stored. (III)
	c. 	If the facility permits licensed nurses to dilute or reconstitute drugs at the nursing station, distinctive supplementary labels shall be available for the purpose. The notation on the label shall be so made as to be indelible. (III)
	d. 	Dilution and reconstitution of drugs and their labeling shall be done by the pharmacist whenever possible. If not possible, the following shall be carried out only by the licensed nurse:
	(1)	Specific directions for dilution or reconstitution and expiration date should accompany the drug; (III)
	(2)	A distinctive supplementary label shall be affixed to the drug container when diluted or reconstituted by the nurse for other than immediate use. (III) The label shall bear the following: resident’s name, dosage and strength per unit/volume, nurse’s name, expiration date, and date and time of dilution. (III)
	58.21(14) Drug safeguards.
	a. 	All prescribed medications shall be clearly labeled indicating the resident’s full name, physician’s name, prescription number, name and strength of drug, dosage, directions for use, date of issue, and name and address and telephone number of pharmacy or physician issuing the drug. Where unit dose is used, prescribed medications shall, as a minimum, indicate the resident’s full name, physician’s name, name and strength of drug, and directions for use. Standard containers shall be utilized for dispensing drugs. Paper envelopes shall not be considered standard containers. (III)
	b. 	Medication containers having soiled, damaged, illegible or makeshift labels, or medication samples shall be returned to the issuing pharmacist, pharmacy, or physician for relabeling or disposal. (III)
	c. 	There shall be no medications or any solution in unlabeled containers. (II, III)
	d. 	The medications of each resident shall be kept or stored in the originally received containers. (II, III)
	e. 	Labels on containers shall be clearly legible and firmly affixed. No label shall be superimposed on another label of a drug container. (II, III)
	f. 	When a resident is discharged or leaves the facility, the unused prescription shall be sent with the resident or with a legal representative only upon the written order of a physician. (III)
	g. 	Unused prescription drugs prescribed for residents who are deceased shall be returned to the supplying pharmacist. (III)
	h. 	Prescriptions shall be refilled only with the permission of the attending physician. (II, III)
	i. 	No medications prescribed for one resident may be administered to or allowed in the possession of another resident. (II)
	j. 	Instructions shall be requested of the Iowa board of pharmacy examiners concerning disposal of unused Schedule II drugs prescribed for residents who have died or for whom the Schedule II drug was discontinued. (III)
	k. 	There shall be a formal routine for the proper disposal of discontinued medications within a reasonable but specified time. These medications shall not be retained with the resident’s current medications. Discontinued drugs shall be destroyed by the responsible nurse with a witness and a notation made to that effect or returned to the pharmacist for destruction or resident credit. Drugs listed under the Schedule II drugs shall be disposed of in accordance with the provisions of the Iowa board of pharmacy examiners. (II, III)
	l. 	All medication orders which do not specifically indicate the number of doses to be administered or the length of time the drug is to be administered shall be stopped automatically after a given time period. The automatic stop order may vary for different types of drugs. The physician, in consultation with the pharmacist serving the home, shall institute policies and provide procedures for review and endorsement of stop orders on drugs. This policy shall be conveniently located for personnel administering medications. (II, III)
	m. 	No resident shall be allowed to keep possession of any medications unless the attending physician has certified in writing on the resident’s medical record that the resident is mentally and physically capable of doing so. (II)
	n. 	Residents who have been certified in writing by the physician as capable of taking their own medications may retain these medications in their bedroom, but locked storage must be provided. (II)
	o. 	No medications or prescription drugs shall be administered to a resident without a written order signed by the attending physician. (II)
	p. 	A qualified nurse shall:
	(1)	Establish a medication schedule system which identifies the time and dosage of each medication prescribed for each resident, is based on the resident’s desired routine, and is approved by the resident’s physician. (II, III)
	(2)	Establish a medication record containing the information specified above needed to monitor each resident’s drug regimen. (II, III)
	q. 	Telephone orders shall be taken by a qualified nurse. Orders shall be written into the resident’s record and signed by the person receiving the order. Telephone orders shall be submitted to the physician for signature within 48 hours. (III)
	r. 	A pharmacy operating in connection with a nursing facility shall comply with the provisions of the pharmacy law requiring registration of pharmacies and the regulations of the Iowa board of pharmacy examiners. (III)
	s. 	In a nursing facility with a pharmacy or drug supply, service shall be under the personal supervision of a pharmacist licensed to practice in the state of Iowa. (III)
	58.21(15) Drug administration.
	a. 	Injectable medications shall not be administered by anyone other than a qualified nurse or physician. In the case of a resident who has been certified by the resident’s physician as capable of taking the resident’s own insulin, the resident may inject the resident’s own insulin. (II)
	b. 	An individual inventory record shall be maintained for each Schedule II drug prescribed for each resident. (II)
	c. 	The health service supervisor shall be responsible for the supervision and direction of all personnel administering medications. (II)
481—58.22(135C) Rehabilitative services. Rehabilitative services shall be provided to maintain function or improve the resident’s ability to carry out the activities of daily living.
	58.22(1) Physical therapy services.
	a. 	Each facility shall have a written agreement with a licensed physical therapist to provide physical therapy services. (III)
	b. 	Physical therapy shall be rendered only by a physical therapist licensed to practice in the state of Iowa. All personnel assisting with the physical therapy of residents must be under the direction of a licensed physical therapist. (II, III)
	c. 	The licensed physical therapist shall:
	(1)	Evaluate the resident and prepare a physical therapy treatment plan conforming to the medical orders and goals; (III)
	(2)	Consult with other personnel in the facility who are providing resident care and plan with them for the integration of a physical therapy treatment program into the overall health care plan; (III)
	(3)	Instruct the nursing personnel responsible for administering selected restorative procedures between treatments; (III)
	(4)	Present programs in the facility’s in-service education programs. (III)
	d. 	Treatment records in the resident’s medical chart shall include:
	(1)	The physician’s prescription for treatment; (III)
	(2)	An initial evaluation note by the physical therapist; (III)
	(3)	The physical therapy care plan defining clearly the long-term and short-term goals and outlining the current treatment program; (III)
	(4)	Notes of the treatments given and changes in the resident’s condition; (III)
	(5)	A complete discharge summary to include recommendations for nursing staff and family. (III)
	e. 	There shall be adequate facilities, space, appropriate equipment, and storage areas as are essential to the treatment or examinations of residents. (III)
	58.22(2) Other rehabilitative services.
	a. 	The facility shall arrange for specialized and supportive rehabilitative services when such services are ordered by a physician. (III) These may include audiology and occupational therapy.
	b. 	Audiology services shall be under the direction of a person licensed in the state of Iowa by the board of speech pathology and audiology. (II, III)
	c. 	Occupational therapy services shall be under the direction of a qualified occupational therapist who is currently registered by the American Occupational Therapy Association. (II, III)
	d. 	The appropriate professional shall:
	(1)	Develop the treatment plan and administer or direct treatment in accordance with the physician’s prescription and rehabilitation goals; (III)
	(2)	Consult with other personnel within the facility who are providing resident care and plan with them for the integration of a treatment program into the overall health care plan. (III)
481—58.23(135C) Dental, diagnostic, and other services.
	58.23(1) Dental services.
	a. 	The nursing facility personnel shall assist residents to obtain regular and emergency dental services. (III)
	b. 	Transportation arrangements shall be made when necessary for the resident to be transported to the dentist’s office. (III)
	c. 	Dental services shall be performed only on the request of the resident, responsible relative, or legal representative. The resident’s physician shall be advised of the resident’s dental problems. (III)
	d. 	All dental reports or progress notes shall be included in the clinical record. (III)
	e. 	Nursing personnel shall assist the resident in carrying out dentist’s recommendations. (III)
	f. 	Dentists shall be asked to participate in the in-service program of the facility. (III)
	58.23(2) Diagnostic services.
	a. 	The nursing facility shall make provisions for promptly securing required clinical laboratory, X-ray, and other diagnostic services. (III)
	b. 	All diagnostic services shall be provided only on the written, signed order of a physician. (III)
	c. 	Agreements shall be made with the local hospital laboratory or independent laboratory to perform specific diagnostic tests when they are required. (III)
	d. 	Transportation arrangements for residents shall be made, when necessary, to and from the source of service. (III)
	e. 	Copies of all diagnostic reports shall be requested by the facility and included in the resident’s clinical record. (III)
	f. 	The physician ordering the specific diagnostic service shall be promptly notified of the results. (III)
	g. 	Simple tests such as customarily done by nursing personnel for diabetic residents may be performed in the facility. (III)
	58.23(3) Other services.
	a. 	The nursing facility shall assist residents to obtain such supportive services as requested by the physician. (III)
	b. 	Transportation arrangements shall be made when necessary. (III)
	c. 	Services could include the need for prosthetic devices, glasses, hearing aids, and other necessary items. (III)
481—58.24(135C) Dietary.
	58.24(1) Organization of dietetic services. The facility shall meet the needs of the residents and provide the services listed in this standard. If the service is contracted out, the contractor shall meet the same standard. A written agreement shall be formulated between the facility and the contractor and shall convey to the department the right to inspect the food service facilities of the contractor. (III)
	a. 	There shall be written policies and procedures for dietetic services that include staffing, nutrition, menu planning, therapeutic diets, preparation, service, ordering, receiving, storage, sanitation, and staff hygiene. The policies and procedures shall be made available for use by dietetic services. (III)
	b. 	There shall be written job descriptions for each position in dietetic services. The job descriptions shall be made available for use by dietetic services. (III)
	58.24(2) Dietary staffing.
	a. 	The facility shall employ a qualified dietary supervisor who:
	(1)	Is a qualified dietitian as defined in 58.24(2)“e”; or
	(2)	Is a graduate of a dietetic technician training program approved by the American Dietetic Association; or
	(3)	Is a certified dietary manager certified by the certifying board for dietary managers of the Dietary Managers Association (DMA) and maintains that credential through 45 hours of DMA-approved continuing education; or
	(4)	Has completed a DMA-approved course curriculum necessary to take the certification examination required to become a certified dietary manager; or
	(5)	Has documented evidence of at least two years’ satisfactory work experience in food service supervision and who is in an approved dietary manager association program and will successfully complete the program within 12 months of the date of enrollment; or
	(6)	Has completed or is in the final 90-hour training course approved by the department. (II, III)
	b. 	The supervisor shall have overall supervisory responsibility for dietetic services and shall be employed for a sufficient number of hours to complete management responsibilities that include:
	(1)	Participating in regular conferences with consultant dietitian, administrator and other department heads; (III)
	(2)	Writing menus with consultation from the dietitian and seeing that current menus are posted and followed and that menu changes are recorded; (III)
	(3)	Establishing and maintaining standards for food preparation and service; (II, III)
	(4)	Participating in selection, orientation, and in-service training of dietary personnel; (II, III)
	(5)	Supervising activities of dietary personnel; (II, III)
	(6)	Maintaining up-to-date records of residents identified by name, location and diet order; (III)
	(7)	Visiting residents to learn individual needs and communicating with other members of the health care team regarding nutritional needs of residents when necessary; (II, III)
	(8)	Keeping records of repairs of equipment in dietetic services. (III)
	c. 	The facility shall employ sufficient supportive personnel to carry out the following functions:
	(1)	Preparing and serving adequate amounts of food that are handled in a manner to be bacteriologically safe; (II, III)
	(2)	Washing and sanitizing dishes, pots, pans and equipment at temperatures required by procedures described elsewhere; (II, III)
	(3)	Serving of therapeutic diets as prescribed by the physician and following the planned menu. (II, III)
	d. 	The facility may assign simultaneous duties in the kitchen and laundry, housekeeping, or nursing service to appropriately trained personnel. Proper sanitary and personal hygiene procedures shall be followed as outlined under the rules pertaining to staff hygiene. (II, III)
	e. 	If the dietetic service supervisor is not a licensed dietitian, a consultant dietitian is required. The consultant dietitian shall be licensed by the state of Iowa pursuant to Iowa Code chapter 152A.
	f. 	Consultants’ visits shall be scheduled to be of sufficient duration and at a time convenient to:
	(1)	Record, in the resident’s medical record, any observations, assessments and information pertinent to medical nutrition therapy; (I, II, III)
	(2)	Work with residents and staff on resident care plans; (III)
	(3)	Consult with the administrator and others on developing and implementing policies and procedures; (III)
	(4)	Write or approve general and therapeutic menus; (III)
	(5)	Work with the dietetic supervisor on developing procedures, recipes and other management tools; (III)
	(6)	Present planned in-service training and staff development for food service employees and others. Documentation of consultation shall be available for review in the facility by the department. (III)
	g. 	In facilities licensed for more than 15 beds, dietetic services shall be available for a minimum of a 12-hour span extending from the time of preparation of breakfast through supper. (III)
	58.24(3) Nutrition and menu planning.
	a. 	Menus shall be planned and followed to meet the nutritional needs of each resident in accordance with the physician’s orders and in consideration of the resident’s choices and preferences. (II, III)
	b. 	Menus shall be planned to provide 100 percent of the daily recommended dietary allowances as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. A current copy of the Simplified Diet Manual published by Blackwell Publishing, Ames, Iowa, shall be available and used in the planning and serving of all meals. (II)
	c. 	At least three meals or their equivalent shall be served daily, at regular hours comparable to normal mealtimes in the community. (II)
	(1)	There shall be no more than a 14-hour span between a substantial evening meal and breakfast except as provided in subparagraph (3) below. (II, III)
	(2)	The facility shall offer snacks at bedtime daily. (II, III)
	(3)	When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast of the following day. The current resident group must agree to this meal span and a nourishing snack must be served. (II)
	d. 	Menus shall include a variety of foods prepared in various ways. The same menu shall not be repeated on the same day of the following week. (III)
	e. 	Menus shall be written at least one week in advance. The current menu shall be located in an accessible place in the dietetic service department for easy use by persons purchasing, preparing and serving food. (III)
	f. 	Records of menus as served shall be filed and maintained for 30 days and shall be available for review by department personnel. When substitutions are necessary, they shall be of similar nutritive value and recorded. (III)
	g. 	A file of tested recipes adjusted to the number of people to be served in the facility shall be maintained. (III)
	h. 	Alternate foods shall be offered to residents who refuse the food served. (II, III)
	58.24(4) Therapeutic diets.
	a. 	Therapeutic diets shall be prescribed by the attending physician. A current therapeutic diet manual shall be readily available to attending physicians, nurses and dietetic service personnel. This manual shall be used as a guide for writing menus for therapeutic diets. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of food. (III)
	b. 	Personnel responsible for planning, preparing and serving therapeutic diets shall receive instructions on those diets. (III)
	58.24(5) Food preparation and service.
	a. 	Methods used to prepare foods shall be those which conserve nutritive value and flavor and meet the taste preferences of the residents. (III)
	b. 	Foods shall be attractively served. (III)
	c. 	Foods shall be cut up, chopped, ground or blended to meet individual needs. (II, III)
	d. 	Self-help devices shall be provided as needed. (II, III)
	e. 	Table service shall be attractive. (III)
	f. 	Plasticware, china and glassware that are unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded. (III)
	g. 	All food that is transported through public corridors shall be covered. (III)
	h. 	All potentially hazardous food or beverages capable of supporting rapid and progressive growth of microorganisms that can cause food infections or food intoxication shall be maintained at temperatures of 41°F or below or at 140°F or above at all times, except during necessary periods of preparation. Frozen food shall be maintained frozen. (I, II, III)
	i. 	Potentially hazardous food that is cooked, cooled and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. (I, II, III)
	j. 	Food must be reheated to 165°F within no more than two hours after the heating process begins. (I, II, III)
	k. 	Cooked potentially hazardous food shall be cooled:
	(1)	Within two hours, from 140°F to 70°F; and
	(2)	Within four hours, from 70°F to 41°F or less. (I, II, III)
	58.24(6) Dietary ordering, receiving, and storage.
	a. 	All food and beverages shall be of wholesome quality and procured from sources approved or considered satisfactory by federal, state and local authorities. Food or beverages from unlabeled, rusty, leaking, broken or damaged containers shall not be served. (I, II, III)
	b. 	A minimum of at least a one-week supply of staple foods and a three-day supply of perishable foods shall be maintained on the premises to meet the planned menu needs until the next food delivery. Supplies shall be appropriate to meet the requirements of the menu. (III)
	c. 	All milk shall be pasteurized. (III)
	d. 	Milk may be served in individual, single-use containers. Milk may be served from refrigerated bulk milk dispensers or from the original container. Milk served from a refrigerated bulk milk dispenser shall be dispensed directly into the glass or other container from which the resident drinks. (II, III)
	e. 	Records which show amount and kind of food purchased shall be retained for three months and shall be made available to the department upon request. (III)
	f. 	Dry or staple items shall be stored at least six inches (15 cm) above the floor in a ventilated room, not subject to sewage or wastewater backflow, and protected from condensation, leakage, rodents or vermin in accordance with the Food Code, 1999 edition. (III)
	g. 	Pesticides, other toxic substances and drugs shall not be stored in the food preparation or storage areas used for food or food preparation equipment and utensils. Soaps, detergents, cleaning compounds or similar substances shall not be stored in food storage rooms or areas. (II)
	h. 	Food storage areas shall be clean at all times. (III)
	i. 	There shall be a reliable thermometer in each refrigerator, freezer and in storerooms used for food. (III)
	j. 	Foods held in refrigerated or other storage areas shall be appropriately covered. Food that was prepared and not served shall be stored appropriately, clearly identifiable and dated. (III)
	58.24(7) Sanitation in food preparation area.
	a. 	Unless otherwise indicated in this chapter or 481—Chapter 61, the sanitary provisions as indicated in Chapters 3, 4 and 7 of the 1999 Food Code, U.S. Public Health Service, Food and Drug Administration, Washington, DC 20204, shall apply.
	b. 	Residents may be allowed in the food preparation area. (III)
	c. 	The food preparation area may be used as a dining area for residents, staff or food service personnel. (III)
	d. 	All food service areas shall be kept clean, free from litter and rubbish, and protected from rodents, animals, roaches, flies and other insects. (II, III)
	e. 	All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, cracks and chipped areas. (II, III)
	f. 	There shall be effective written procedures established for cleaning all work and serving areas. (III)
	g. 	A schedule of cleaning duties to be performed daily shall be posted. (III)
	h. 	An exhaust system and hood shall be clean, operational and maintained in good repair. (III)
	i. 	Spillage and breakage shall be cleaned up immediately and disposed of in a sanitary manner. (III)
	j. 	Wastes from the food service that are not disposed of by mechanical means shall be kept in leakproof, nonabsorbent, tightly closed containers when not in immediate use and shall be disposed of frequently. (III)
	k. 	The food service area shall be located so it will not be used as a passageway by residents, guests or non-food service staff. (III)
	l. 	The walls, ceilings and floors of all rooms in which food is prepared and served shall be in good repair, smooth, washable, and shall be kept clean. Walls and floors in wet areas should be moisture-resistant. (III)
	m. 	Ice shall be stored and handled in such a manner as to prevent contamination. Ice scoops should be sanitized daily and kept in a clean container. (III)
	n. 	There shall be no animals or birds in the food preparation area. (III)
	o. 	All utensils used for eating, drinking, and preparing and serving food and drink shall be cleaned and disinfected or discarded after each use. (III)
	p. 	If utensils are washed and rinsed in an automatic dishmachine, one of the following methods shall be used:
	(1)	When a conventional dishmachine is utilized, the utensils shall be washed in a minimum of 140°F using soap or detergent and sanitized in a hot water rinse of not less than 170°F. (II, III)
	(2)	When a chemical dishmachine is utilized, the utensils shall be washed in a minimum of 120°F using soap or detergent and sanitized using a chemical sanitizer that is automatically dispensed by the machine and is in a concentration equivalent to 50 parts per million (ppm) available chloride. (II, III)
	q. 	If utensils are washed and rinsed in a three-compartment sink, the utensils shall be thoroughly washed in hot water at a minimum temperature of 110°F using soap or detergent, rinsed in hot water to remove soap or detergent, and sanitized by one of the following methods:
	(1)	Immersion for at least 30 seconds in clean water at 180°F; (II, III)
	(2)	Immersion in water containing bactericidal chemical at a minimum concentration as recommended by the manufacturer. (II, III)
	r. 	After sanitation, the utensils shall be allowed to drain and dry in racks or baskets on nonabsorbent surfaces. Drying cloths shall not be used. (III)
	s. 	Procedures for washing and handling dishes shall be followed in order to protect the welfare of the residents and employees. Persons handling dirty dishes shall not handle clean dishes without first washing their hands. (III)
	t. 	A mop and mop pail shall be provided for exclusive use in kitchen and food storage areas. (III)
	58.24(8) Hygiene of food service personnel.
	a. 	Personnel, if involved in dietetic services, shall be trained in basic food sanitation techniques, shall be clean and wear clean clothing, including a cap or a hairnet sufficient to contain, cover and restrain hair. Beards, mustaches and sideburns that are not closely cropped and neatly trimmed shall be covered. (III)
	b. 	Personnel shall be excluded from duty when affected by skin infections or communicable diseases in accordance with the facility’s infection control policies. (II, III)
	c. 	Employee street clothing stored in the food service area shall be in a closed area. (III)
	d. 	Food preparation sinks shall not be used for hand washing. Separate hand-washing facilities with soap, hot and cold running water, and single-use towels shall be used properly. (II, III)
	e. 	The use of tobacco shall be prohibited in the food preparation area. (III)
	58.24(9) Paid nutritional assistants. A paid nutritional assistant means an individual who meets the requirements of this subrule and who is an employee of the facility or an employee of a temporary employment agency employed by the facility. A facility may use an individual working in the facility as a paid nutritional assistant only if that individual has successfully completed a state-approved training program for paid nutritional assistants. (I, II, III)
	a. 	Training program requirements.
	(1)	A state-approved training program for paid nutritional assistants must include, at a minimum, eight hours of training in the following areas:
	1.	Feeding techniques.
	2.	Assistance with feeding and hydration.
	3.	Communication and interpersonal skills.
	4.	Appropriate responses to resident behavior.
	5.	Safety and emergency procedures, including the Heimlich maneuver.
	6.	Infection control.
	7.	Resident rights.
	8.	Recognizing changes in residents that are inconsistent with their normal behavior and reporting these changes to the supervisory nurse.
	(2)	In addition to the training program requirements specified above, the training program must include at least four hours of classroom study, two hours of supervised laboratory work, and two hours of supervised clinical experience.
	(3)	A facility that offers a paid nutritional assistant training program must provide sufficient supplies in order to teach the objectives of the course.
	(4)	All paid nutritional assistant training program instructors shall be registered nurses. Other qualified health care professionals may assist the instructor in teaching the classroom portion and clinical or laboratory experiences. The ratio of students to instructor shall not exceed ten students per instructor in the clinical setting.
	(5)	Each individual enrolled in a paid nutritional assistant training program shall complete a 50-question multiple choice written test and must obtain a score of 80 percent or higher. In addition, the individual must successfully perform the feeding of a resident in a clinical setting. A registered nurse shall conduct the final competency determination.
	(6)	If an individual does not pass either the written test or competency demonstration, the individual may retest the failed portion a second time. If the individual does not pass either the written test or competency demonstration portion the second time, the individual shall not be allowed to retest.
	b. 	Program approval. A facility or other entity may not offer or teach a paid nutritional assistant training program until the department has approved the program. Individuals trained in a program not approved by the department will not be allowed to function as paid nutritional assistants.
	(1)	A facility or other institution offering a paid nutritional assistant training program must provide the following information about the training program to the department before offering the program or teaching paid nutritional assistants:
	1.	Policies and procedures for program administration.
	2.	Qualifications of the instructors.
	3.	Maintenance of program records, including attendance records.
	4.	Criteria for determining competency.
	5.	Program costs and refund policies.
	6.	Lesson plans, including the objectives to be taught, skills demonstrations, assignments, quizzes, and classroom, laboratory and clinical hours.
	(2)	The facility or other institution offering a paid nutritional assistant training program must submit the materials specified above for department review. The department shall, within ten days of receipt of the material, advise the facility or institution whether the program is approved, or request additional information to assist the department in determining whether the curriculum meets the requirements for a paid nutritional assistant training program. Before approving any paid nutritional assistant training program, the department shall determine whether the curriculum meets the requirements specified in this subrule. The department shall maintain a list of facilities and institutions eligible to provide paid nutritional assistant training. (I, II, III)
	(3)	A facility shall maintain a record of all individuals who have successfully completed the required training program and are used by the facility as paid nutritional assistants. The individual shall complete the training program with a demonstration of knowledge and competency skills necessary to serve as a paid nutritional assistant. (I, II, III)
	(4)	Upon successful completion of the training program, the facility or other institution providing the training shall, within ten calendar days, provide the individual with a signed and dated certificate of completion. A facility that employs paid nutritional assistants shall maintain on file copies of the completed certificate and skills checklist for each individual who has successfully completed the training program. (I, II, III)
	c. 	Working restrictions.
	(1)	A paid nutritional assistant must work under the supervision of a registered nurse or a licensed practical nurse. In an emergency, a paid nutritional assistant must call a supervisory nurse for help on the resident call system. (I, II, III)
	(2)	A facility must ensure that a paid nutritional assistant feeds only residents who have no complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube, parenteral or intravenous feedings. The facility must base resident selection on the charge nurse’s assessment and the resident’s latest assessment and plan of care. (I, II, III)
481—58.25(135C) Social services program.
	58.25(1) The administrator or designee shall be responsible for developing a written, organized orientation program for all residents. (III)
	58.25(2) The program shall be planned and implemented to resolve or reduce personal, family, business, and emotional problems that may interfere with the medical or health care, recovery, and rehabilitation of the individual. (III)
	58.25(3) The social services plan, including specific goals and regular evaluation of progress, shall be incorporated into the overall plan of care. (III)
481—58.26(135C) Resident activities program.
	58.26(1) Organized activities. Each nursing facility shall provide an organized resident activity program for the group and for the individual resident which shall include suitable activities for evenings and weekends. (III)
	a. 	The activity program shall be designed to meet the needs and interests of each resident and to assist residents in continuing normal activities within limitations set by the resident’s physician. This shall include helping residents continue in their individual interests or hobbies. (III)
	b. 	The program shall include individual goals for each resident. (III)
	c. 	The program shall include both group and individual activities. (III)
	d. 	No resident shall be forced to participate in the activity program. (III)
	e. 	The activity program shall include suitable activities for those residents unable to leave their rooms. (III)
	f. 	The program shall be incorporated into the overall health plan and shall be designed to meet the goals as written in the plan.
	58.26(2) Coordination of activities program.
	a. 	Each nursing facility shall employ a person to direct the activities program. (III)
	1b. 	2Staffing for the activity program shall be provided on the minimum basis of 35 minutes per licensed bed per week. (II, III)
	c. 	The activity coordinator shall have completed the activity coordinators’ orientation course offered through the department within six months of employment or have comparable training and experience as approved by the department. (III)
	d. 	The activity coordinator shall attend workshops or educational programs which relate to activity programming. These shall total a minimum of ten contact hours per year. These programs shall be approved by the department. (III)
	e. 	There shall be a written plan for personnel coverage when the activity coordinator is absent during scheduled working hours. (III)
	58.26(3) Duties of activity coordinator. The activity coordinator shall:
	a. 	Have access to all residents’ records excluding financial records; (III)
	b. 	Coordinate all activities, including volunteer or auxiliary activities and religious services; (III)
	c. 	Keep all necessary records including:
	(1)	Attendance; (III)
	(2)	Individual resident progress notes recorded at regular intervals (at least quarterly). A copy of these notes shall be placed in the resident’s clinical record; (III)
	(3)	Monthly calendars, prepared in advance. (III)
	d. 	Coordinate the activity program with all other services in the facility; (III)
	e. 	Participate in the in-service training program in the facility. This shall include attending as well as presenting sessions. (III)
	58.26(4) Supplies, equipment, and storage.
	a. 	Each facility shall provide a variety of supplies and equipment of a nature calculated to fit the needs and interests of the residents. (III) These may include: books (standard and large print), magazines, newspapers, radio, television, and bulletin boards. Also appropriate would be box games, game equipment, songbooks, cards, craft supplies, record player, movie projector, piano, outdoor equipment, etc.
	b. 	Storage shall be provided for recreational equipment and supplies. (III)
	c. 	Locked storage should be available for potentially dangerous items such as scissors, knives, and toxic materials. (III)
1	Emergency, pursuant to Iowa Code section 17A.5(2)“b”(2).
2	Objection filed 2/14/79, see insert IAC 3/7/79 following Ch 57.
481—58.27(135C) Resident advocate committee. Each facility shall have a resident advocate committee in accordance with Iowa Code section 135C.25, which shall operate within the scope of the rules for resident advocate committees promulgated by the department of elder affairs. (II)
	58.27(1) Role of committee in complaint investigations.
	a. 	The department shall notify the facility’s resident advocate committee of a complaint from the public. The department shall not disclose the name of a complainant.
	b. 	The department may refer complaints to the resident advocate committee for initial evaluation or investigation by the committee pursuant to rules promulgated by the department of elder affairs. Within ten days of completion of the investigation, the committee shall report to the department in writing the results of the evaluation or the investigation.
	c. 	When the department investigates a complaint, upon conclusion of its investigation, it shall notify the resident advocate committee and the department of elder affairs of its findings, including any citations and fines issued.
	d. 	Results of all complaint investigations addressed by the resident advocate committee shall be forwarded to the department within ten days of completion of the investigation.
	58.27(2) The resident advocate committee shall, upon department request, be responsible for monitoring correction of substantiated complaints.
	58.27(3) When requested, names, addresses and telephone numbers of family members shall be given to the resident advocate committee, unless the family refuses. The facility shall provide a form on which a family member may refuse to have the family member’s name, address or telephone number given to the resident advocate committee.
This rule is intended to implement Iowa Code section 135C.25.
481—58.28(135C) Safety. The licensee of a nursing facility shall be responsible for the provision and maintenance of a safe environment for residents and personnel. (III)
	58.28(1) Fire safety.
	a. 	All nursing facilities shall meet the fire safety rules and regulations as promulgated by the state fire marshal. (I, II)
	b. 	The size of the facility and needs of the residents shall be taken into consideration in evaluating safety precautions and practices.
	58.28(2) Safety duties of administrator. The administrator shall have a written emergency plan to be followed in the event of fire, tornado, explosion, or other emergency. (III)
	a. 	The plan shall be posted. (III)
	b. 	In-service shall be provided to ensure that all employees are knowledgeable of the emergency plan. (III)
	58.28(3) Resident safety.
	a. 	Residents shall be permitted to smoke only where proper facilities are provided. Smoking shall not be permitted in bedrooms. Smoking by residents considered to be careless shall be prohibited except when the resident is under direct supervision. (II, III)
	b. 	Smoking is prohibited in all rooms where oxygen is being administered or in rooms where oxygen is stored. (II, III)
	c. 	Whenever full or empty tanks of oxygen are being used or stored, they shall be securely supported in an upright position. (II, III)
	d. 	Smoking shall be permitted only in posted areas. (II, III)
	e. 	Each resident shall receive adequate supervision to ensure against hazard from self, others, or elements in the environment. (II, III)
481—58.29(135C) Resident care.
	58.29(1) There shall be a readily available supply of self-help and ambulation devices such as wheelchairs, walkers, and such other devices maintained in good repair that will meet the current needs of all residents. (III)
	58.29(2) The facility shall ensure that each ambulatory resident has well-fitting shoes to provide support and prevent slipping. (III)
	58.29(3) Equipment for personal care shall be maintained in a safe and sanitary condition. (II, III)
	58.29(4) The expiration date for sterile equipment shall be exhibited on its wrappings. (III)
	58.29(5) Residents who have been known to wander shall be provided with appropriate means of identification. (II, III)
	58.29(6) Electric heating pads, blankets, or sheets shall be used only on the written order of a physician, when allowed by the Life Safety Code or applicable state or local fire regulations. (II, III)
481—58.30 Rescinded, effective 7/14/82.
481—58.31(135C) Housekeeping.
	58.31(1) Written procedures shall be established and implemented for daily and weekly cleaning schedules. (III)
	58.31(2) Each resident unit shall be cleaned on a routine schedule. (III)
	58.31(3) All rooms, corridors, storage areas, linen closets, attics, and basements shall be kept in a clean, orderly condition, free of unserviceable furniture and equipment and accumulations of refuse. (III)
	58.31(4) A hallway or corridor shall not be used for storage of equipment. (III)
	58.31(5) All odors shall be kept under control by cleanliness and proper ventilation. (III)
	58.31(6) Clothing worn by personnel shall be clean and washable. (III)
	58.31(7) Housekeeping and maintenance personnel shall be provided with well-constructed and properly maintained equipment appropriate to the function for which it is to be used. (III)
	58.31(8) All furniture, bedding, linens, and equipment shall be cleaned periodically and before use by another resident. (III)
	58.31(9) Polishes used on floors shall provide a nonslip finish. (III)
	58.31(10) *Throw or scatter rugs shall not be permitted. (III)
*Objection, see filed rules (Ch 58) published IAC Supp. 9/7/77, 10/5/77.
	58.31(11) Entrances, exits, steps, and outside walkways shall be kept free from ice, snow, and other hazards. (II, III)
	58.31(12) Residents shall not have access to storage areas for all cleaning agents, bleaches, insecticides, or any other poisonous, dangerous, or flammable materials. (II, III)
	58.31(13) Sufficient numbers of noncombustible trash containers, which have covers, shall be available. (III)
	58.31(14) Definite procedures shall be established for training housekeeping personnel. (III)
	58.31(15) Rescinded IAB 12/6/06, effective 1/10/07.
	58.31(16) There shall be provisions for the cleaning and storage of housekeeping equipment and supplies for each nursing unit. (III)
	58.31(17) Bathtubs, shower stalls, or lavatories shall not be used for laundering, cleaning of utensils and mops, or for storage. (III)
	58.31(18) Bedside utensils shall be stored in enclosed cabinets. (III)
	58.31(19) Kitchen sinks shall not be used for the cleaning of mops, soaking of laundry, cleaning of bedside utensils, nursing utensils, or dumping of wastewater. (III)
	58.31(20) Personal possessions of residents which may constitute hazards to themselves or others shall be removed and stored. (III)
481—58.32(135C) Maintenance.
	58.32(1) Each facility shall establish a maintenance program in writing to ensure the continued maintenance of the facility, to promote good housekeeping procedures, and to ensure sanitary practices throughout the facility. (III)
	58.32(2) The building, grounds, and other buildings shall be maintained in a clean, orderly condition and in good repair. (III)
	58.32(3) Draperies and furniture shall be clean and in good repair. (III)
	58.32(4) Cracks in plaster, peeling wallpaper or paint, and tears or splits in floor coverings shall be promptly repaired or replaced in a professional manner. (III)
	58.32(5) The electrical systems, including appliances, cords, and switches, shall be maintained to guarantee safe functioning and comply with the national electrical code. (III)
	58.32(6) All plumbing fixtures shall function properly and comply with the state plumbing code. (III)
	58.32(7) Yearly inspections of the heating and cooling systems shall be made to guarantee safe operation. Documentation of these inspections shall be available for review. (III)
	58.32(8) The building, grounds, and other buildings shall be kept free of breeding areas for flies, other insects, and rodents. (III)
	58.32(9) The facility shall be kept free of flies, other insects, and rodents. (III)
	58.32(10) Maintenance personnel.
	a. 	A written program shall be established for the orientation of maintenance personnel. (III)
	b. 	Maintenance personnel shall:
	(1)	Follow established written maintenance programs; (III)
	(2)	Be provided with appropriate, well-constructed, and properly maintained equipment. (III)
481—58.33(135C) Laundry.
	58.33(1) All soiled linens shall be collected in and transported to the laundry room in closed, leakproof laundry bags or covered, impermeable containers. (III)
	58.33(2) Except for related activities, the laundry room shall not be used for other purposes. (III)
	58.33(3) Procedures shall be written for the proper handling of wet, soiled, and contaminated linens. (III)
	58.33(4) Residents’ personal laundry shall be marked with an identification. (III)
	58.33(5) Bed linens, towels, and washcloths shall be clean and stain-free. (III)
481—58.34(135C) Garbage and waste disposal.
	58.34(1) All garbage shall be gathered, stored, and disposed of in a manner that will not permit transmission of disease, create a nuisance, or provide a breeding or feeding place for vermin or insects. (III)
	58.34(2) All containers for refuse shall be watertight, rodent-proof, and have tight-fitting covers. (III)
	58.34(3) All containers shall be thoroughly cleaned each time the containers are emptied. (III)
	58.34(4) All wastes shall be properly disposed of in compliance with local ordinances and state codes. (III)
	58.34(5) Special provision shall be made for the disposal of soiled dressings and similar items in a safe, sanitary manner. (III)
481—58.35(135C) Buildings, furnishings, and equipment.
	58.35(1) Buildings—general requirements.
	a. 	For purposes of computation of usable floor space in bedrooms and other living areas of the facility, that part of the room having no less than seven feet of ceiling height shall be used. Usable floor space may include irregularities in the rooms such as alcoves and offsets with approval of the department. Usable floor space shall not include space needed for corridor door swings or wardrobes being used as a substitute for closet space. (III)
	b. 	Battery-operated, portable emergency lights in good working condition shall be available at all times, at a ratio of one light per one employee on duty from 6 p.m.	to 6 a.m.	(III)
	c. 	All windows shall be supplied with curtains and shades or drapes which are kept clean and in good repair. (III)
	d. 	Light fixtures shall be so equipped to prevent glare and to prevent hazards to the residents. (III)
	e. 	Exposed heating pipes, hot water pipes, or radiators in rooms and areas used by residents and within reach of residents shall be covered or protected to prevent injury or burns to residents. (II, III)
	f. 	All fans located within seven feet of the floor shall be protected by screen guards of not more than one-half-inch mesh. (III)
	g. 	Whenever glass sliding doors or transparent panels are used, they shall be marked conspicuously. (III)
	h. 	The facility shall meet the equivalent requirements of the appropriate group occupancy of the state building code. (III)
	i. 	No part of any room shall be enclosed, subdivided, or partitioned unless such part is separately lighted and ventilated and meets such other requirements as its usage and occupancy dictates, except closets used for the storage of residents’ clothing. (III)
	58.35(2) Furnishings and equipment.
	a. 	All furnishings and equipment shall be durable, cleanable, and appropriate to its function and in accordance with the department’s approved program of care. (III)
	b. 	All resident areas shall be decorated, painted, and furnished to provide a home-like atmosphere. (III)
	c. 	Upholstery materials shall be moisture- and soil-resistant, except on furniture provided by the resident and the property of the resident. (III)
	58.35(3) Dining and living rooms.
	a. 	Every facility shall have a dining room and a living room easily accessible to all residents. (III)
	b. 	Dining rooms and living rooms shall at no time be used as bedrooms. (III)
	c. 	Dining rooms and living rooms shall be available for use by residents at appropriate times to provide periods of social and diversional individual and group activities. (III)
	d. 	A combination dining room and living room may be permitted if the space requirements of a multipurpose room as provided in 58.35(3)“e” are met. (III)
	e. 	Multipurpose rooms. When space is provided for multipurpose dining and activities and recreational purposes, the area shall total at least 30 square feet per licensed bed for the first 100 beds and 27 square feet per licensed bed for all beds in excess of 100. An open area of sufficient size shall be provided to permit group activities such as religious meetings or presentation of demonstrations or entertainment. (III)
	f. 	Living rooms.
	(1)	Living rooms shall be maintained for the use of residents and their visitors and may be used for recreational activities. (III)
	(2)	Living rooms shall be suitably provided with parlor furniture, television and radio receivers in good working order, recreational material such as games, puzzles, and cards, and reading material such as current newspapers and magazines. Furnishings and equipment of the room should be such as to allow group activities. (III)
	(3)	Card tables or game tables shall be made available. The tables should be of a height to allow a person seated in a wheelchair to partake in the games or card playing. (III)
	(4)	Chairs of proper height and appropriate to their use shall be provided for seating residents at game tables and card tables. (III)
	g. 	Dining rooms.
	(1)	Dining rooms shall be furnished with dining tables and chairs appropriate to the size and function of the facility. These rooms and furnishings shall be kept clean and sanitary. (III)
	(2)	Dining tables and chairs shall be provided. (III)
	(3)	Dining tables should be so constructed that a person seated in a wheelchair can dine comfortably. (III)
	(4)	Tables shall be of sturdy construction with smooth, durable, nonpermeable tops that can be cleaned with a detergent sanitizing solution. (III)
	(5)	Dining chairs shall be sturdy and comfortable. Some arm chairs should be provided for ease of movement for some residents. (III)
	(6)	Residents shall be encouraged to eat in the dining room. (III)
	58.35(4) Bedrooms.
	a. 	Each resident shall be provided with a standard, single, or twin bed that is substantially constructed and in good repair. Rollaway beds, metal cots, or folding beds are not acceptable. Seventy-five percent of the beds shall have a spring with an adjustable head and foot section. A resident shall have the right to sleep in a chair per the resident’s request and to have the bed removed from the room to allow for additional space. (III)
	b. 	Each bed shall be equipped with the following: casters or glides unless a low bed and mattress are being used for fall precautions; a clean, comfortable, well-constructed mattress approximately five inches thick and standard in size for the bed; clean, comfortable pillows of average size; and moisture-proof covers and sheets as necessary to keep the mattress and pillows dry and clean. (III)
	c. 	Each resident shall have a bedside table with a drawer to accommodate personal possessions. (III)
	d. 	There shall be a comfortable chair, either a rocking chair or armchair, per resident bed. The resident’s personal wishes shall be considered. (III)
	e. 	There shall be drawer space for each resident’s clothing. In a multiple bedroom, drawer space shall be assigned each resident. (III)
	f. 	Walls, ceilings, and floors shall have easily cleanable surfaces and shall be kept clean and in good repair. (III)
	g. 	Beds and other furnishings shall not obstruct free passage to and through doorways. (III)
	h. 	Clothing shall be hung in closets or wardrobes available in each room. (III)
	i. 	Beds shall not be placed with the head of the bed in front of a window or radiator. (III)
	j. 	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 it is covered so as to protect the resident from contact with it or from excessive heat. (III)
	k. 	Reading lamps shall be provided each resident in the resident’s room. (III)
	l. 	Each room shall have sufficient accessible mirrors to serve the resident’s needs. Mirrors are not required if the room is located in a CCDI unit and the mirrors cause concern for the resident. (III)
	m. 	Sturdy, adjustable overbed tables shall be provided for each resident who is unable to eat in the dining room. (III)
	n. 	Each resident bedroom shall have a door. The door shall be the swing type and shall not swing into the corridor. (III)
	58.35(5) Heating. A centralized heating system capable of maintaining a minimum temperature of 78°F (26°C) shall be provided. Portable units or space heaters are prohibited from being used in the facility except in an emergency. (III)
	58.35(6) Water supply.
	a. 	Every facility shall have an adequate water supply from an approved source. A municipal source of supply shall be considered as meeting this requirement. (III)
	b. 	Private sources of supply shall be tested annually and the report submitted with the annual application for license. (III)
	c. 	A bacterially unsafe source of supply shall be grounds for denial, suspension, or revocation of license. (III)
	d. 	The department may require testing of private sources of supply at its discretion in addition to the annual test. The facility shall supply reports of such tests as directed by the department. (III)
	e. 	Hot and cold running water under pressure shall be available in the facility. (III)
	f. 	Prior to construction of a new facility or new water source, private sources of supply shall be surveyed and shall comply with the requirements of the department of health. (III)
	58.35(7) Nonambulatory residents.
	a. 	All nonambulatory residents shall be housed on the grade level floor. (II, III)
	b. 	These provisions in “a” above relating to nonambulatory residents are not applicable if the facility has a suitably sized elevator.
481—58.36(135C) Family and employee accommodations.
	58.36(1) Children under 14 years of age shall not be allowed into the service areas. (III)
	58.36(2) The residents’ bedrooms shall not be occupied by employees or family members of the licensee. (III)
	58.36(3) In facilities where the total occupancy of family, employees, and residents is five or less, one toilet and one tub or shower shall be the minimum requirement. (III)
	58.36(4) In facilities where the total occupancy of family, employees, and residents is more than five, separate bathing and toilet facilities shall be required for the family or employees distinct from such areas provided for residents. (III)
	58.36(5) In all health care facilities, if the family or employees live within the facility, separate living quarters and recreation facilities shall be required for the family or employees distinct from such areas provided for residents. (III)
481—58.37(135C) Animals. Animals may be permitted within the facility with prior approval of the department and under controlled conditions. (III)
481—58.38(135C) Supplies.
	58.38(1) Linen supplies.
	a. 	There shall be an adequate supply of linen so that each resident shall have at least three washcloths, hand towels, and bath towels per week. (III)
	b. 	A complete change of bed linens shall be available in the linen storage area for each bed. (III)
	c. 	Sufficient lightweight, clean, serviceable blankets shall be available. All blankets shall be laundered as often as necessary for cleanliness and freedom from odors. (III)
	d. 	Each bed shall be provided with clean, washable bedspreads. There shall be a supply available when changes are necessary. (III)
	e. 	Uncrowded and convenient storage shall be provided for linens, pillows, and bedding. (III)
	58.38(2) First-aid kit. A first-aid emergency kit shall be available on each floor in every facility. (II, III)
	58.38(3) Supplies and equipment for nursing services.
	a. 	All nursing care equipment shall be properly sanitized or sterilized before use by another resident. (II)
	b. 	There shall be disposable or one-time use items available with provisions for proper disposal to prevent reuse except as allowed by 58.10(8)“h,” 481—paragraph 59.12(10)“h,” or 481—paragraph 64.12(14)“h.” (I, II, III)
	c. 	Convenient, safe storage shall be provided for bath and toilet supplies, bathroom scales, mechanical lifts, and shower chairs. (III)
	d. 	Sanitary and protective storage shall be provided for all equipment and supplies. (III)
	e. 	All items that must be sterilized shall be autoclaved unless sterile disposable items are furnished which are promptly disposed of after a single use. (III)
	f. 	Supplies and equipment for nursing and personal care sufficient in quantities to meet the needs of the residents shall be provided and, as a minimum, include the following: (III)

Bath basins	Rectal tubes	
Soap containers	Catheters and catheterization equipment	
Denture cups	Douche nozzle	
Emesis basins	Oxygen therapy equipment	
Mouthwash cups	Naso-gastric feeding equipment	
Bedpans	Wheelchairs	
Urinals	Moisture-proof draw sheets	
Enema equipment	Moisture-proof pillow covers	
Commodes	Moisture-proof mattress covers	
Quart graduate measure	Foot tubs	
Thermometer for measurement of bath	Metal pitcher	
water temperature	Disinfectant solutions	
Oral thermometer	Alcohol	
Rectal thermometer	Lubricating jelly	
Basins for sterilizing thermometers	Skin lotion	
Basins for irrigations	Applicators	
Asepto syringes	Tongue blades	
Sphygmomanometer	Toilet paper	
Paper towels	Rubber gloves or disposable gloves	
Paper handkerchiefs	Scales for nonambulatory patients	
Insulin syringes	Tourniquet	
2 cc hypodermic syringes	Suction machine	
Weight scales	Medicine dispensing containers	
Hypodermic needles	Bandages	
Stethoscope	Adhesive	
Ice caps	Portable linen hampers	
Hot water bottles	Denture identification equipment	
 	Tracheotomy care equipment	
481—58.39(135C) Residents’ rights in general.
	58.39(1) Each facility shall ensure that policies and procedures are written and implemented which include, at a minimum, all of the following provisions (subrules 58.39(2) to 58.39(6)) and which govern all areas of service provided by the facility. These policies and procedures shall be available to staff, residents, their families or legal representatives and the public and shall be reviewed annually. (II)
	58.39(2) Policies and procedures shall address the admission and retention of persons with histories of dangerous or disturbing behavior. For the purposes of the subrule, persons with histories of dangerous or disturbing behavior are those persons who have been found to be seriously mentally impaired pursuant to Iowa Code section 229.13 or 812.1 within six months of the request for admission to the facility. In addition to establishing the criteria for admission and retention of persons so defined, the policies and procedures shall provide for:
	a. 	Reasonable precautions to prevent the resident from harming self, other residents, or employees of the facility.
	b. 	Treatment of persons with mental illness as defined in Iowa Code section 229.1(1) and which is provided in accordance with the individualized health care plan.
	c. 	Ongoing and documented staff training on individualized health care planning for persons with mental illness.
	58.39(3) Policies and procedures regarding the admission, transfer, and discharge of residents shall ensure that:
	a. 	Only those persons are accepted whose needs can be met by the facility directly or in cooperation with community resources or other providers of care with which it is affiliated or has contracts. (II)
	b. 	As changes occur in residents’ physical or mental condition, necessitating services or care which cannot be adequately provided by the facility, they are transferred promptly to other appropriate facilities. (II)
	58.39(4) Policies and procedures regarding the use of chemical and physical restraints shall define the use of said restraints and identify the individual who may authorize the application of physical restraints in emergencies, and describe the mechanism for monitoring and controlling their use. (II)
	58.39(5) Policies and procedures shall include a method for submitting complaints and recommendations by residents or their responsible party and for ensuring a response and disposition by the facility. (II)
	58.39(6) Policies and procedures shall include provisions governing access to, duplication of, and dissemination of information from the residents’ records. (II)
	58.39(7) 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, or in the case of residents already in the facility, upon the facility’s adoption or amendment of residents’ rights policies. (II)
	a. 	The facility shall make known to residents what they may expect from the facility and its staff, and what is expected from them. The facility shall communicate these expectations during the period of not more than two weeks before or five days after admission. The communication shall be in writing, e.g., in a separate handout or brochure describing the facility, and interpreted verbally, e.g., as part of a preadmission interview, resident counseling, or in individual or group orientation sessions following admission. (II)
	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, steps shall be taken to translate the information into a foreign or sign language. In the case of blind residents, either Braille or a recording shall be provided. Residents shall be encouraged to ask questions about their rights and responsibilities and these questions shall be answered. (II)
	c. 	A statement shall be signed by the resident, or the resident’s responsible party, indicating an understanding of these rights and responsibilities, and shall be maintained in the record. The statement shall be signed no later than five days after admission, and a copy of the signed statement shall be given to the resident or responsible party, if applicable. In the case of a mentally retarded resident, the signature shall be witnessed by a person not associated with or employed by the facility. The witness may be a parent, guardian, Medicaid agency representative, etc.	(II)
	d. 	In order to ensure that residents continue to be aware of these rights and responsibilities during their stay, a written copy shall be prominently posted in a location that is available to all residents. (II)
	e. 	All residents shall be advised within 30 days following changes made in the statement of residents’ rights and responsibilities. Appropriate means shall be utilized to inform non-English speaking, deaf, or blind residents of such changes. (II)
	58.39(8) Each resident or responsible party shall be fully informed in a contract as required in rule 58.13(135C), prior to or at the time of admission and during the resident’s stay, of services available in the facility, and of related charges including any charges for services not covered under the Title XIX program or not covered by the facility’s basic per diem rate. (II)
	58.39(9) Each resident or responsible party shall be fully informed by a physician of the resident’s health and medical condition unless medically contraindicated (as documented by a physician in the resident’s record). Each resident shall be afforded the opportunity to participate in the planning of the resident’s total care and medical treatment, which may include, but is not limited to, nursing care, nutritional care, rehabilitation, restorative therapies, activities, and social work services. Each resident only participates in experimental research conducted under the U.S. Department of Health and Human Services protection from research risks policy and then only upon the resident’s informed written consent. Each resident has the right to refuse treatment except as provided by Iowa Code chapter 229. In the case of a confused or mentally retarded individual, the responsible party shall be informed by the physician of the resident’s medical condition and be afforded the opportunity to participate in the planning of the resident’s total care and medical treatment, to be informed of the medical condition, and to refuse to participate in experimental research. (II)
	a. 	The requirement that residents shall be informed of their conditions, involved in the planning of their care, and advised of any significant changes in either, shall be communicated to every physician responsible for the medical care of residents in the facility. (II)
	b. 	The administrator or designee shall be responsible for working with attending physicians in the implementation of this requirement. (II)
	c. 	If the physician determines or in the case of a confused or mentally retarded resident the responsible party determines that informing the resident of the resident’s condition is contraindicated, this decision and reasons for it shall be documented in the resident’s record by the physician. (II)
	d. 	The resident’s plan of care shall be based on the physician’s orders. It shall be developed upon admission by appropriate facility staff and shall include participation by the resident if capable. Residents shall be advised of alternative courses of care and treatment and their consequences when such alternatives are available. The resident’s preference about alternatives shall be elicited and honored if feasible.
	e. 	Any clinical investigation involving residents must be under the sponsorship of an institution with a human subjects review board functioning in accordance with the requirements of Public Law 93-348, as implemented by Part 46 of Title 45 of the Code of Federal Regulations, as amended to December 1, 1981 (45 CFR 46). A resident being considered for participation in experimental research must be fully informed of the nature of the experiment, e.g., medication, treatment, and understand the possible consequences of participating or not participating. The resident’s (or responsible party’s) written informed consent must be received prior to participation. (II)
This rule is intended to implement Iowa Code section 135C.23(2).
481—58.40(135C) Involuntary discharge or transfer.
	58.40(1) A facility shall not involuntarily discharge or transfer a resident from a facility except: for medical reasons; for the resident’s welfare or that of other residents; for nonpayment for the resident’s stay (as contained in the contract for the resident’s stay), except as prohibited by Title XIX of the Social Security Act, 42 U.S.C. 1396 to 1396k by reason of action pursuant to Iowa Code chapter 229; by reason of negative action by the Iowa department of social services; and by reason of negative action by the professional standards review organization. A resident shall not be transferred or discharged solely because the cost of the resident’s care is being paid under Iowa Code chapter 249A, or because the resident’s source of payment is changing from private support to payment under chapter 249A. (I, II)
	a. 	“Medical reasons” for transfer or discharge are based on the resident’s needs and are determined and documented in the resident’s record by the attending physician. Transfer or discharge may be required to provide a different level of care. In the case of transfer or discharge for the reason that the resident’s condition has improved such that the resident no longer needs the level of care being provided by the facility, the determination that such medical reason exists is the exclusive province of the professional standards review organization or utilization review process in effect for residents whose care is paid in full or in part by Title XIX. (II)
	b. 	“Welfare” of a resident or that of other residents refers to their social, emotional, or physical well-being. A resident might be transferred or discharged because the resident’s behavior poses a continuing threat to the resident (e.g., suicidal) or to the well-being of other residents or staff (e.g., the resident’s behavior is incompatible with the resident’s needs and rights). Evidence that the resident’s continued presence in the facility would adversely affect the resident’s own welfare or that of other residents shall be made by the administrator or designee and shall be in writing and shall include specific information to support this determination.
	c. 	Involuntary transfer or discharge of a resident from a facility shall be preceded by a written notice to the resident or responsible party at least 30 days in advance of the proposed transfer or discharge. The 30-day requirement shall not apply in any of the following instances:
	(1)	If an emergency transfer or discharge is mandated by the resident’s health care needs and is in accord with the written orders and medical justification of the attending physician. Emergency transfers or discharges may also be mandated to protect the health, safety, or well-being of other residents and staff from the resident being transferred. (II)
	(2)	If the transfer or discharge is subsequently agreed to by the resident or the resident’s responsible party, and notification is given to the responsible party, physician, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility.
	(3)	If the discharge or transfer is the result of a final, nonappealable decision by the department of social services or the professional standards review organization.
	d. 	The notice required by paragraph “c” shall contain all of the following information:
	(1)	The stated reason for the proposed transfer or discharge. (II)
	(2)	The effective date of the proposed transfer or discharge. (II)
	(3)	A statement in not less than 12-point type (elite), which reads: “You have a right to appeal the facility’s decision to transfer or discharge you. If you think you should not have to leave this facility, you may request a hearing in writing or verbally with the Iowa state department of inspections and appeals (hereinafter referred to as “department”) within 7 days after receiving this notice. You have a right to be represented at the hearing by an attorney or any other individual of your choice. If you request a hearing, it will be held no later than 14 days after receipt of your request by the department and you will not be transferred prior to a final decision. Provision may be made for extension of the 14-day requirement upon request to the department of inspections and appeals designee in emergency circumstances. If you lose the hearing, you will not be transferred before the expiration of 30 days following receipt of the original notice of the discharge or transfer, or no sooner than 5 days following final decision of such hearing. To request a hearing or receive further information, call the department at (515)281-4115 or you may write to the department to the attention of: Administrator, Division of Health Facilities, Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa 50319-0083.” (II)
	e. 	A request for a hearing made under 58.40(1)“d”(3) shall stay a transfer or discharge pending a hearing or appeal decision. (II)
	f. 	The type of hearing shall be determined by a representative of the department. Notice of the date, time, and place of the hearing shall be sent by certified mail or delivered in person to the licensee, resident, responsible party, and Iowa department of elder affairs long-term care ombudsman of record not later than five full business days after receipt of request. This notice shall also inform the licensee, resident or responsible party that they have a right to appear at the hearing in person or be represented by their attorneys or other individual. The hearing shall be dismissed if neither party is present or represented at the hearing. If only one party appears or is represented, the hearing shall proceed with one party present. The Iowa department of elder affairs long-term care ombudsman shall have the right to appear at the hearing.
	g. 	The hearing shall be heard by a department of inspections and appeals designee pursuant to Iowa Code chapter 17A. (The hearing shall be public unless the resident or representative requests in writing that it be closed.) The licensee or designee shall have the opportunity to present to the representative of the department any oral testimony or written materials to show by a preponderance of the evidence just cause why a transfer or discharge may be made. The resident and responsible party shall also have an opportunity to present to the representative of the department any oral testimony or written material to show just cause why a transfer or discharge should not be made. In a determination as to whether a transfer or discharge is authorized, the burden of proof rests on the party requesting the transfer or discharge.
	h. 	Based upon all testimony and materials submitted to the representative of the department, the representative shall issue, in accordance with Iowa Code chapter 17A, written findings of fact and conclusions of law and issue a decision and order in respect to the adverse action. This decision shall be mailed by certified mail to the licensee, resident, responsible party, and department of elder affairs long-term care ombudsman within 10 working days after the hearing has been concluded. The representative shall have the power to issue fines and citations against the facility in appropriate circumstances.
A request for review of a proposed decision in which the department is the final decision maker shall be made within 15 days of issuance of the proposed decision, unless otherwise provided by statute. Requests shall be mailed or delivered by either party to the Director, Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa 50319-0083. Failure to request review will preclude judicial review unless the department reviews a proposed decision upon its own motion within 15 days of the issuance of the decision.
	i. 	A copy of the notice required by paragraph “c” shall be personally delivered to the resident and a copy placed in the resident’s record. A copy shall also be transmitted to the department, the resident’s responsible party, physician, the person or agency responsible for the resident’s placement, maintenance, and care in the facility, and the department of elder affairs long-term care ombudsman.
	j. 	If the basis for an involuntary transfer or discharge is the result of a negative action by the Iowa department of human services or the professional standards review organization (Iowa Foundation for Medical Care), appeals shall be filed with those agencies as appropriate. Continued payment shall be consistent with rules of those agencies.
	k. 	If nonpayment is the basis for involuntary transfer or discharge, the resident shall have the right to make full payment up to the date that the discharge or transfer is to be made and then shall have the right to remain in the facility. (II)
	l. 	The involuntary transfer or discharge shall be discussed with the resident, the resident’s responsible party, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility within 48 hours after notice of discharge has been received. The explanation and discussion of the reasons for involuntary transfer or discharge shall be given by the facility administrator or other appropriate facility representative as the administrator’s designee. The content of the discussion and explanation shall be summarized in writing and shall include the names of the individuals involved in the discussions and made part of the resident’s record. (II)
	m. 	The resident shall receive counseling services before (by the sending facility) and after (by the receiving facility) the involuntary transfer to minimize the possible adverse effects of the involuntary transfer. Counseling shall be documented in the resident’s record. (II)
	(1)	Counseling shall be provided by a qualified individual who meets one of the following criteria:
	1.	Has a bachelor’s or master’s degree in social work from an accredited college. (II)
	2.	Is a graduate of an accredited four-year college and has had at least one year of full-time paid employment in a social work capacity with a public or private agency. (II)
	3.	Has been employed in a social work capacity for a minimum of four years in a public or private agency. (II)
	4.	Is a licensed psychologist or psychiatrist. (II)
	5.	Is any other person of the resident’s choice. (II)
	(2)	The facility shall develop a plan to provide for the orderly and safe transfer or discharge of each resident to be transferred or discharged. (II)
	(3)	The receiving health care facility of a resident involuntarily discharged or transferred shall immediately formulate and implement a plan of care which takes into account possible adverse effects the transfer may cause. (II)
	n. 	In the case of an emergency transfer or discharge as outlined in 58.40(1)“c”(1), the resident must still be given a written notice prior to or within 48 hours following transfer or discharge. A copy of this notice must be placed in the resident’s file and it must contain all the information required by 58.40(1)“d”(1) and (2). In addition, the notice must contain a statement in not less than 12-point type (elite), which reads: “You have a right to appeal the facility’s decision to transfer or discharge you on an emergency basis. If you think you should not have to leave this facility, you may request a hearing in writing or verbally with the Iowa state department of inspections and appeals within 7 days after receiving this notice. If you request a hearing, it will be held no later than 14 days after receipt of your request by the department. You may be transferred or discharged before the hearing is held or before a final decision is rendered. If you win the hearing, you have the right to be transferred back into the facility. To request a hearing or receive further information, call the department at (515)281-4115 or you may write to the department to the attention of: Administrator, Division of Health Facilities, Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa 50319-0083.” A hearing requested pursuant to this subrule shall be held in accordance with paragraphs “f,” “g,” and “h.”  (II)
	o. 	Residents shall not have the right to a hearing to contest an involuntary discharge or transfer resulting from the revocation of the facility’s license by the department of inspections and appeals. In the case of a facility voluntarily closing, a period of 30 days must be allowed for an orderly transfer of residents to other facilities.
	58.40(2) Intrafacility transfer:
	a. 	Residents shall not be relocated from room to room within a licensed health care facility arbitrarily. (I, II) Involuntary relocation may occur only in the following situations and such situation shall be documented in the resident’s record.
	(1)	Incompatibility with or disturbing to other roommates, as documented in the resident’s record.
	(2)	For the welfare of the resident or other residents of the facility.
	(3)	For medical, nursing or psychosocial reasons, as documented in the resident’s record, as judged by the attending physician, nurse or social worker in the case of a facility which groups residents by medical, nursing or psychosocial needs.
	(4)	To allow a new admission to the facility which would otherwise not be possible due to separation of roommates by sex.
	(5)	In the case of a resident whose source of payment was previously private, but who now is eligible for Title XIX assistance, the resident may be transferred from a private room to a semiprivate room or from one semiprivate room to another.
	(6)	Reasonable and necessary administrative decisions regarding the use and functioning of the building.
	b. 	Unreasonable and unjustified reasons for changing a resident’s room without the concurrence of the resident, or responsible party include:
	(1)	Change from private pay status to Title XIX, except as outlined in 58.40(2)“a”(5). (II)
	(2)	As punishment or behavior modification, except as specified in 58.40(2)“a”(1). (II)
	(3)	Discrimination on the basis of race or religion. (II)
	c. 	If intrafacility relocation is necessary for reasons outlined in paragraph “a,” the resident shall be notified at least 48 hours prior to the transfer and the reason therefor shall be explained. The responsible party shall be notified as soon as possible. The notification shall be documented in the resident’s record and signed by the resident or responsible party. (II)
	d. 	If emergency relocation is required to protect the safety or health of the resident or other residents, the notification requirements may be waived. The conditions of the emergency shall be documented. The family or responsible party shall be notified immediately or as soon as possible of the condition requiring emergency relocation and such notification shall be documented. (II)
481—58.41(135C) Residents’ rights. Each resident shall be encouraged and assisted throughout the resident’s period of stay, to exercise rights as a resident and as a citizen and may voice grievances and recommend changes in policies and services to administrative staff or to outside representatives of the resident’s choice, free from interference, coercion, discrimination, or reprisal. (II)
	58.41(1) The facility shall provide ongoing opportunities for residents to be aware of and to exercise their rights as residents. Residents shall be kept informed of issues or pending decisions of the facility that affect them and their views shall be solicited prior to action. (II)
	58.41(2) The facility shall implement a written procedure for registering and resolving grievances and recommendations by residents or their responsible party. The procedure shall ensure protection of the resident from any form of reprisal or intimidation. The written procedure shall include:
	a. 	Designation of an employee responsible for handling grievances and recommendations. (II)
	b. 	A method of investigating and assessing the validity of a grievance or recommendation. (II)
	c. 	Methods of resolving grievances. (II)
	d. 	Methods of recording grievances and actions taken. (II)
	58.41(3) The facility shall post in a prominent area the name, telephone number, and address of the ombudsman, survey agency, local law enforcement agency, and resident advocate committee members and the text of Iowa Code section 135C.46 to provide to residents a further course of redress. (II)
481—58.42(135C) Financial affairs—management. Each resident who has not been assigned a guardian or conservator by the court may manage the resident’s own personal financial affairs, and to the extent, under written authorization by the resident that the facility assists in management, the management shall be carried out in accordance with Iowa Code section 135C.24. (II)
	58.42(1) The facility shall maintain a written account of all residents’ funds received by or deposited with the facility. (II)
	58.42(2) An employee shall be designated in writing to be responsible for resident accounts. (II)
	58.42(3) The facility shall keep on deposit personal funds over which the resident has control in accordance with Iowa Code section 135C.24(2). Should the resident request these funds, they shall be given to the resident on request with receipts maintained by the facility and a copy to the resident. In the case of a confused or mentally retarded resident, the resident’s responsible party shall designate a method of disbursing the resident’s funds. (II)
	58.42(4) If the facility makes financial transactions on a resident’s behalf, the resident must receive or acknowledge that the resident has seen an itemized accounting of disbursements and current balances at least quarterly. A copy of this statement shall be maintained in the resident’s financial or business record. (II)
	58.42(5) A resident’s personal funds shall not be used without the written consent of the resident or the resident’s guardian. (II)
	58.42(6) A resident’s personal funds shall be returned to the resident when the funds have been used without the written consent of the resident or the resident’s guardian. The department may report findings that resident funds have been used without written consent to the audits division or the local law enforcement agency, as appropriate. (II)
481—58.43(135C) Resident abuse prohibited. Each resident shall receive kind and considerate care at all times and shall be free from mental and physical abuse. Each resident shall be free from chemical and physical restraints except as follows: when authorized in writing by a physician for a specified period of time; when necessary in an emergency to protect the resident from injury to the resident or to others, in which case restraints may be authorized by designated professional personnel who promptly report the action taken to the physician; and in the case of a mentally retarded individual when ordered in writing by a physician and authorized by a designated qualified mental retardation professional for use during behavior modification sessions. Mechanical supports used in normative situations to achieve proper body position and balance shall not be considered to be a restraint. (II)
	58.43(1) Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. (II)
	58.43(2) Physical abuse includes, but is not limited to, corporal punishment and the use of restraints as punishment. (II)
	58.43(3) Drugs such as tranquilizers may not be used as chemical restraints to limit or control resident behavior for the convenience of staff. (II)
	58.43(4) Physicians’ orders are required to utilize all types of physical restraints and shall be renewed at least quarterly. (II) Physical restraints are defined as the following:
Type I—the equipment used to promote the safety of the individual but is not applied directly to their person. Examples: divided doors and totally enclosed cribs.
Type II—the application of a device to the body to promote safety of the individual. Examples: vest devices, soft-tie devices, hand socks, geriatric chairs.
Type III—the application of a device to any part of the body which will inhibit the movement of that part of the body only. Examples: wrist, ankle or leg restraints and waist straps.
	58.43(5) Physical restraints are not to be used to limit resident mobility for the convenience of staff and must comply with life safety requirements. If a resident’s behavior is such that it may result in injury to the resident or others and any form of physical restraint is utilized, it should be in conjunction with a treatment procedure(s) designed to modify the behavioral problems for which the resident is restrained, or as a last resort, after failure of attempted therapy. (I, II)
	58.43(6) Each time a Type II or III restraint is used documentation on the nurse’s progress record shall be made which includes type of restraint and reasons for the restraint and length of time resident was restrained. The documentation of the use of Type III restraint shall also include the time of position change. (II)
	58.43(7) Each facility shall implement written policies and procedures governing the use of restraints which clearly delineate at least the following:
	a. 	Physicians’ orders shall indicate the specific reasons for the use of restraints. (II)
	b. 	Their use is temporary and the resident will not be restrained for an indefinite amount of time. (I, II)
	c. 	A qualified nurse shall make the decision for the use of a Type II or Type III restraint for which there shall be a physician’s order. (II)
	d. 	A resident placed in a Type II or III restraint shall be checked at least every 30 minutes by appropriately trained staff. No form of restraint shall be used or applied in such a manner as to cause injury or the potential for injury and provide a minimum of discomfort to resident restrained. (I, II)
	e. 	Reorders are issued only after the attending physician reviews the resident’s condition. (II)
	f. 	Their use is not employed as punishment, for the convenience of the staff, or as a substitute for supervision or program. (I, II)
	g. 	The opportunity for motion and exercise shall be provided for a period of not less than ten minutes during each two hours in which Type II and Type III restraints are employed, except when resident is sleeping. However, when resident awakens, this shall be provided. This shall be documented each time. A check sheet may serve this purpose. (I, II)
	h. 	Locked restraints or leather restraints shall not be permitted except in life-threatening situations. Straight jackets and secluding residents behind locked doors shall not be employed. (I, II)
	i. 	Nursing assessment of the resident’s need for continued application of a Type III restraint shall be made every 12 hours and documented on the nurse’s progress record. Documentation shall include the type of restraint, reason for the restraint and the circumstances. Nursing assessment of the resident’s need for continued application of either a Type I or Type II restraint and nursing evaluation of the resident’s physical and mental condition shall be made every 30 days and documented on the nurse’s progress record. (II)
	j. 	A divided door equipped with a securing device that may be readily opened by personnel shall be considered an appropriate means of temporarily confining a resident in the resident’s room. (II)
	k. 	Divided doors shall be of the type that when the upper half is closed the lower section shall close. (II)
	l. 	Methods of restraint shall permit rapid removal of the resident in the event of fire or other emergency. (I, II)
	m. 	The facility shall provide orientation and ongoing education programs in the proper use of restraints.
	58.43(8) In the case of a mentally retarded individual who participates in a behavior modification program involving use of restraints or aversive stimuli, the program shall be conducted only with the informed consent of the individual’s parent or responsible party. Where restraints are employed, an individualized program shall be developed by the interdisciplinary team with specific methodologies for monitoring its progress. (II)
	a. 	The resident’s responsible party shall receive a written account of the proposed plan of the use of restraints or aversive stimuli and have an opportunity to discuss the proposal with a representative(s) of the treatment team. (II)
	b. 	The responsible party must consent in writing prior to the use of the procedure. Consent may also be withdrawn in writing. (II)
	58.43(9) Upon a claim of dependent adult abuse of a resident being reported, the administrator of the facility shall separate the victim and accused abuser immediately and maintain that separation until the abuse investigation is completed. (I, II)
	58.43(10) Suspected abuse reports. The department shall investigate all complaints of dependent adult abuse which are alleged to have happened in a health care facility. The department shall inform the department of human services of the results of all evaluations and dispositions of dependent adult abuse investigations.
	58.43(11) Pursuant to Iowa Code chapter 235B, a mandatory reporter of dependent adult abuse is any person who, in the course of employment, examines, attends, counsels, or treats a dependent adult and reasonably believes the dependent adult has suffered abuse. This includes a member of the staff or employee of a health care facility. (II, III)
If a staff member or employee is required to report pursuant to this subrule, the staff member or employee shall immediately notify the person in charge of the facility or the person’s designated agent, and the person in charge or the designated agent shall make the report to the department of human services. (II, III)
This rule is intended to implement Iowa Code sections 135C.14, 235B.3(1), and 235B.3(11).
481—58.44(135C) Resident records. Each resident shall be ensured confidential treatment of all information contained in the resident’s records, including information contained in an automatic data bank. The resident’s written consent shall be required for the release of information to persons not otherwise authorized under law to receive it. (II)
	58.44(1) The facility shall limit access to any medical records to staff and consultants providing professional service to the resident. This is not meant to preclude access by representatives of state and federal regulatory agencies. (II)
	58.44(2) Similar procedures shall safeguard the confidentiality of residents’ personal records, e.g., financial records and social services records. Only those personnel concerned with the financial affairs of the residents may have access to the financial records. This is not meant to preclude access by representatives of state and federal regulatory agencies. (II)
	58.44(3) The resident, or the resident’s responsible party, shall be entitled to examine all information contained in the resident’s record and shall have the right to secure full copies of the record at reasonable cost upon request, unless the physician determines the disclosure of the record or section thereof is contraindicated in which case this information will be deleted prior to making the record available to the resident or responsible party. This determination and the reasons for it must be documented in the resident’s record. (II)
481—58.45(135C) Dignity preserved. The resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. (II)
	58.45(1) Staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. (II)
	58.45(2) Schedules of daily activities shall allow maximum flexibility for residents to exercise choice about what they will do and when they will do it. Residents’ individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, entertainment, sleeping and eating, also times to retire at night and arise in the morning shall be elicited and considered by the facility. (II)
	58.45(3) Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or a drawn curtain 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. (II)
	58.45(4) Privacy of a resident’s body also shall be maintained during toileting, bathing, and other activities of personal hygiene, except as needed for resident safety or assistance. (II)
	58.45(5) Staff shall knock and be acknowledged before entering a resident’s room unless the resident is not capable of a response. This shall not apply in emergency conditions. (II)
481—58.46(135C) Resident work. No resident may be required to perform services for the facility, except as provided by Iowa Code sections 35D.14 and 347B.5. (II)
	58.46(1) Residents may not be used to provide a source of labor for the facility against their will. Physician’s approval is required for all work programs. (I, II)
	58.46(2) If the plan of care requires activities for therapeutic or training reasons, the plan for these activities shall be professionally developed and implemented. Therapeutic or training goals must be clearly stated and measurable and the plan shall be time limited and reviewed at least quarterly. (II)
	58.46(3) Residents who perform work for the facility must receive remuneration unless the work is part of their approved training program. Persons on the resident census performing work shall not be used to replace paid employees in fulfilling staffing requirements. (II)
481—58.47(135C) 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, and may send and receive personal mail unopened. (II)
	58.47(1) Subject to reasonable scheduling restrictions, visiting policies and procedures shall permit residents to receive visits from anyone they wish. Visiting hours shall be posted. (II)
	58.47(2) 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:
	a. 	The resident refuses to see the visitor(s). (II)
	b. 	The resident’s physician documents specific reasons why such a visit would be harmful to the resident’s health. (II)
	c. 	The visitor’s behavior is unreasonably disruptive to the functioning of the facility (this judgment must be made by the administrator and the reasons shall be documented and kept on file). (II)
	58.47(3) Decisions to restrict a visitor are reviewed and reevaluated: each time the medical orders are reviewed by the physician; at least quarterly by the facility’s staff; or at the resident’s request. (II)
	58.47(4) Space shall be provided for residents to receive visitors in reasonable comfort and privacy. (II)
	58.47(5) Telephones consistent with ANSI standards (405.1134(c)) 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. (II)
	58.47(6) Arrangements shall be made to provide assistance to residents who require help in reading or sending mail. (II)
	58.47(7) Residents shall be permitted to leave the facility and environs at reasonable times unless there are justifiable reasons established in writing by the attending physician, qualified mental retardation professional or facility administrator for refusing permission. (II)
	58.47(8) Residents shall not have their personal lives regulated beyond reasonable adherence to meal schedules, bedtime hours, and other written policies which may be necessary for the orderly management of the facility and as required by these rules. However, residents shall be encouraged to participate in recreational programs. (II)
481—58.48(135C) Resident activities. Each resident may participate in activities of social, religious, and community groups at the resident’s discretion unless contraindicated for reasons documented by the attending physician or qualified mental retardation professional as appropriate in the resident’s record. (II)
	58.48(1) Residents who wish to meet with or participate in activities of social, religious, or other community groups in or outside of the facility shall be informed, encouraged, and assisted to do so. (II)
	58.48(2) All residents shall have the freedom to refuse to participate in these activities. (II)
481—58.49(135C) Resident property. Each resident may retain and use personal clothing and possessions as space permits and provided such use is not otherwise prohibited by these rules. (II)
	58.49(1) Residents shall be permitted to keep reasonable amounts of personal clothing and possessions for their use while in the facility. The personal property shall be kept in a safe location which is convenient to the resident. (II)
	58.49(2) 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. (II)
	58.49(3) Any personal clothing or possessions retained by the facility for the resident during the resident’s stay shall be identified and recorded on admission and a record placed on the resident’s chart. The facility shall be responsible for secure storage of the items, and they shall be returned to the resident promptly upon request or upon discharge from the facility. (II)
	58.49(4) A resident’s personal property shall not be used without the written consent of the resident or the resident’s guardian. (II)
	58.49(5) A resident’s personal property shall be returned to the resident when it has been used without the written consent of the resident or the resident’s guardian. The department may report findings that a resident’s property has been used without written consent to the local law enforcement agency, as appropriate. (II)
481—58.50(135C) Family visits. Each resident, if married, shall be ensured privacy for visits by the resident’s spouse; if both are residents in the facility, they shall be permitted to share a room if available. (II)
	58.50(1) The facility shall provide for needed privacy in visits between spouses. (II)
	58.50(2) Spouses who are residents in the same facility shall be permitted to share a room, if available, unless one of their attending physicians documents in the medical record those specific reasons why an arrangement would have an adverse effect on the health of the resident. (II)
	58.50(3) Family members shall be permitted to share a room, if available, if requested by both parties, unless one of their attending physicians documents in the medical record those specific reasons why such an agreement would have an adverse effect on the health of the resident. (II)
481—58.51(135C) Choice of physician and pharmacy. Each resident shall be permitted free choice of a physician and a pharmacy, if accessible. The facility may require the pharmacy selected to utilize a drug distribution system compatible with the system currently used by the facility.
A facility shall not require the repackaging of medications dispensed by the Veterans Administration or an institution operated by the Veterans Administration for the purpose of making the drug distribution system compatible with the system used by the facility. (II)
481—58.52(135C) Incompetent resident.
	58.52(1) Each facility shall provide that all rights and responsibilities of the resident devolve to the resident’s responsible party when a resident is adjudicated incompetent in accordance with state law or, in the case of a resident who has not been adjudicated incompetent under the laws of the state, in accordance with 42 CFR 483.10. This subrule is not intended to limit the authority of any individual acting pursuant to Iowa Code chapter 144A. (II)
	58.52(2) The fact that a resident has been adjudicated incompetent does not absolve the facility from advising the resident of these rights to the extent the resident is able to understand them. The facility shall also advise the responsible party, if any, and acquire a statement indicating an understanding of residents’ rights. (II)
481—58.53(135C) County care facilities. In addition to Chapter 58 licensing rules, county care facilities licensed as nursing facilities must also comply with department of human services rules, 441—Chapter 37. Violation of any standard established by the department of human services is a Class II violation pursuant to 481—56.2(135C).
481—58.54(73GA,ch 1016) Special unit or facility dedicated to the care of persons with chronic confusion or a dementing illness (CCDI unit or facility).
	58.54(1) A nursing facility which chooses to care for residents in a distinct part shall obtain a license for a CCDI unit or facility. In the case of a distinct part, this license will be in addition to its ICF license. The license shall state the number of beds in the unit or facility. (III)
	a. 	Application for this category of care shall be submitted on a form provided by the department. (III)
	b. 	Plans to modify the physical environment shall be submitted to the department. The plans shall be reviewed based on the requirements of 481—Chapter 61. (III)
	58.54(2) A statement of philosophy shall be developed for each unit or facility which states the beliefs upon which decisions will be made regarding the CCDI unit or facility. Objectives shall be developed for each CCDI unit or facility as a whole. The objectives shall be stated in terms of expected results. (II, III)
	58.54(3) A résumé of the program of care shall be submitted to the department for approval at least 60 days before a separate CCDI unit or facility is opened. A new résumé of the program of care shall be submitted when services are substantially changed. (II, III)
The résumé of the program of care shall:
	a. 	Describe the population to be served; (II, III)
	b. 	State philosophy and objectives; (II, III)
	c. 	List admission and discharge criteria; (II, III)
	d. 	Include a copy of the floor plan; (II, III)
	e. 	List the titles of policies and procedures developed for the unit or facility; (II, III)
	f. 	Propose a staffing pattern; (II, III)
	g. 	Set out a plan for specialized staff training; (II, III)
	h. 	State visitor, volunteer, and safety policies; (II, III)
	i. 	Describe programs for activities, social services and families; (II, III) and
	j. 	Describe the interdisciplinary care planning team. (II, III)
	58.54(4) Separate written policies and procedures shall be implemented in each CCDI unit or facility. There shall be:
	a. 	Admission and discharge policies and procedures which state the criteria to be used to admit residents and the evaluation process which will be used. These policies shall require a statement from the attending physician agreeing to the placement before a resident can be moved into a CCDI unit or facility. (II, III)
	b. 	Safety policies and procedures which state the actions to be taken by staff in the event of a fire, natural disaster, emergency medical or catastrophic event. Safety procedures shall also explain steps to be taken when a resident is discovered to be missing from the unit or facility and when hazardous cleaning materials or potentially dangerous mechanical equipment is being used in the unit or facility. The facility shall identify its method for security of the unit or facility and the manner in which the effectiveness of the security system will be monitored. (II, III)
	c. 	Program and service policies and procedures which explain programs and services offered in the unit or facility including the rationale. (III)
	d. 	Policies and procedures concerning staff which state minimum numbers, types and qualifications of staff in the unit or facility. (II, III)
	e. 	Policies about visiting which suggest times and ensure the residents’ rights to free access to visitors. (II, III)
	f. 	Quality assurance policies and procedures which list the process and criteria which will be used to monitor and to respond to risks specific to the residents. This shall include, but not be limited to, drug use, restraint use, infections, incidents and acute behavioral events. (II, III)
	58.54(5) Preadmission assessment of physical, mental, social and behavioral status shall be completed to determine whether the applicant meets admission criteria. This assessment shall be completed by a registered nurse and a staff social worker or social work consultant and shall become part of the permanent record upon admission of the resident. (II, III)
	58.54(6) All staff working in a CCDI unit or facility shall have training appropriate to the needs of the residents. (II, III)
	a. 	Upon assignment to the unit or facility, everyone working in the unit or facility shall be oriented to the needs of people with chronic confusion or dementing illnesses. They shall have special training appropriate to their job description within 30 days of assignment to the unit or facility. (II, III) The orientation shall be at least six hours. The following topics shall be covered:
	(1)	Explanation of the disease or disorder; (II, III)
	(2)	Symptoms and behaviors of memory-impaired people; (II, III)
	(3)	Progression of the disease; (II, III)
	(4)	Communication with CCDI residents; (II, III)
	(5)	Adjustment to care facility residency by the CCDI unit or facility residents and their families; (II, III)
	(6)	Inappropriate and problem behavior of CCDI unit or facility residents and how to deal with it; (II, III)
	(7)	Activities of daily living for CCDI residents; (II, III)
	(8)	Handling combative behavior; (II, III) and
	(9)	Stress reduction for staff and residents. (II, III)
	b. 	Licensed nurses, certified aides, certified medication aides, social services personnel, housekeeping and activity personnel shall have a minimum of six hours of in-service training annually. This training shall be related to the needs of CCDI residents. The six-hour training shall count toward the required annual in-service training. (II, III)
	58.54(7) There shall be at least one nursing staff person on a CCDI unit at all times. (I, II, III)
	58.54(8) The CCDI unit or facility license may be revoked, suspended or denied pursuant to Iowa Code chapter 135C and Iowa Administrative Code 481—Chapter 50.
This rule is intended to implement 1990 Iowa Acts, chapter 1016.
481—58.55(135C) Another business or activity in a facility. A facility is allowed to have another business or activity in a health care facility or in the physical structure of the facility, if the other business or activity meets the requirements of applicable state and federal laws, administrative rules, and federal regulations.
To obtain the approval of the department and the state fire marshal, the facility must submit to the department a written request for approval which identifies the service(s) to be offered by the business and addresses the factors outlined in paragraphs “a” through “f” of subrule 58.55(1). (I, II, III)
	58.55(1) The following factors will be considered by the department in determining whether a business or activity will interfere with the use of the facility by residents, interfere with services provided to residents, or be disturbing to residents:
	a. 	Health and safety risks for residents;
	b. 	Noise created by the proposed business or activity;
	c. 	Odors created by the proposed business or activity;
	d. 	Use of the facility’s corridors or rooms as thoroughfares to the business or activity in regard to safety and disturbance of residents and interference with delivery of services;
	e. 	Proposed staffing for the business or activity; and
	f. 	Sharing of services and staff between the proposed business or activity and the facility.
	58.55(2) Approval of the state fire marshal shall be obtained before approval of the department will be considered.
	58.55(3) A business or activity conducted in a health care facility or in the same physical structure as a health care facility shall not reduce space, services or staff available to residents below minimums required in these rules and 481—Chapter 61. (I, II, III)
481—58.56(135C) Respite care services. Respite care services means an organized program of temporary supportive care provided for 24 hours or more to a person in order to relieve the usual caregiver of the person from providing continual care to the person. A nursing facility which chooses to provide respite care services must meet the following requirements related to respite services and must be licensed as a nursing facility.
	58.56(1) A nursing facility certified as a Medicaid nursing facility or Medicare skilled nursing facility must meet all Medicaid and Medicare requirements including CFR 483.12, admission, transfer and discharge rights.
	58.56(2) A nursing facility which chooses to provide respite care services is not required to obtain a separate license or pay a license fee.
	58.56(3) Rule 481—58.40(135C) regarding involuntary discharge or transfer rights, does not apply to residents who are being cared for under a respite care contract.
	58.56(4) Pursuant to rule 481—58.13(135C), the facility shall have a contract with each resident in the facility. When the resident is there for respite care services, the contract shall specify the time period during which the resident will be considered to be receiving respite care services. At the end of that period, the contract may be amended to extend that period of time. The contract shall specifically state the resident may be involuntarily discharged while being considered as a respite care resident. The contract shall meet other requirements under 481—58.13(135C), except the requirements under subrule 58.13(7).
	58.56(5) Respite care services shall not be provided by a health care facility to persons requiring a level of care which is higher than the level of care the facility is licensed to provide.
These rules are intended to implement Iowa Code sections 10A.202, 10A.402, 135C.6(1), 135C.14, 135C.25, 135C.32, 135C.36 and 227.4 and 1990 Iowa Acts, chapter 1016.
[Filed 8/6/76, Notice 4/19/76—published 8/23/76, effective 9/27/76]
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[Filed 1/15/93, Notice 11/25/92—published 2/3/93, effective 3/10/93]
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[Filed 5/16/95, Notice 3/15/95—published 6/7/95, effective 7/12/95]
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[Filed emergency 7/25/97—published 8/13/97, effective 7/25/97]
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[Filed 3/31/98, Notice 12/3/97—published 4/22/98, effective 5/27/98]
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[Filed 1/21/99, Notice 10/7/98—published 2/10/99, effective 3/17/99]
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◊	Two or more ARCs
1	Effective date of 470—58.15(2)“c” delayed 70 days by the Administrative Rules Review Committee, IAB 2/26/86.Effective date of 470—58.15(2)“c” delayed until the expiration of 45 calendar days into the 1987 session of the General Assembly pursuant to Iowa Code section 17A.8(9), IAB 6/4/86.
2	See IAB, Inspections and Appeals Department.