CHAPTER 81
NURSING FACILITIES
[Prior to 7/1/83 Social Services[770] Ch 81]
[Prior to 2/11/87, Human Services[498]]
DIVISION I
GENERAL POLICIES
441—81.1(249A) Definitions.
“Abuse” means any of the following which occurs as a result of the willful or negligent acts or omissions of a nursing facility employee:
	1.	Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punishment or assault as defined in Iowa Code section 708.1 of a resident.
	2.	The commission of a sexual offense under Iowa Code chapter 709 or Iowa Code section 726.2 or 728.12, subsection 1, or sexual exploitation under Iowa Code chapter 235B, as a result of the acts or omissions of the facility employee responsible for the care of the resident with or against a resident.
	3.	Exploitation of a resident which means the act or process of taking unfair advantage of a resident or the resident’s physical or financial resources for one’s own personal or pecuniary profit without the informed consent of the resident, including theft, by the use of undue influence, harassment, duress, deception, false representation or false pretenses.
	4.	The deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a resident’s life or health.
“Advance directive” means a written instruction, such as a living will or durable power of attorney for health care, recognized under state law and related to the provision of health care when the resident is incapacitated.
“Allowable costs” means the price a prudent, cost-conscious buyer would pay a willing seller for goods or services in an arm’s-length transaction, not to exceed the limitations set out in rules.
“Beginning eligibility date” means date of an individual’s admission to the facility or date of eligibility for medical assistance, whichever is the later date.
“Case mix” means a measure of the intensity of care and services used by similar residents in a facility.
“Case-mix index” means a numeric score within a specific range that identifies the relative resources used by similar residents and represents the average resource consumption across a population or sample.
“Civil penalty” shall mean a civil money penalty not to exceed the amount authorized under Iowa Code section 135C.36 for health care facility violations.
“Clinical experience” means application or learned skills for direct resident care in a nursing facility.
“Complete replacement” means completed construction on a new nursing facility to replace an existing licensed and certified nursing facility. The replacement facility shall have no more licensed beds than the facility being replaced and shall be located either in the same county as the facility being replaced or within 30 miles from the facility being replaced.
“Cost normalization” refers to the process of removing cost variations associated with different levels of resident case mix. Normalized cost is determined by dividing a facility’s per diem direct care component costs by the facility cost report period case-mix index.
“Denial of critical care” is a pattern of care in which the resident’s basic needs are denied or ignored to such an extent that there is imminent or potential danger of the resident suffering injury or death, or is a denial of, or a failure to provide the mental health care necessary to adequately treat the resident’s serious social maladjustment, or is a gross failure of the facility employee to meet the emotional needs of the resident necessary for normal functioning, or is a failure of the facility employee to provide for the proper supervision of the resident.
“Department” means the Iowa department of human services.
“Department’s accounting firm” means the firm on contract with the department to calculate nursing facility rates and provide other accounting services as requested.
“Direct care component” means the portion of the Medicaid reimbursement rates that is attributable to the salaries and benefits of registered nurses, licensed practical nurses, certified nursing assistants, rehabilitation nurses, and contracted nursing services.
“Discharged resident” means a resident whose accounts and records have been closed out and whose personal effects have been taken from the facility. When a resident is discharged, the facility shall notify the department via Form 470-0042, Case Activity Report.
“Facility” means a licensed nursing facility certified in accordance with the provisions of 42 CFR Part 483, as amended to September 23, 1992, to provide health services and includes hospital-based nursing facilities that are Medicare-certified and provide only skilled level of care and swing-bed hospitals unless stated otherwise.
“Facility-based nurse aide training program” means a nurse aide training program that is offered by a nursing facility and taught by facility employees or under the control of the licensee.
“Facility cost report period case-mix index” is the average of quarterly facilitywide average case-mix indices, carried to four decimal places. The quarters used in this average will be the quarters that most closely coincide with the financial and statistical reporting period. For example, a 01/01/2000-12/31/2000 financial and statistical reporting period would use the facilitywide average case-mix indices for quarters ending 03/31/00, 06/30/00, 09/30/00 and 12/31/00.
“Facilitywide average case-mix index” is the simple average, carried to four decimal places, of all resident case-mix indices based on the last day of each calendar quarter.
“Informed consent” means a resident’s agreement to allow something to happen that is based on a full disclosure of known facts and circumstances needed to make the decision intelligently, i.e., with knowledge of the risks involved or alternatives.
“Iowa Foundation for Medical Care (IFMC)” is the peer review organization on contract with the department to provide level of care determinations. The address of IFMC is 6000 Westown Parkway, West Des Moines, Iowa 50266.
“Iowa Medicaid enterprise” means the entity comprised of department staff and contractors responsible for the management and reimbursement of Medicaid services.
“Laboratory experience” means practicing care-giving skills prior to contact in the clinical setting.
“Major renovations” means new construction or facility improvements to an existing licensed and certified nursing facility in which the total depreciable asset value of the new construction or facility improvements exceeds $1.5 million. The $1.5 million threshold shall be calculated based on the total depreciable asset value of new construction or facility improvements placed into service during a two-year period ending on the date the last asset was placed into service. When the property costs of an asset have been included in a facility’s financial and statistical report that has already been used in a biennial rebasing, the costs of that asset shall not be considered in determining whether the facility meets the $1.5 million threshold.
“Medicaid average case-mix index” is the simple average, carried to four decimal places, of all resident case-mix indices where Medicaid is known to be the per diem payor source on the last day of the calendar quarter.
“Minimum data set” or “MDS” refers to a federally required resident assessment tool. Information from the MDS is used by the department to determine the facility’s case-mix index for purposes of normalizing per diem allowable direct care costs as provided by paragraph 81.6(16)“b,” for determining the Medicaid average case-mix index to adjust the direct care component pursuant to paragraphs 81.6(16)“c” and “e,” the excess payment allowance pursuant to paragraph 81.6(16)“d,” and the limits on reimbursement components pursuant to paragraph 81.6(16)“f.” MDS is described in subrule 81.13(9).
“Minimum food, shelter, clothing, supervision, physical or mental health care, or other care” means that food, shelter, clothing, supervision, physical or mental health care, or other care which, if not provided, would constitute denial of critical care.
“Mistreatment” means any intentional act, or threat of an act, coupled with the apparent ability to execute the act, which causes or puts another person in fear of mental anguish, humiliation, deprivation or physical contact which is or will be painful, insulting or offensive. Actions utilized in providing necessary treatment or care in accordance with accepted standards of practice are not considered mistreatment.
“New construction” means the construction of a new nursing facility that does not replace an existing licensed and certified facility and that requires the provider to obtain a certificate of need pursuant to Iowa Code chapter 135, division VI.
“Non-direct care component” means the portion of Medicaid reimbursement rates attributable to administrative, environmental, property, and support care costs reported on the financial and statistical report.
“Non-facility-based nurse aide training program” means a nurse aide training program that is offered by an organization that is not licensed to provide nursing facility services.
“Nurse aide” means any individual who is not a licensed health professional or volunteer providing nursing or nursing-related services to residents in a nursing facility.
“Nurse aide registry” means Nurse Aide Registry, Department of Inspections and Appeals, Third Floor, Lucas State Office Building, Des Moines, Iowa 50319.
“Nurse aide training and competency evaluation programs (NATCEP)” are educational programs approved by the department of inspections and appeals for nurse aide training as designated in subrule 81.16(3).
“Patient-day-weighted median cost” means the per diem cost of the nursing facility that is at the median per diem cost of all nursing facilities based on patient days provided when per diem allowable costs are ranked from low to high. A separate patient-day-weighted median cost amount shall be determined for the direct care and non-direct care components.
“Physical abuse” means any nonaccidental physical injury, or injury which is at variance with the history given of it, suffered by a resident as the result of the acts or omissions of a person responsible for the care of the resident.
“Physical injury” means damage to any bodily tissue to the extent that the tissue must undergo a healing process in order to be restored to a sound and healthy condition, or damage to any bodily tissue to the extent that the tissue cannot be restored to a sound and healthy condition, or damage to any bodily tissue which results in the death of the person who has sustained the damage.
“Poor performing facility (PPF)” is a facility designated by the department of inspections and appeals as a poor performing facility (PPF) based on surveys conducted by the department of inspections and appeals pursuant to subrule 81.13(1). A facility shall be designated a PPF if it has been cited for substandard quality of care on the current standard survey and it:
	1.	Has been cited for substandard quality of care or immediate jeopardy on at least one of the previous two standard surveys;
	2.	Has a history of substantiated complaints during the last two years;
	3.	Has a current deficiency for not having a quality assurance program; or
	4.	Does not have an effective quality assurance program as defined in paragraph 81.13(19)“o.”
“Primary instructor” means a registered nurse responsible for teaching a state-approved nurse aide training course.
“Program coordinator” means a registered nurse responsible for administrative aspects of a state-approved nurse aide training course.
“Rate determination letter” means the letter that is distributed quarterly by the Iowa Medicaid enterprise to each nursing facility notifying the facility of the facility’s Medicaid reimbursement rate calculated in accordance with this rule and of the effective date of the reimbursement rate.
“Skills performance record” means a record of major duties and skills taught which consists of, at a minimum:
	1.	A listing of the duties and skills expected to be learned in the program.
	2.	Space to record the date when the aide performs the duty or skill.
	3.	Space to note satisfactory or unsatisfactory performance.
	4.	The signature of the instructor supervising the performance.
“Special population nursing facility” refers to a nursing facility that serves the following populations:
	1.	One hundred percent of the residents served are aged 21 and under and require the skilled level of care.
	2.	Seventy percent of the residents served require the skilled level of care for neurological disorders.
“Terminated from the Medicare or Medicaid program” means a facility has lost the final appeal to which it is entitled.
“Testing entity” means a person, agency, institution, or facility approved by the department of inspections and appeals to take responsibility for obtaining, keeping secure and administering the competency test and reporting nurse aide scores to the nurse aide registry.
This rule is intended to implement Iowa Code sections 249A.2(6), 249A.3(2)“a,” and 249A.4.
441—81.2 Rescinded, effective 11/21/79.
441—81.3(249A) Initial approval for nursing facility care.
	81.3(1) Need for nursing facility care. Residents of nursing facilities must be in need of either nursing facility care or skilled nursing care. Payment will be made for nursing facility care residents only upon certification of the need for the level of care by a licensed physician of medicine or osteopathy and approval of the level of care by the department. Initial decisions on level of care shall be made for the department by the Iowa Foundation for Medical Care (IFMC) within two working days of receipt of medical information. After notice of an adverse decision by IFMC, the Medicaid applicant or recipient, the applicant’s or recipient’s representative, the attending physician, or the nursing facility may request reconsideration by IFMC by sending a letter requesting a review to IFMC not more than 60 days after the date of the notice of adverse decision. On initial and reconsideration decisions, IFMC determines whether the level of care provided or to be provided should be approved based on medical necessity and the appropriateness of the level of care under 441—subrules 79.9(1) and 79.9(2). Adverse decisions by IFMC on reconsiderations may be appealed to the department pursuant to 441—Chapter 7.
	a. 	If a timely request for reconsideration of an initial denial determination is made, IFMC will complete its reconsidered determination and send written notice including appeal rights to the Medicaid applicant or recipient, the applicant’s or recipient’s representative, the attending physician or the facility provider within the following time limits:
	(1)	Within three working days after IFMC receives the request for reconsideration and a copy of the medical record, if the initial determination was made before the Medicaid applicant or recipient was admitted to the nursing facility.
	(2)	Within ten working days after IFMC receives the request for reconsideration and a copy of the medical record, if the Medicaid applicant or recipient was admitted to the nursing facility when the initial determination was made and is still in the nursing facility when the request for reconsideration is received.
	(3)	Within 30 working days after IFMC receives the request for reconsideration and a copy of the medical record, if the Medicaid applicant or recipient was admitted to the nursing facility when the initial determination was made but is no longer in the nursing facility when the request for reconsideration is received.
	b. 	If a copy of the medical record is not submitted with the reconsideration request, IFMC shall request a copy from the facility within two working days.
	c. 	Written notice of the IFMC reconsidered determination shall contain the following:
	(1)	The basis for the reconsidered determination.
	(2)	A detailed rationale for the reconsidered determination.
	(3)	A statement explaining the Medicaid payment consequences of the reconsidered determination.
	(4)	A statement informing the parties of their appeal rights, including the information that must be included in the request for an administrative hearing, the locations for submitting a request for an administrative hearing, and the time period for filing a request.
	d. 	If the request for reconsideration is mailed or delivered to IFMC within ten days of the date of the initial determination, any medical assistance payments previously approved will not be terminated until the decision on reconsideration. If the initial decision is upheld on reconsideration, medical assistance benefits continued pursuant to this subrule will be treated as an overpayment to be repaid to the department.
	81.3(2) Skilled nursing care level of need. Rescinded IAB 7/11/01, effective 7/1/01.
	81.3(3) Screening. All persons, regardless of the source of payment, seeking admission to a nursing facility shall also be screened by the Iowa Foundation for Medical Care to determine if mental illness, mental retardation, or a related condition is present. The Iowa Medicaid program will cover the cost of this screening through the managed mental health contractor.
Final approval for initial admissions and continued stay of persons with mental illness, mental retardation, or a related condition is determined by the department of human services, division of mental health, mental retardation and developmental disabilities.
Nursing facility payment under the Iowa Medicaid program will be made for persons with mental illness, mental retardation, or a related condition only if it is determined by the division of mental health, mental retardation and developmental disabilities that the person’s treatment needs will be or are being met.
	81.3(4) Special care level of need. Rescinded IAB 3/20/91, effective 3/1/91.
This rule is intended to implement Iowa Code sections 249A.2(6), 249A.3(2)“a” and 249A.4.
441—81.4(249A) Arrangements with residents.
	81.4(1) Resident care agreement. Rescinded IAB 12/6/95, effective 2/1/96.
	81.4(2) Financial participation by resident. A resident’s payment for care may include any voluntary payments made by family members toward cost of care of the resident. The resident’s client participation and medical payments from a third party shall be paid toward the total cost of care for the month before any state payment is made. The state will pay the balance of the cost of care for the remainder of the month. The facility shall make arrangements directly with the resident for payment of client participation.
	81.4(3) Personal needs account. When a facility manages the personal needs funds of a resident, it shall establish and maintain a system of accounting for expenditures from the resident’s personal needs funds. (See subrule 81.13(5)“c.”) The funds shall be deposited in a bank within the state of Iowa insured by FDIC. Expense for bank service charges for this account is an allowable expense under rule 441—81.6(249A) if the service cannot be obtained free of charge. The department shall charge back to the facility any maintenance item included in the computation of the audit cost that is charged to the resident’s personal needs when the charge constitutes double payment. Unverifiable expenditures charged to personal needs accounts may be charged back to the facility. The accounting system is subject to audit by representatives of the department and shall meet the following criteria:
	a. 	Upon admittance, a ledger sheet shall be credited with the resident’s total incidental money on hand. Thereafter, the ledger shall be kept current on a monthly basis. The facility may combine the accounting with the disbursement section showing the date, amount given the resident, and the resident’s signature. A separate ledger shall be maintained for each resident.
	b. 	When something is purchased for the resident and is not a direct cash disbursement, each expenditure item in the ledger shall be supported by a signed, dated receipt. The receipt shall indicate the article furnished for the resident’s benefit.
	c. 	Personal funds shall only be turned over to the resident, the resident’s guardian, or other persons selected by the resident. With the consent of the resident, when the resident is able and willing to give consent the administrator may turn over personal funds to a close relative or friend of the resident to purchase a particular item. A signed, dated receipt shall be required to be deposited in the resident’s files.
	d. 	The ledger and receipts for each resident shall be made available for periodic audits by an accredited department representative. Audit certification shall be made by the department’s representative at the bottom of the ledger sheet. Supporting receipts may then be destroyed.
	e. 	Upon a patient’s death, a receipt shall be obtained from the next of kin, the resident’s guardian, or the representative handling the funeral before releasing the balance of the personal needs funds. In the event there is no next of kin or guardian available and there are no outstanding funeral expenses, any funds shall revert to the department. In the event that an estate is opened, the department shall turn the funds over to the estate.
	81.4(4) Safeguarding personal property. The facility shall safeguard the resident’s personal possessions. Safeguarding shall include, but is not limited to:
	a. 	Providing a method of identification of the resident’s suitcases, clothing, and other personal effects, and listing these on an appropriate form attached to the resident’s record at the time of admission. These records shall be kept current. Any personal effects released to a relative of the resident shall be covered by a signed receipt.
	b. 	Providing adequate storage facilities for the resident’s personal effects.
	c. 	Ensuring that all mail is delivered unopened to the resident to whom it is addressed, except in those cases where the resident is too confused, as documented in the person’s permanent medical record, to receive it, in which case the mail is held unopened for the resident’s conservator or relatives. Mail may be opened by the facility in cases where the resident or relatives or guardian have given permission in writing for mail to be opened and read to the resident.
This rule is intended to implement Iowa Code sections 249A.2, 249A.3(2)“a,” and 249A.4.
441—81.5(249A) Discharge and transfer. (See subrules 81.13(2)“a” and 81.13(6)“c.”)
	81.5(1) Notice. When a public assistance recipient requests transfer or discharge, or another person requests this for the recipient, the administrator shall promptly notify the local office of the department. This shall be done in sufficient time to permit a social service worker to assist in the planning for the transfer or discharge.
	81.5(2) Case activity report. A Case Activity Report, Form 470-0042, shall be submitted to the department whenever a Medicaid applicant or recipient enters the facility, changes level of care, or is discharged from the facility.
	81.5(3) Plan. The administrator and staff shall assist the resident in planning for transfer or discharge through development of a discharge plan.
	81.5(4) Transfer records. When a resident is transferred to another facility, transfer information shall be summarized from the facility’s records in a copy to accompany the resident. This information shall include:
	a. 	A transfer form of diagnosis.
	b. 	Aid to daily living information.
	c. 	Transfer orders.
	d. 	Nursing care plan.
	e. 	Physician’s orders for care.
	f. 	The resident’s personal records.
	g. 	When applicable, the personal needs fund record.
	h. 	Resident care review team assessment.
	81.5(5) Unused client participation. When a resident leaves the facility during the month, any unused portion of the resident’s client participation shall be refunded.
This rule is intended to implement Iowa Code sections 249A.2, 249A.3(2)“a,” and 249A.4.
441—81.6(249A) Financial and statistical report and determination of payment rate. With the exception of hospital-based nursing facilities that are Medicare-certified and provide only the skilled level of care, herein referred to as Medicare-certified hospital-based nursing facilities, all facilities in Iowa wishing to participate in the program shall submit a Financial and Statistical Report, Form 470-0030, to the department’s accounting firm. All Medicare-certified hospital-based nursing facilities shall submit a copy of their Medicare cost report to the department’s accounting firm. Costs for patient care services shall be reported, divided into the subcategories of “Direct Patient Care Costs” and “Support Care Costs.” Costs associated with food and dietary wages shall be included in the “Support Care Costs” subcategory. The financial and statistical report shall be submitted in an electronic format approved by the department. These reports shall be based on the following rules.
	81.6(1) Failure to maintain records. Failure to adequately maintain fiscal records, including census records, medical charts, ledgers, journals, tax returns, canceled checks, source documents, invoices, and audit reports by or for a facility may result in the penalties specified in subrule 81.14(1).
	81.6(2) Accounting procedures. Financial information shall be based on that appearing in the audited financial statement. Adjustments to convert to the accrual basis of accounting shall be made when the records are maintained on other accounting bases. Facilities which are a part of a larger health facility extending short-term, intensive, or other health care not generally considered nursing care may submit a cost apportionment schedule prepared in accordance with recognized methods and procedures. A schedule shall be required when necessary for a fair presentation of expense attributable to nursing facility patients.
	81.6(3) Submission of reports. All nursing facilities, except the Iowa Veterans Home, shall submit reports to the department’s accounting firm no later than three months after the close of the facility’s established fiscal year. The Iowa Veterans Home shall submit the report to the department’s accounting firm no later than three months after the close of each six-month period of the facility’s established fiscal year. Failure to submit a report that meets the requirements of this rule within this time shall reduce payment to 75 percent of the current rate. The reduced rate shall be paid for no longer than three months, after which time no further payments will be made.
A facility may change its fiscal year one time in any two-year period. If the facility changes its fiscal year, the facility shall notify the department’s accounting firm 60 days prior to the first date of the change.
	81.6(4) Payment at new rate.
	a. 	Except for state-operated nursing facilities and special population nursing facilities, payment rates shall be updated July 1, 2001, and every second year thereafter with new cost report data, and adjusted quarterly to account for changes in the Medicaid average case-mix index. For nursing facilities receiving both an ICF and SNF Medicaid rate effective June 30, 2001, the June 30, 2001, Medicaid rate referenced in subparagraphs (1) and (2) below shall be the patient-day-weighted average of the ICF and SNF Medicaid rates effective June 30, 2001, excluding the case-mix transition add-on amount.
	(1)	The Medicaid payment rates for services rendered from July 1, 2001, through June 30, 2002, shall be 66.67 percent of the facility’s Medicaid rate effective June 30, 2001, excluding the case-mix transition add-on amount, plus an inflation allowance of 6.21 percent, not to exceed $94, and 33.33 percent of the July 1, 2001, modified price-based rate pursuant to subrule 81.6(16). In no case shall the July 1, 2001, Medicaid rate be less than the Medicaid rate effective June 30, 2001, excluding the case-mix transition add-on amount, and increased by a 6.21 percent inflation allowance.
	(2)	Payment rates for services rendered from July 1, 2002, through June 30, 2003, shall be 33.33 percent of the facility’s Medicaid rate effective June 30, 2001, excluding the case-mix transition add-on amount, plus an inflation allowance of 6.21 percent, and an additional inflation factor based on the CMS/SNF Total Market Basket Index. However, the current system rate to be used effective July 1, 2002, shall not exceed $94, times an inflation factor pursuant to subrule 81.6(18), and 66.67 percent of the July 1, 2002, modified price-based rate. In no case shall the July 1, 2002, Medicaid rate be less than the Medicaid rate effective June 30, 2002, plus an inflation factor pursuant to subrule 81.6(18) projected for the following 12 months.
	(3)	Payment rates for services rendered from July 1, 2003, and thereafter will be 100 percent of the modified price-based rate.
	(4)	Aggregate payments to a nursing facility that is owned or operated by state or non-state government shall not exceed the facility’s actual medical assistance program costs. Aggregate payments shall include amounts received from the Medicaid program, as well as receipts from patient and other third-party payments up to the Medicaid-allowed amount.
	b. 	The Medicaid payment rate for special population nursing facilities shall be updated annually without a quarterly adjustment.
	c. 	The Medicaid payment rate for state-operated nursing facilities shall be updated annually without a quarterly adjustment.
	81.6(5) Accrual basis. Facilities not using the accrual basis of accounting shall adjust recorded amounts to the accrual basis. Records of cash receipts and disbursements shall be adjusted to reflect accruals of income and expense.
	81.6(6) Census of public assistance recipients. Census figures of public assistance recipients shall be obtained on the last day of the month ending the reporting period.
	81.6(7) Patient days. In determining inpatient days, a patient day is that period of service rendered a patient between the census-taking hours on two successive days, the day of discharge being counted only when the patient was admitted that same day.
	81.6(8) Opinion of accountant. The department may require that an opinion of a certified public accountant or public accountant accompany the report when adjustments made to prior reports indicate disregard of the certification and reporting instructions.
	81.6(9) Calculating patient days. When calculating patient days, facilities shall use an accumulation method.
	a. 	Census information shall be based on a patient’s status at midnight at the end of each day.
	b. 	When a recipient is on a reserve bed status and the department is paying on a per diem basis for the holding of a bed, or any day a bed is reserved for a public assistance or nonpublic assistance patient and a per diem rate for the bed is charged to any party, the reserved days shall be included in the total census figures for inpatient days.
	81.6(10) Revenues. Revenues shall be reported as recorded in the general books and records. Expense recoveries credited to expense accounts shall not be reclassified in order to be reflected as revenues.
	a. 	Routine daily services shall represent the established charge for daily care. Routine daily services are those services which include room, board, nursing services, and such services as supervision, feeding, incontinency, and similar services, for which the associated costs are in nursing service.
	b. 	Revenue from ancillary services provided to patients shall be applied in reduction of the related expense.
	c. 	Revenue from the sale of medical supplies, food or services to employees or nonresidents of the facility shall be applied in reduction of the related expense. Revenue from the sale to private pay residents of items or services which are included in the medical assistance per diem will not be offset.
	d. 	Investment income adjustment is necessary only when interest expense is incurred, and only to the extent of the interest expense.
	e. 	Laundry revenue shall be applied to laundry expense.
	f. 	Accounts receivable charged off or provision for uncollectible accounts shall be reported as a deduction from gross revenue.
	81.6(11) Limitation of expenses. Certain expenses that are not normally incurred in providing patient care shall be eliminated or limited according to the following rules.
	a. 	Federal and state income taxes are not allowed as reimbursable costs.
	b. 	Fees paid directors and nonworking officers’ salaries are not allowed as reimbursable costs.
	c. 	Bad debts are not an allowable expense.
	d. 	Charity allowances and courtesy allowances are not an allowable expense.
	e. 	Personal travel and entertainment are not allowable as reimbursable costs. Certain expenses such as rental or depreciation of a vehicle and expenses of travel which include both business and personal costs shall be prorated. Amounts which appear to be excessive may be limited after consideration of the specific circumstances. Records shall be maintained to substantiate the indicated charges.
	(1)	Commuter travel by the owner(s), owner-administrator(s), administrator, nursing director or any other employee is not an allowable cost (from private residence to facility and return to residence).
	(2)	The expense of one car or one van or both designated for use in transporting patients shall be an allowable cost. All expenses shall be documented by a sales slip, invoice or other document setting forth the designated vehicle as well as the charges incurred for the expenses to be allowable.
	(3)	Each facility which supplies transportation services as defined in Iowa Code section 601J.1, subsection 1, shall provide current documentation of compliance with or exemption from public transit coordination requirements as found in Iowa Code chapter 601J and 820—[09,A] chapter 2 of the department of transportation rules at the time of annual contract renewal. Failure to cooperate in obtaining or in providing the required documentation of compliance or exemption after receipt from the Iowa department of transportation, public transit division shall, result in disallowance of vehicle costs and other costs associated with transporting residents.
	(4)	Expenses related to association business meetings, limited to individual members of the association who are members of a national affiliate, and expenses associated with workshops, symposiums, and meetings which provide administrators or department heads with hourly credits required to comply with continuing education requirements for licensing, are allowable expenses.
	(5)	Travel of an emergency nature required for supplies, repairs of machinery or equipment, or building is an allowable expense.
	(6)	Travel for which a patient must pay is not an allowable expense.
	(7)	Allowable expenses in subparagraphs (2) through (5) above are limited to 6 percent of total administrative expense.
	f. 	Entertainment provided by the facility for participation of all residents who are physically and mentally able to participate is an allowable expense except that entertainment for which the patient is required to pay is not an allowable expense.
	g. 	Loan acquisition fees and standby fees are not considered part of the current expense of patient care, but should be amortized over the life of the related loan.
	h. 	A reasonable allowance of compensation for services of owners or immediate relatives is an allowable cost, provided the services are actually performed in a necessary function. For this purpose, the following persons are considered immediate relatives: husband and wife; natural parent, child and sibling; adopted child and adoptive parent; stepparent, stepchild, stepbrother, and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and grandchild. Adequate time records shall be maintained. Adjustments may be necessary to provide compensation as an expense for nonsalaried working proprietors and partners. Members of religious orders serving under an agreement with their administrative office are allowed salaries paid persons performing comparable services. When maintenance is provided these persons by the facility, consideration shall be given to the value of these benefits and this amount shall be deducted from the amount otherwise allowed for a person not receiving maintenance.
	(1)	Compensation means the total benefit received by the owner or immediate relative for services rendered. It includes salary amounts paid for managerial, administrative, professional, and other services; amounts paid by the facility for the personal benefit of the proprietor or immediate relative; the cost of assets and services which the proprietor or immediate relative receives from the facility; and deferred compensation.
	(2)	Reasonableness requires that the compensation allowance be the same amount as would ordinarily be paid for comparable services by comparable institutions, and depends upon the facts and circumstances of each case.
	(3)	Necessary requires that the function be such that had the owner or immediate relative not rendered the services, the facility would have had to employ another person to perform the service, and be pertinent to the operation and sound conduct of the institution.
	(4)	Effective July 1, 2001, the base maximum allowed compensation for an administrator who is involved in ownership of the facility or who is an immediate relative of an owner of the facility is $3,296 per month plus $35.16 per month per licensed bed capacity for each bed over 60, not to exceed $4,884 per month. An administrator is considered to be involved in ownership of a facility when the administrator has ownership interest of 5 percent or more.
On an annual basis, the maximum allowed compensation amounts for these administrators shall be increased or decreased by an annual inflation factor as specified by subrule 81.6(18).
	(5)	The maximum allowed compensation for an assistant administrator who is involved in ownership of the facility or who is an immediate relative of an owner of the facility in facilities having a licensed capacity of 151 or more beds is 60 percent of the amount allowed for the administrator. An assistant administrator is considered to be involved in ownership of a facility when the assistant administrator has ownership interest of 5 percent or more.
	(6)	The maximum allowed compensation for a director of nursing or any employee who is involved in ownership of the facility or who is an immediate relative of an owner of the facility is 60 percent of the amount allowed for the administrator. Persons involved in ownership or relatives providing professional services shall be limited to rates prevailing in the community not to exceed 60 percent of the allowable rate for the administrator on a semiannual basis. Records shall be maintained in the same manner for an employee involved in ownership or a relative as are maintained for any other employee of the facility. Ownership is defined as an interest of 5 percent or more.
	i. 	Management fees shall be limited on the same basis as the owner administrator’s salary, but shall have the amount paid the resident administrator deducted. When the parent company can separately identify accounting costs, the costs are allowed.
	j. 	Depreciation based upon tax cost using only the straight-line method of computation, recognizing the estimated useful life of the asset as defined in the American Hospital Association Useful Life Guide, 1983 edition, may be included as a patient cost. When accelerated methods of computation have been elected for income tax purposes, an adjustment shall be made. For change of ownership, refer to subrule 81.6(12).
	k. 	Necessary and proper interest on both current and capital indebtedness is an allowable cost.
	(1)	Interest is the cost incurred for the use of borrowed funds. Interest on current indebtedness is the cost incurred for funds borrowed for a relatively short term. Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes.
	(2)	“Necessary” requires that the interest be incurred on a loan made to satisfy a financial need of the provider, be incurred on a loan made for a purpose reasonably related to patient care, and be reduced by investment income except where the income is from gifts and grants whether restricted or unrestricted, and which are held separate and not commingled with other funds.
	(3)	“Proper” requires that interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market on the date the loan was made, and be paid to a lender not related through control or ownership to the borrowing organization.
	(4)	Interest on loans is allowable as cost at a rate not in excess of the amount an investor could receive on funds invested in the locality on the date the loan was made.
	(5)	Interest is an allowable cost when the general fund of a provider borrows from a donor-restricted fund, a funded depreciation account of the provider, or the provider’s qualified pension fund, and pays interest to the fund, or when a provider operated by members of a religious order borrows from the order.
	(6)	When funded depreciation is used for purposes other than improvement, replacement or expansion of facilities or equipment related to patient care, allowable interest expense is reduced to adjust for offsets not made in prior years for earnings on funded depreciation. A similar treatment will be accorded deposits in the provider’s qualified pension fund where the deposits are used for other than the purpose for which the fund was established.
	l. 	Costs applicable to supplies furnished by a related party or organization are a reimbursable cost when included at the cost to the related party or organization. The cost shall not exceed the price of comparable supplies that could be purchased elsewhere.
	(1)	Related means that the facility, to a significant extent, is associated with or has control of or is controlled by the organization furnishing the services, facilities, or supplies.
	(2)	Common ownership exists when an individual or individuals possess significant ownership or equity in the facility and the institution or organization serving the provider.
	(3)	Control exists where an individual or an organization has power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution.
	(4)	When the facility demonstrates by convincing evidence that the supplying organization is a bona fide separate organization; that a substantial part of its business activity of the type carried on with the facility is transacted with others and there is an open competitive market for the type of services, facilities, or supplies furnished by the organization; that the services, facilities, or supplies are those which commonly are obtained by similar institutions from other organizations and are not a basic element of patient care ordinarily furnished directly to patients by the institutions; and that the charge to the facility is in line with the charge for the services, facilities, or supplies in the open market and no more than the charge made under comparable circumstances to others by the organization for the services, facilities, or supplies, the charges by the supplier shall be allowable costs.
	m. 	When the operator of a participating facility rents from a nonrelated party, the amount of rent expense allowable on the cost report shall be based on the cost of the facility as identified in subrule 81.6(12), paragraph “a,” plus the landlord’s other expenses and a reasonable rate of return, not to exceed actual rent payments.
When the operator of a participating facility rents the building from a related party, the amount of rent expense allowable on the cost report shall be no more than the amortized cost of the facility as identified in subrule 81.6(12), paragraph “a,” plus the landlord’s other expenses.
The landlord must be willing to provide documentation of these costs for rental arrangements.
	n. 	Depreciation, interest and other capital costs attributable to construction of new facilities, expanding existing facilities, or the purchase of an existing facility, are allowable expenses only if prior approval has been gained through the health planning process specified in rules of the public health department, 641—Chapter 201.
	o. 	Reasonable legal fees are an allowable cost when directly related to patient care. Legal fees related to defense against threatened state license revocation or Medicaid decertification are allowable costs only up to the date a final appeal decision is issued. However, in no case will legal fees related to Medicaid decertification be allowable costs following the decertification date.
	p. 	The nursing facility quality assurance assessment paid pursuant to 441—Chapter 36, Division II, shall not be an allowable cost for cost reporting and audit purposes but shall be reimbursed pursuant to paragraph 81.6(21)“a.”
	81.6(12) Termination or change of owner.
	a. 	A participating facility contemplating termination of participation or negotiating a change of ownership shall provide the department of human services with at least 60 days’ prior notice. A transfer of ownership or operation terminates the participation agreement. A new owner or operator shall establish that the facility meets the conditions for participation and enter into a new agreement. The person responsible for transfer of ownership or for termination is responsible for submission of a final financial and statistical report through the date of the transfer. No payment to the new owner will be made until formal notification is received. The following situations are defined as a transfer of ownership:
	(1)	In the case of a partnership which is a party to an agreement to participate in the medical assistance program, the removal, addition, or substitution of an individual for a partner in the association in the absence of an express statement to the contrary, dissolves the old partnership and creates a new partnership which is not a party to the previously executed agreement and a transfer of ownership has occurred.
	(2)	When a participating nursing facility is a sole proprietorship, a transfer of title and property to another party constitutes a change of ownership.
	(3)	When the facility is a corporation, neither a transfer of corporate stock nor a merger of one or more corporations with the participating corporation surviving is a transfer of ownership. A consolidation of two or more corporations resulting in the creation of a new corporate entity constitutes a change of ownership.
	(4)	When a participating facility is leased, a transfer of ownership is considered to have taken place. When the entire facility is leased, the total agreement with the lessor terminates. When only part of the facility is leased, the agreement remains in effect with respect to the unleased portion, but terminates with respect to the leased portion.
	b. 	No increase in the value of property shall be allowed in determining the Medicaid rate for the new owner with any change of ownership (including lease agreements). When filing the first cost report, the new owner shall either continue the schedule of depreciation and interest established by the previous owner, or the new owner may choose to claim the actual rate of interest expense. The results of the actual rate of interest expense shall not be higher than would be allowed under the Medicare principles of reimbursement and shall be applied to the allowed depreciable value established by the previous owner, less any down payment made by the new owner.
	c. 	Other acquisition costs of the new owner such as legal fees, accounting and administrative costs, travel costs and the costs of feasibility studies attributable to the negotiation or settlement of the sale or purchase of the property shall not be allowed.
	d. 	In general, the provisions of Section 1861(v)(1)(0) of the Social Security Act regarding payment allowed under Medicare principles of reimbursement at the time of a change of ownership shall be followed, except that no return on equity or recapture of depreciation provisions shall be employed.
	e. 	A new owner or lessee wishing to claim a new rate of interest expense must submit documentation which verifies the amount of down payment made, the actual rate of interest, and the number of years required for repayment with the next annual cost report. In the absence of the necessary supportive documentation, interest and other property costs for all facilities that have changed or will change ownership shall continue at the rate allowed the previous owner.
	81.6(13) Facility-requested rate adjustment. A facility may request a rate adjustment for a period of time no more than 18 months prior to the facility’s rate effective date. The request for adjustment shall be made to the department’s accounting firm.
	81.6(14) Payment to new facility. The payment to a new facility shall be the sum of the patient-day-weighted median cost for the direct care and non-direct care components pursuant to paragraph 81.6(16)“c.” After the first full calendar quarter of operation, the patient-day-weighted median cost for the direct care component shall be adjusted by the facility’s average Medicaid case-mix index pursuant to subrule 81.6(19). A financial and statistical report shall be submitted from the beginning day of operation to the end of the fiscal year. Following the completion of the new facility’s first fiscal year, rates will be established in accordance with subrule 81.6(16). Subsequent financial and statistical reports shall be submitted annually for a 12-month period ending with the facility’s fiscal year.
	81.6(15) Payment to new owner. An existing facility with a new owner shall continue to be reimbursed using the previous owner’s per diem rate adjusted quarterly for changes in the Medicaid average case-mix index. The facility shall submit a financial and statistical report for the period from beginning of actual operation under new ownership to the end of the facility’s fiscal year. Subsequent financial and statistical reports shall be submitted annually for a 12-month period ending with the facility’s fiscal year. The facility shall notify the department’s accounting firm of the date its fiscal year will end.
	81.6(16) Establishment of the direct care and non-direct care patient-day-weighted medians and modified price-based reimbursement rate. This subrule provides for the establishment of the modified price-based reimbursement rate. The first step in the rate calculation (paragraph “a”) determines the per diem direct care and non-direct care component costs. The second step (paragraph “b”) normalizes the per diem direct care component costs to remove cost variations associated with different levels of resident case mix. The third step (paragraph “c”) calculates the patient-day-weighted medians for the direct care and non-direct care components that are used in subsequent steps to establish rate component limits and excess payment allowances, if any. The fourth step (paragraph “d”) calculates the potential excess payment allowance. The fifth step (paragraph “e”) calculates the reimbursement rate, including any applicable capital cost per diem instant relief add-on described in paragraph “h,” that is further subjected to the rate component limits, including any applicable enhanced non-direct care rate component limit described in paragraph “h,” in step six (paragraph “f”). The seventh step (paragraph “g”) calculates the additional reimbursement based on accountability measures available beginning July 1, 2002.
	a. 	Calculation of per diem cost. For purposes of calculating the non-state-owned nursing facility Medicaid reimbursement rate and the Medicare-certified hospital-based nursing facility Medicaid reimbursement rate, the costs shall be divided into two components, the direct care component and non-direct care component as defined in rule 441—81.1(249A). Each nursing facility’s per diem allowable direct care and non-direct care cost shall be established. Effective July 1, 2001, and every second year thereafter, the per diem allowable cost shall be arrived at by dividing total reported allowable costs by total inpatient days during the reporting period. On July 1, 2001, July 1, 2003, July 1, 2004, July 1, 2005, and every second year thereafter, total reported allowable costs shall be adjusted using the inflation factor specified in subrule 81.6(18) from the midpoint of the cost report period to the beginning of the state fiscal year rate period.
	(1)	Non-state-owned nursing facilities. Patient days for purposes of the computation of administrative, environmental, and property expenses for non-state-owned facilities shall be inpatient days as determined in subrule 81.6(7) or 90 percent of the licensed capacity of the facility, whichever is greater. Patient days for purposes of the computation of all other expenses shall be inpatient days as determined in subrule 81.6(7).
	(2)	Medicare-certified hospital-based nursing facilities. Patient days for purposes of the computation of all expenses shall be inpatient days as determined by subrule 81.6(7).
	b. 	Cost normalization. The per diem allowable direct care costs are normalized by dividing a facility’s per diem direct care costs by the facility’s cost report period case-mix index as defined in rule 441—81.1(249A) and subrule 81.6(19).
	c. 	Calculation of patient-day-weighted medians. For each of the rate components, a patient-day-weighted median shall be established for both the non-state-owned nursing facilities and the Medicare-certified hospital-based nursing facilities, hereinafter referred to as the non-state-owned nursing facility patient-day-weighted medians and the Medicare-certified hospital-based nursing facility patient-day-weighted medians.
The per diem normalized direct care cost for each facility is arrayed from low to high to determine the direct care component patient-day-weighted median cost based on the number of patient days provided by facilities. The per diem non-direct care cost for each facility is also arrayed from low to high to determine the non-direct care component patient-day-weighted median cost based on the number of patient days provided by facilities. An array and patient-day-weighted median for each cost component is determined separately for both non-state-owned nursing facilities and the Medicare-certified hospital-based nursing facilities.
	(1)	For the fiscal period beginning July 1, 2001, and ending June 30, 2003, the non-state-owned nursing facility direct care and non-direct care patient-day-weighted medians and the Medicare-certified hospital-based nursing facility direct care and non-direct care patient-day-weighted medians shall be calculated using the latest financial and statistical report with a fiscal year end of December 31, 2000, or earlier, inflated from the midpoint of the cost report period to July 1, 2001, using the inflation factor specified in subrule 81.6(18).
	(2)	Effective July 1, 2003, and each second year thereafter, the patient-day-weighted medians used in rate setting shall be recalculated. The non-state-owned nursing facility direct care and non-direct care patient-day-weighted medians and the Medicare-certified hospital-based nursing facility direct care and non-direct care patient-day-weighted medians shall be calculated using the latest completed cost report with a fiscal year end of the preceding December 31 or earlier. When patient-day-weighted medians are recalculated, inflation is applied from the midpoint of the cost report period to the first day of the state fiscal year rate period using the inflation factor specified in subrule 81.6(18).
	(3)	For the fiscal period beginning July 1, 2004, and ending June 30, 2005, the non-state-owned and Medicare-certified hospital-based nursing facility direct care and the non-direct care patient-day-weighted medians calculated July 1, 2003, shall be inflated to July 1, 2004, using the inflation factor specified in subrule 81.6(18).
	d. 	Excess payment allowance.
	(1)	For non-state-operated nursing facilities not located in a Metropolitan Statistical Area as defined by the Centers for Medicare and Medicaid Services (not including Medicare-certified hospital-based nursing facilities), the excess payment allowance is calculated as follows:
	1.	For the direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the direct care non-state-operated nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2) times the Medicaid average case-mix index pursuant to subrule 81.6(19), minus a provider’s allowable normalized per patient day direct care costs pursuant to 81.6(16)“b” times the Medicaid average case-mix index pursuant to subrule 81.6(19). In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the direct care non-state-operated nursing facility patient-day-weighted median.
	2.	For the non-direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the non-direct care non-state-operated nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2), minus a provider’s allowable per patient day non-direct care cost pursuant to paragraph 81.6(16)“a.” In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the non-direct care non-state-operated nursing facility patient-day-weighted median.
	(2)	For non-state-operated nursing facilities located in a Metropolitan Statistical Area as defined by the Centers for Medicare and Medicaid Services (not including Medicare-certified hospital-based nursing facilities), the excess payment allowance is calculated as follows:
	1.	For the direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the direct care non-state-operated nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2) times the wage index factor specified below times the Medicaid average case-mix index pursuant to subrule 81.6(19), minus a provider’s allowable normalized per patient day direct care costs pursuant to paragraph 81.6(16)“b” times the Medicaid average case-mix index pursuant to subrule 81.6(19). In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the direct care non-state-operated nursing facility patient-day-weighted median.
The wage index factor applied July 1, 2001, through June 30, 2002, shall be 11.46 percent. Beginning July 1, 2002, and thereafter, the wage index factor shall be determined annually by calculating the average difference between the Iowa hospital-based rural wage index and all Iowa hospital-based Metropolitan Statistical Area wage indices as published by the Centers for Medicare and Medicaid Services (CMS) each July. The geographic wage index adjustment shall not exceed $8 per patient day.
A nursing facility may request an exception to application of the geographic wage index based upon a reasonable demonstration of wages, locations, and total cost. The nursing facility shall request the exception within 30 days of receipt of notification to the nursing facility of the new reimbursement rate using the department’s procedures for requesting exceptions at rule 441—1.8(17A,217).
	2.	For the non-direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the non-direct care non-state-operated nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2), minus a provider’s allowable per patient day non-direct care cost pursuant to paragraph 81.6(16)“a.” In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the non-direct care non-state-operated nursing facility patient-day-weighted median.
	(3)	For Medicare-certified hospital-based nursing facilities, the excess payment allowance is calculated as follows:
	1.	For the direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the direct care Medicare-certified hospital-based nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2) times the Medicaid average case-mix index pursuant to subrule 81.6(19), minus a provider’s normalized allowable per patient day direct care costs pursuant to paragraph 81.6(16)“b” times the Medicaid average case-mix index pursuant to subrule 81.6(19). In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the direct care Medicare-certified hospital-based nursing facility patient-day-weighted median.
	2.	For the non-direct care component, subject to the limit provided below, the excess payment allowance is equal to the percentage specified in 441—subrule 79.1(2) times the difference (if greater than zero) of the following: the non-direct care Medicare-certified hospital-based nursing facility patient-day-weighted median times the percentage specified in 441—subrule 79.1(2), minus a provider’s allowable per patient day non-direct care cost pursuant to paragraph 81.6(16)“a.” In no case shall the excess payment allowance exceed the percentage specified in 441—subrule 79.1(2) times the non-direct care Medicare-certified hospital-based nursing facility patient-day-weighted median.
	e. 	Reimbursement rate. The Medicaid reimbursement rate is based on allowable costs, updated July 1, 2001, and every second year thereafter, as specified in subparagraphs (1) and (2) below, plus a potential excess payment allowance determined by the methodology in paragraph “d,” not to exceed the rate component limits determined by the methodology in paragraph “f.”
	(1)	For non-state-owned nursing facilities and Medicare-certified hospital-based nursing facilities, direct care and non-direct care rate components are calculated as follows:
	1.	The direct care component is equal to the provider’s normalized allowable per patient day costs times the Medicaid average case-mix index pursuant to subrule 81.6(19), plus the allowed excess payment allowance as determined by the methodology in paragraph “d.”
	2.	The non-direct care component is equal to the provider’s allowable per patient day costs, plus the allowed excess payment allowance as determined by the methodology in paragraph “d” and the allowable capital cost per diem instant relief add-on as determined by the methodology in paragraph “h.”
	(2)	The reimbursement rate for state-operated nursing facilities and special population nursing facilities shall be the facility’s average allowable per diem costs, adjusted for inflation pursuant to subrule 81.6(18), based on the most current financial and statistical report.
	f. 	Notwithstanding paragraphs “d” and “e,” in no instance shall a rate component exceed the rate component limit defined as follows:
	(1)	For non-state-operated nursing facilities not located in a Metropolitan Statistical Area (not including Medicare-certified hospital-based nursing facilities), the direct care and non-direct care rate component limits are calculated as follows:
	1.	The direct care rate component limit is the direct care non-state-operated nursing facility patient-day-weighted median times the percentage of the median specified in 441—subrule 79.1(2) times the Medicaid average case-mix index pursuant to subrule 81.6(19).
	2.	The non-direct care rate component limit is the non-direct care non-state-operated nursing facility patient-day-weighted median multiplied by the percentage of the median specified in 441—subrule 79.1(2) or is 120 percent of the median if the facility qualifies for the enhanced non-direct care rate component limit pursuant to paragraph “h.”
	(2)	For non-state-operated nursing facilities located in a Metropolitan Statistical Area (not including Medicare-certified hospital-based nursing facilities), the direct care and non-direct care rate component limits are calculated as follows:
	1.	The direct care rate component limit is the direct care non-state-operated nursing facility patient-day-weighted median times the percentage of the median specified in 441—subrule 79.1(2) times the wage factor specified in paragraph “d” times the Medicaid average case-mix index pursuant to subrule 81.6(19).
	2.	The non-direct care rate component limit is the non-direct care non-state-operated nursing facility patient-day-weighted median multiplied by the percentage of the median specified in 441—subrule 79.1(2) or is 120 percent of the median if the facility qualifies for the enhanced non-direct care rate component limit pursuant to paragraph “h.”
	(3)	For Medicare-certified hospital-based nursing facilities, the direct care and non-direct care rate component limits are calculated as follows:
	1.	The direct care rate component limit is the direct care Medicare-certified hospital-based nursing facility patient-day-weighted median times the percentage of the median specified in 441—subrule 79.1(2) times the Medicaid average case-mix index pursuant to subrule 81.6(19).
	2.	The non-direct care rate component limit is the non-direct care Medicare-certified hospital-based nursing facility patient-day-weighted median multiplied by the percentage of the median specified in 441—subrule 79.1(2) or is 120 percent of the median if the facility qualifies for the enhanced non-direct care rate component limit pursuant to paragraph “h.”
	(4)	For special population nursing facilities enrolled on or after June 1, 1993, the upper limit on their rate is equal to the sum of the following:
	1.	The direct care Medicare-certified hospital-based nursing facility patient-day-weighted median times the percentage of the median specified in 441—subrule 79.1(2).
	2.	The non-direct care Medicare-certified hospital-based nursing facility patient-day-weighted median multiplied by the percentage of the median specified in 441—subrule 79.1(2) or 120 percent of the median if the facility qualifies for the enhanced non-direct care rate component limit pursuant to paragraph “h.”
	g. 	Accountability measures. Additional reimbursement for non-state-owned facilities, based on accountability measures, is available beginning July 1, 2008, as provided in this paragraph. Accountability measures are nursing facility characteristics that indicate the quality of care, efficiency, or commitment to care for certain resident populations. These characteristics are objective, measurable, and, when considered in combination with each other, deemed to have a correlation to a resident’s quality of life and care. While any single measure does not ensure the delivery of quality care, a nursing facility’s achievement of multiple measures suggests that quality is an essential element in the facility’s delivery of resident care.
Additional reimbursement for accountability measures is not available to Medicare-certified hospital-based nursing facilities, state-operated nursing facilities, or special population nursing facilities. Therefore, data from these facility types shall not be used when determining eligibility for or amount of additional reimbursement based on accountability measures.
To qualify for additional Medicaid reimbursement for accountability measures, a facility must achieve a minimum score of 3 points. The maximum available points are 11.
The Iowa Medicaid enterprise shall award points based on the measures described in subparagraphs (1) through (10).
	(1)	Deficiency-free survey.
	1.	Standard. Facilities shall be deficiency-free on the latest annual state and federal licensing and certification survey and any subsequent surveys, complaint investigations, or revisit investigations. If a nursing facility’s only scope and severity deficiencies are an “A” level pursuant to 42 CFR, Part 483, Subparts B and C, as amended to July 30, 1999, the facility shall, for purposes of this measure, be deemed to have a deficiency-free survey. Surveys are considered complete when all appeal rights have been exhausted.
	2.	Measurement period. The measurement period shall be the latest annual survey completed on or before December 31 of each year and any subsequent surveys, complaint investigations, or revisit investigations completed between the annual survey date and December 31.
	3.	Value. 2 points.
	4.	Source. The department shall request that the department of inspections and appeals furnish by May 1 of each year a listing of nursing facilities that have met the standard.
	(2)	Regulatory compliance with survey.
	1.	Standard. Facilities shall be considered to be in regulatory compliance if no on-site revisit is required for recertification surveys or for any substantiated complaint investigations during the measurement period.
	2.	Measurement period. The measurement period shall include any recertification survey or complaint investigations completed on or before December 31 of each year.
	3.	Value. 1 point. (A nursing facility that achieves a deficiency-free survey according to subparagraph (1) cannot also receive a point value for this standard.)
	4.	Source. The department shall request that the department of inspections and appeals furnish by May 1 of each year a listing of nursing facilities that have met the standard.
	(3)	Nursing hours provided.
	1.	Standard. A nursing facility’s per resident day nursing hours are at or above the fiftieth percentile of per resident day nursing hours. Nursing hours include those of registered nurses, licensed practical nurses, certified nursing assistants, rehabilitation nurses and other contracted nursing services. Nursing hours shall be normalized to remove variations in staff hours associated with different levels of resident case mix. The case-mix index used to normalize nursing hours shall be the facility cost report period case-mix index.
	2.	Measurement period. The measurement period shall be calculated using the latest financial and statistical report with a fiscal year end of December 31 or earlier.
	3.	Value. 1 point for a nursing facility that falls between the fiftieth and seventy-fifth percentiles. 2 points for a nursing facility at or above the seventy-fifth percentile.
	4.	Source. The fiscal consultant shall calculate whether the nursing facility has met this measure from Form 470-0030, Financial and Statistical Report.
	(4)	Resident satisfaction.
	1.	Standard. A nursing facility shall be at or above the fiftieth percentile of resident satisfaction. Resident satisfaction shall be measured using Form 470-3890, Resident Opinion Survey. To be considered for this measure, a nursing facility must have a minimum survey response rate of 35 percent from its residents or their responsible parties.
	2.	Measurement period. For purposes of determining the July 1, 2002, rate, Form 470-3890, Resident Opinion Survey, must be completed by April 1, 2002, and Form 470-3891, Resident Opinion Survey Transmittal Report, must be submitted to the department by May 1, 2002. For purposes of determining rates for years on or after July 1, 2003, Form 470-3890, Resident Opinion Survey, may be completed anytime during the period September through December of the preceding year and the transmittal report submitted to the department by April 1 of the following year.
	3.	Value. 1 point.
	4.	Source. The nursing facility shall distribute Form 470-3890, Resident Opinion Survey, and instructions to all residents or their responsible parties. The nursing facility shall have an independent party collect and compile the results of the survey and communicate the results to the department by May 1 of 2002 and April 1 of each year thereafter on Form 470-3891, Resident Opinion Survey Transmittal Report. The department or its contractor shall calculate whether the nursing facility has met this measure.
	(5)	Resident advocate committee resolution rate.
	1.	Standard. A nursing facility shall have a resident advocate committee resolution rate of issues and grievances pursuant to 321—Chapter 9 at or above 60 percent.
	2.	Measurement period. For the purpose of determining the July 1, 2002, rates, the resolution rate shall be computed for the period October 1, 2001, through March 31, 2002. For the purpose of determining rates for July 1, 2003, and thereafter, the resident advocate committee resolution rate shall be computed using data from the immediately preceding calendar year.
	3.	Value. 1 point.
	4.	Source. The department shall request that the office of the long-term care ombudsman furnish by May 1 of each year a listing of nursing facilities that have met the standard.
	(6)	High employee retention rate.
	1.	Standard. A nursing facility shall have an employee retention rate at or above the fiftieth percentile.
	2.	Measurement period. The high employee retention rate shall be calculated using Schedule I of the latest Form 470-0030, Financial and Statistical Report, with a fiscal year end of December 31 or earlier.
	3.	Value. 1 point.
	4.	Source. The department’s fiscal consultant shall calculate whether the nursing facility has met this measure from Form 470-0030, Financial and Statistical Report, Schedule I.
	(7)	High occupancy rate.
	1.	Standard. A nursing facility shall have an occupancy rate at or above 95 percent. “Occupancy rate” is defined as the percentage derived when dividing total patient days based on census logs by total bed days available based on the number of authorized licensed beds within the facility.
	2.	Measurement period. The high occupancy rate shall be calculated using the latest Form 470-0030, Financial and Statistical Report, with a fiscal year end of December 31 or earlier.
	3.	Value. 1 point.
	4.	Source. The department’s fiscal consultant shall calculate whether the nursing facility has met this measure from Form 470-0030, Financial and Statistical Report.
	(8)	Low administrative costs.
	1.	Standard. A nursing facility’s percentage of administrative costs to total costs shall be at or below the fiftieth percentile.
	2.	Measurement period. The low administrative costs shall be calculated using the latest Form 470-0030, Financial and Statistical Report, with a fiscal year end of December 31 or earlier.
	3.	Value. 1 point.
	4.	Source. The department’s fiscal consultant shall calculate whether the nursing facility has met this measure from Form 470-0030, Financial and Statistical Report.
	(9)	Special licensure classification.
	1.	Standard. Nursing facility units shall be licensed for the care of residents with chronic confusion or a dementing illness (CCDI units).
	2.	Measurement period. The measurement period shall be the facility’s status on December 31 of each year.
	3.	Value. 1 point.
	4.	Source. The department shall request that the department of inspections and appeals furnish the department by May 1 of each year a listing of nursing facilities that were licensed as CCDI units as of December 31.
	(10)	High Medicaid utilization.
	1.	Standard. A nursing facility shall have Medicaid utilization at or above the fiftieth percentile. Medicaid utilization is determined by dividing total nursing facility Medicaid days by total nursing facility patient days.
	2.	Measurement period. The Medicaid utilization rate shall be calculated using the latest Form 470-0030, Financial and Statistical Report, with a fiscal year end of December 31 or earlier.
	3.	Value. 1 point.
	4.	Source. The department’s fiscal consultant shall calculate whether the nursing facility has met this measure from Form 470-0030, Financial and Statistical Report.
	(11)	Calculation of potential reimbursement. The number of points awarded shall be determined annually on the first day of the state fiscal year and shall be used to calculate the amount of the additional reimbursement for accountability measures as follows:

0 - 2 points	No additional reimbursement	
3 - 4 points	1 percent of the direct care plus non-direct care cost component patient-day-weighted medians multiplied by 80 percent, subject to reduction as provided in subparagraph (12)	
5 - 6 points	2 percent of the direct care plus non-direct care cost component patient-day-weighted medians multiplied by 80 percent, subject to reduction as provided in subparagraph (12)	
7 or more points	3 percent of the direct care plus non-direct care cost component patient-day-weighted medians multiplied by 80 percent, subject to reduction as provided in subparagraph (12)	
	(12)	Reduction of additional reimbursement. The additional reimbursement for accountability measures calculated according to subparagraph (11) shall be subject to reduction as follows:
	1.	A facility’s additional reimbursement shall be reduced by 25 percent for each citation received during the year for a deficiency resulting in actual harm at a scope and severity level of G pursuant to the federal certification guidelines.
	2.	If the facility fails to cure a cited level G deficiency within the time allowed by the department of inspections and appeals, the additional reimbursement shall be forfeited and the facility shall not receive any accountability measure payment for the year.
	3.	If a facility receives a citation for a deficiency resulting in actual harm or immediate jeopardy at a scope and severity level of H or higher pursuant to the federal certification guidelines, regardless of the amount of any fines assessed, the additional reimbursement shall be forfeited and the facility shall not receive any accountability measure payment for the year.
	(13)	Report of deficiencies. The department shall request that the department of inspections and appeals furnish by September 1, December 1, March 1 and August 1 of each year a list of nursing facilities subject to a reduction of the additional reimbursement for accountability measures pursuant to the criteria in subparagraph (12).
	(14)	Application of additional payments. The additional reimbursement for accountability measures shall be paid to qualifying facilities at the end of the state fiscal year. At the end of each state fiscal year, the Iowa Medicaid enterprise shall:
	1.	Retroactively adjust each qualifying facility’s quarterly rates to the first day of the state fiscal year to include the amount of additional reimbursement for accountability measures calculated according to 81.6(16)“g”; and
	2.	Reprice all facility claims with dates of service during the period in which an additional reimbursement for accountability measures is effective to reflect the adjusted reimbursement rate.
	h. 	Capital cost per diem instant relief add-on and enhanced non-direct care rate component limit. Contingent upon approval from the Centers for Medicare and Medicaid Services (CMS) and to the extent that funding is appropriated by the Iowa general assembly, additional reimbursement is available for nursing facilities that have completed a complete replacement, new construction, or major renovations. Additional reimbursement under this paragraph is available for services rendered beginning on October 1, 2007, or beginning on the effective date of CMS approval if CMS approval is effective on a later date.
	(1)	Types of additional reimbursement. Two types of additional reimbursement are available:
	1.	The capital cost per diem instant relief add-on is an amount per patient day to be added to the non-direct care component of the reimbursement rate and is subject to the non-direct care rate component limit as determined in paragraph “f.”
	2.	The enhanced non-direct care rate component limit provides an increase in the percentage of the median that is applied when calculating the non-direct care rate component limit as defined in paragraph “f.” The percentage of the median is increased to 120 percent when the enhanced non-direct care rate component limit is granted.
	(2)	Eligible projects. To qualify for either the capital cost per diem instant relief add-on or the enhanced non-direct care rate component limit, a facility must have undertaken a complete replacement, new construction, or major renovations for the purpose of:
	1.	Rectification of a violation of Life Safety Code requirements; or
	2.	Development of home- and community-based waiver program services.
	(3)	Additional requirements for all requests. To qualify for additional reimbursement, a facility with an eligible project must also meet the following requirements:
	1.	The facility has Medicaid utilization at or above 40 percent for the two-month period before the request for additional reimbursement is submitted. Medicaid utilization for this purpose is calculated as total nursing facility Medicaid patient days divided by total licensed bed capacity as reported on the facility’s most current financial and statistical report.
	2.	The facility meets the accountability measure criteria set forth in paragraph “g,” subparagraph (1), deficiency-free survey, or subparagraph (2), regulatory compliance with survey, based on the most current information available when the request for additional reimbursement is submitted.
	3.	The facility has documented active participation in a quality of care program.
	4.	The facility has documented plans to facilitate person-directed care, dementia units, or specialty post-acute services.
	(4)	Additional requirements for waiver services. To qualify for additional reimbursement for the development of home- and community-based waiver services, the facility shall also meet the following requirements:
	1.	Services shall be provided in an underserved area, which may include a rural area.
	2.	Services shall be provided on the direct site of the facility but not as a nursing facility service.
	3.	Services shall meet all federal and state requirements for Medicaid reimbursement.
	4.	Services shall include one or more of the following: adult day care as defined by 441—subrule 78.37(1), consumer-directed attendant care as defined by 441—subrule 78.37(15) provided in an assisted living setting, day habilitation as defined by 441—subrule 78.41(14), home-delivered meals as defined by 441—subrule 78.37(8), emergency response system as defined by 441—subrule 78.37(2), and respite care as defined by 441—subrule 78.37(6).
	(5)	Submission of request. A facility shall submit a written request for the capital cost per diem instant relief add-on, the enhanced non-direct care rate component limit, or a preliminary evaluation of whether a project may qualify for additional reimbursement to the Iowa Medicaid Enterprise, Provider Cost Audit and Rate Setting Unit, 100 Army Post Road, Des Moines, Iowa 50315. A qualifying facility may request one or both types of additional reimbursement.
	1.	A request for the capital cost per diem instant relief add-on may be submitted no earlier than 30 days before the complete replacement, new construction, or major renovations are placed in service.
	2.	A request for the enhanced non-direct care rate component limit may be submitted with a request for a capital cost per diem instant relief add-on or within 60 days after the release of a rate determination letter reflecting a change in the non-direct care rate component limit.
	3.	A request for a preliminary evaluation may be submitted when a facility is preparing a feasibility projection for a construction or renovation project. A preliminary evaluation does not guarantee approval of the capital cost per diem instant relief add-on or enhanced non-direct care rate component limit upon submission of a formal request.
	(6)	Content of request for add-on. A facility’s request for the capital cost per diem instant relief add-on shall include:
	1.	A description of the project for which the add-on is requested, including a list of goals for the project and a time line of the project that spans the life of the project.
	2.	Documentation that the facility meets the qualifications in subparagraphs (2) and (3) and, if applicable, in subparagraph (4).
	3.	The period during which the add-on is requested (no more than two years).
	4.	Whether the facility is also requesting the enhanced non-direct care rate component limit. (See subparagraph (7) for requirements.)
	5.	A copy of the facility’s most current depreciation schedule which clearly identifies the cost of the project for which the add-on is requested if assets placed in service by that project are included on the schedule. Any removal of assets shall be clearly identifiable either on the depreciation schedule or on a separate detailed schedule, and that schedule shall include the amount of depreciation expense for removed assets that is included in the current reimbursement rate.
	6.	If the cost of the project is not reported on the submitted depreciation schedule, a detailed schedule of the assets to be placed in service by the project, including:
	●	The estimated date the assets will be placed into service;
	●	The total estimated depreciable value of the assets;
	●	The estimated useful life of the assets based upon existing Medicaid and Medicare provisions; and
	●	The estimated annual depreciation expense of the assets using the straight-line method in accordance with generally accepted accounting principles.
7. The facility’s estimated annual licensed bed capacity and estimated annual total patient days. If this information is not provided, estimated annual total patient days shall be determined using the most current submitted financial and statistical report.
	8.	If interest expense has been or will be incurred and is related to the project for which the add-on is requested, a copy of the general terms of the debt service and the estimated annual amount of interest expense shall be submitted.
	9.	If any debt service has been retired, a copy of the general terms of the debt service and the amount of interest expense for debt service retired that is included in the current reimbursement rate.
	(7)	Content of request for enhanced limit. A facility’s request for the enhanced non-direct care rate component limit shall include:
	1.	A description of the project for which the enhanced non-direct care rate component limit is requested, including a list of goals for the project and a time line of the project that spans the life of the project.
	2.	Documentation that the facility meets the qualifications in subparagraphs (2) and (3) and, if applicable, in subparagraph (4).
	3.	Identification of any period in which the capital cost per diem instant relief add-on was previously granted and the number of times the capital cost per diem instant relief add-on and the enhanced non-direct care rate component limit have previously been granted.
	(8)	Content of request for preliminary evaluation. A facility’s request for a preliminary evaluation of a proposed project shall include:
	1.	The estimated completion date of the project.
	2.	The estimated date when a formal request for an add-on or enhanced limit will be submitted.
	3.	For a preliminary evaluation for a capital cost per diem instant relief add-on, all information required in subparagraph (6).
	4.	For a preliminary evaluation for the enhanced non-direct care rate component limit, all information required in subparagraph (7).
	(9)	Calculation of capital cost per diem instant relief add-on. The capital cost per diem instant relief add-on is calculated by dividing the annual estimated property costs for the complete replacement, new construction, or major renovation project for which the add-on is granted by the facility’s estimated annual total patient days.
	1.	Total patient days shall be determined using the most current submitted financial and statistical report or using the estimated total patient days as reported in the request for the add-on. For purposes of calculating the add-on, total patient days shall be the greater of the estimated annual total patient days or 90 percent of the facility’s estimated licensed capacity.
	2.	The annual estimated property costs for the project are calculated as the estimated annual depreciation expense for the cost of the project, plus estimated annual interest expense for the cost of the project, less the amount of depreciation expense for assets removed that is included in the current reimbursement rate and the amount of interest expense for debt service retired that is included in the current reimbursement rate.
	3.	A reconciliation between the estimated amounts and actual amounts shall be completed as described in subparagraph (12).
	(10)	Effective date of capital cost per diem instant relief add-on. Subject to available funding and previously approved requests for capital cost per diem instant relief add-ons and enhanced non-direct care rate component limits, a capital cost per diem instant relief add-on shall be effective the first day of the calendar quarter following the placement in service of the assets associated with the add-on and receipt of all required information. The capital cost per diem instant relief add-on shall be added to the non-direct care component of the reimbursement rate, not to exceed the non-direct care rate component limit as determined in paragraph “f.”
	(11)	Term of capital cost per diem instant relief add-on. The period for which a facility may be granted the capital cost per diem instant relief add-on shall not exceed two years. The capital cost per diem instant relief add-on shall terminate at the time of the subsequent biennial rebasing. If the facility’s submitted annual financial and statistical report used in the subsequent biennial rebasing does not include 12 months of property costs for the assets with which the capital cost per diem instant relief add-on is associated, including interest expense, if applicable, the facility may submit a new request for the capital cost per diem instant relief add-on.
	(12)	Reconciliation of capital cost per diem instant relief add-on. During the period in which the capital cost per diem instant relief add-on is granted, the Iowa Medicaid enterprise shall recalculate the amount of the add-on based on actual allowable costs and patient days reported on the facility’s submitted annual financial and statistical report. A separate reconciliation shall be performed for each cost report period in which the capital cost per diem instant relief add-on was paid. The facility shall submit with the annual financial and statistical report a separate schedule reporting total patient days per calendar quarter and a current depreciation schedule identifying the assets related to the add-on.
	1.	For purposes of recalculating the capital cost per diem instant relief add-on, total patient days shall be based on the greater of the number of actual patient days during the period in which the add-on was paid or 90 percent of the facility’s actual licensed bed capacity during the period in which the add-on was paid.
	2.	The recalculated capital cost per diem instant relief add-on shall be added to the non-direct care component of the reimbursement rate for the relevant period, not to exceed the non-direct care rate component limit as determined in paragraph “f.” The facility’s quarterly rates for the relevant period shall be retroactively adjusted to reflect the recalculated non-direct care component of the reimbursement rate. All claims with dates of service during the period the capital cost per diem instant relief add-on is paid shall be repriced to reflect the recalculated capital cost per diem instant relief add-on.
	(13)	Effective date of enhanced non-direct care rate component limit. Subject to available funding and previously approved requests for capital cost per diem instant relief add-ons and enhanced non-direct care rate component limits, an enhanced non-direct care rate component limit shall be effective:
	1.	With a capital cost per diem instant relief add-on (if requested at the same time); or
	2.	Retroactive to the first day of the quarter in which the revised non-direct care rate component limit amount is effective. All claims with dates of service from the effective date shall be repriced.
	(14)	Term of enhanced non-direct care rate component limit. The period for which a facility may be granted an enhanced non-direct care rate component limit without reapplication shall not exceed two years. The total period for which a facility may be granted enhanced non-direct care rate component limits shall not exceed ten years. If the amount of the non-direct care rate component limit is revised during the period for which a facility is granted the enhanced limit, the approval shall be terminated effective the first day of the quarter in which the revised non-direct care rate component limit is effective. The facility may submit a new request for the enhanced non-direct care rate component limit.
	(15)	Ongoing conditions. Any capital cost per diem instant relief add-on or enhanced non-direct care rate component limit granted by the Iowa Medicaid enterprise is temporary. Additional reimbursement shall be immediately terminated if:
	1.	The facility does not continue to meet all of the initial qualifications for additional reimbursement; or
	2.	The facility does not make reasonable progress on any plans required for initial qualification; or
	3.	The facility’s medical assistance program or Medicare certification is revoked. A facility whose certification is revoked is not eligible to submit a subsequent request for a capital cost per diem instant relief add-on or the enhanced non-direct care rate component limit.
	(16)	Change of ownership. Following a change in nursing facility ownership, any capital cost per diem instant relief add-on or enhanced non-direct care rate component limit that was granted before the change in ownership shall continue under the new owner. Future reimbursement rates shall be determined pursuant to subrules 81.6(15) and 81.6(16).
	81.6(17) Cost report documentation. All nursing facilities, except the Iowa Veterans Home, shall submit an annual cost report based on the closing date of the facility’s fiscal year that incorporates documentation as set forth below. The Iowa Veterans Home shall submit semiannual cost reports based on the closing date of the facility’s fiscal year and the midpoint of the facility’s fiscal year that incorporate documentation as set forth below. The documentation incorporated in all cost reports shall include all of the following information:
	a. 	Information on staffing costs, including the number of hours of the following provided per resident per day by all the following: nursing services provided by registered nurses, licensed practical nurses, certified nurse aides, restorative aides, certified medication aides, and contracted nursing services; other care services; administrative functions; housekeeping and maintenance; and dietary services.
	b. 	The starting and average hourly wage for each class of employees for the period of the report.
	c. 	An itemization of expenses attributable to the home or principal office or headquarters of the nursing facility included in the administrative cost line item.
	81.6(18) Inflation factor. The department shall consider an inflation factor in determining the reimbursement rate. The inflation factor shall be based on the CMS Total Skilled Nursing Facility (CMS/SNF) Market Basket Index published by Data Resources, Inc.	The CMS/SNF index listed in the latest available quarterly publication prior to the July 1 rate setting shall be used to determine the inflation factor.
	81.6(19) Case-mix index calculation.
	a. 	The Resource Utilization Groups-III (RUG-III) Version 5.12b, 34 group, index maximizer model shall be used as the resident classification system to determine all case-mix indices, using data from the minimum data set (MDS) submitted by each facility pursuant to subrule 81.13(9). Standard Version 5.12b case-mix indices developed by CMS shall be the basis for calculating the average case-mix index and shall be used to adjust the direct care costs in the determination of the direct care patient-day-weighted median and the reimbursement rate pursuant to subrule 81.6(16).
	b. 	Each resident in the facility on the last day of each calendar quarter with a completed and submitted assessment shall be assigned a RUG-III 34 group calculated on the resident’s most current assessment available on the last day of each calendar quarter. This RUG-III group shall be translated to the appropriate case-mix index referenced in paragraph “a.” From the individual resident case-mix indices, two average case-mix indices for each Medicaid nursing facility shall be determined four times per year based on the last day of each calendar quarter.
The facilitywide average case-mix index is the simple average, carried to four decimal places, of all resident case-mix indices. The Medicaid average case-mix index is the simple average, carried to four decimal places, of all indices for residents where Medicaid is known to be the per diem payor source on the last day of the calendar quarter. Assessments that cannot be classified to a RUG-III group due to errors shall be excluded from both average case-mix index calculations.
	81.6(20) Medicare crossover claims for nursing facility services.
	a. 	Definitions. For purposes of this subrule:
“Crossover claim” means a claim for Medicaid payment for Medicare-covered nursing facility services rendered to a Medicare beneficiary who is also eligible for Medicaid. Crossover claims include claims for services rendered to beneficiaries who are eligible for Medicaid in any category including, but not limited to, qualified Medicare beneficiaries and beneficiaries who are eligible for full Medicaid coverage.
“Medicaid-allowed amount” means the Medicaid reimbursement rate for the services rendered (including any portion to be paid by the Medicaid beneficiary as client participation) multiplied by the number of Medicaid units of service included in a crossover claim, as determined under state and federal law and policies.
“Medicaid reimbursement” includes any amount to be paid by the Medicaid beneficiary as Medicaid client participation and any amount to be paid by the department after application of any applicable Medicaid client participation.
“Medicare payment amount” means the Medicare reimbursement rate for the services rendered multiplied by the number of Medicare units of service included in a crossover claim, excluding any Medicare coinsurance or deductible amounts to be paid by the Medicare beneficiary.
	b. 	Crossover claims. Crossover claims for services covered under Medicare Part A and under Medicaid are reimbursed as set out in this paragraph.
	(1)	If the Medicare payment amount for a crossover claim exceeds or equals the Medicaid-allowed amount for that claim, Medicaid reimbursement for the crossover claim will be zero.
	(2)	If the Medicaid-allowed amount for a crossover claim exceeds the Medicare payment amount for that claim, Medicaid reimbursement for the crossover claim is the lesser of:
	1.	The Medicaid-allowed amount minus the Medicare payment amount; or
	2.	The Medicare coinsurance and deductible amounts applicable to the claim.
	c. 	Additional Medicaid payment for crossover claims uncollectible from Medicare. Medicaid shall reimburse nursing facilities for the portion of crossover claims not covered by Medicaid reimbursement pursuant to paragraph “b” and not reimbursable by Medicare as an allowable bad debt pursuant to 42 CFR 413.80, as amended June 13, 2001, up to a limit of 30 percent of the amount not paid by Medicaid pursuant to paragraph “b.” The department shall calculate these amounts for each provider on a calendar-year basis and make payment for these amounts by March 31 of each year for the preceding calendar year or by a mutually acceptable schedule consistent with Medicare interim payment schedules.
	d. 	Application of savings. Effective May 1, 2003, savings in Medicaid reimbursements attributable to the limits on nursing facility crossover claims established by this subrule shall be used to pay costs associated with development and implementation of this subrule before reversion to Medicaid.
	81.6(21) Nursing facility quality assurance payments.
	a. 	Quality assurance assessment pass-through. Effective with the implementation of the quality assurance assessment paid pursuant to 441—Chapter 36, Division II, a quality assurance assessment pass-through shall be added to the Medicaid per diem reimbursement rate as otherwise calculated pursuant to this rule. The quality assurance assessment pass-through shall equal the per-patient-day assessment determined pursuant to 441—subrule 36.6(2).
	b. 	Quality assurance assessment rate add-on. Effective with the implementation of the quality assurance assessment paid pursuant to 441—Chapter 36, Division II, a quality assurance add-on of $10 per patient day shall be added to the Medicaid per diem reimbursement rate as otherwise calculated pursuant to this rule.
	c. 	Use of the pass-through and add-on. As a condition for receipt of the pass-through and add-on, each nursing facility shall submit information to the department on Form 470-4829, Nursing Facility Medicaid Enhanced Payment Report, demonstrating compliance by the nursing facility with the requirements for use of the pass-through and add-on. If the sum of the quality assurance assessment pass-through and the quality assurance assessment rate add-on is greater than the total cost incurred by a nursing facility in payment of the quality assurance assessment:
	(1)	No less than 35 percent of the difference shall be used to increase compensation and costs of employment for direct care workers determined pursuant to 2009 Iowa Acts, Senate File 476.
	(2)	No less than 60 percent of the difference shall be used to increase compensation and costs of employment for all nursing facility staff, with increases in compensation and costs of employment determined pursuant to 2009 Iowa Acts, Senate File 476.
	d. 	Effective date. Until federal financial participation to match money collected from the quality assurance assessment pursuant to 441—Chapter 36, Division II, has been approved by the federal Centers for Medicare and Medicaid Services, none of the nursing facility rate-setting methodologies of this subrule shall become effective.
	e. 	End date. If the federal Centers for Medicare and Medicaid Services determines that federal financial participation to match money collected from the quality assurance assessment pursuant to 441—Chapter 36, Division II, is unavailable for any period, or if the department no longer has the authority to collect the assessment, then beginning on the effective date that such federal financial participation is not available or authority to collect the assessment is rescinded, none of the nursing facility rate-setting methodologies of this subrule shall be effective. If the period for which federal match money is unavailable or the authority to collect the assessment is rescinded includes a retroactive period, the department shall:
	(1)	Recalculate Medicaid rates in effect during that period without the rate-setting methodologies of this subrule;
	(2)	Recompute Medicaid payments due based on the recalculated Medicaid rates;
	(3)	Recoup any previous overpayments; and
	(4)	Determine for each nursing facility the amount of quality assurance assessment collected during that period and refund that amount to the facility.
This rule is intended to implement Iowa Code sections 249A.2(7), 249A.3(2)“c,” 249A.4, and 249A.16, chapter 249K, and 2009 Iowa Acts, Senate File 476.
[ARC 8258B, IAB 11/4/09, effective 1/1/10; ARC 8344B, IAB 12/2/09, effective 12/1/09]
441—81.7(249A) Continued review. The Iowa Foundation for Medical Care shall review Medicaid recipients’ need of continued care in nursing facilities, pursuant to the standards and subject to the reconsideration and appeals processes in subrule 81.3(1).
This rule is intended to implement Iowa Code sections 249A.2(6) and 249A.3(2)“a.”
441—81.8(249A) Quality of care review. Rescinded IAB 8/8/90, effective 10/1/90.
441—81.9(249A) Records.
	81.9(1) Content. The facility shall as a minimum maintain the following records:
	a. 	All records required by the department of public health and the department of inspections and appeals.
	b. 	Records of all treatments, drugs, and services for which vendors’ payments have been made or are to be made under the medical assistance program, including the authority for and the date of administration of the treatment, drugs, or services.
	c. 	Documentation in each resident’s records which will enable the department to verify that each charge is due and proper prior to payment.
	d. 	Financial records maintained in the standard, specified form including the facility’s most recent audited cost report.
	e. 	All other records as may be found necessary by the department in determining compliance with any federal or state law or rule or regulation promulgated by the United States Department of Health and Human Services or by the department.
	f. 	Census records to include the date, number of residents at the beginning of each day, names of residents admitted, and names of residents discharged.
	(1)	Census information shall be provided for all residents of the facility.
	(2)	Census figures for each type of care shall be totaled monthly to indicate the number admitted, the number discharged, and the number of patient days.
	(3)	Failure to maintain acceptable census records shall result in the per diem rate being computed on the basis of 100 percent occupancy and a request for refunds covering indicated recipients of nursing care which have not been properly accounted for.
	g. 	Resident accounts.
	h. 	In-service education program records.
	i. 	Inspection reports pertaining to conformity with federal, state and local laws.
	j. 	Residents’ personal records.
	k. 	Residents’ medical records.
	l. 	Disaster preparedness reports.
	81.9(2) Retention. Records identified in subrule 81.9(1) shall be retained in the facility for a minimum of five years or until an audit is performed on those records, whichever is longer.
	81.9(3) Change of owner. All records shall be retained within the facility upon change of ownership.
This rule is intended to implement Iowa Code sections 249A.2(6) and 249A.3(2)“a.”
441—81.10(249A) Payment procedures.
	81.10(1) Method of payment. Except for Medicaid accountability measures payment established in paragraph 81.6(16)“g,” facilities shall be reimbursed under a modified price-based vendor payment program. A per diem rate shall be established based on information submitted according to rule 441—81.6(249A). Effective July 1, 2002, the per diem rate shall include an amount for Medicaid accountability measures.
	81.10(2) Authorization of payment. The department shall authorize payment for care in a facility. The authorization shall be obtained prior to admission of the resident, whenever possible. For a nursing facility to be eligible for Medicaid payment for a resident, the facility must, when applicable, exhaust all Medicare benefits.
	81.10(3) Rescinded IAB 8/9/89, effective 10/1/89.
	81.10(4) Periods authorized for payment.
	a. 	Payment shall be made on a per diem basis for the portion of the month the resident is in the facility.
	b. 	Payment will be authorized as long as the resident is certified as needing care in a nursing facility.
	c. 	Payment will be approved for the day of admission but not the day of discharge or death.
	d. 	Payment will be approved for periods the resident is absent overnight for purpose of visitation or vacation. The facility will be paid to hold the bed for a period not to exceed 18 days in any calendar year. Additional days shall be based upon a recommendation by the resident’s physician in the plan of care that additional days would be rehabilitative.
	e. 	Payment will be approved for a period not to exceed 10 days in any calendar month when the resident is absent due to hospitalization. Medicaid payment to the facility may not be initiated while a resident is on reserve bed days unless the person was residing in the facility as a private pay resident prior to the hospitalization and returns to the facility as a resident.
	f. 	Payment for periods when residents are absent for a visit shall be made at 42 percent of the nursing facility’s rate. Payment for periods when residents are absent for hospitalization shall:
	(1)	Be made at 25 percent of the nursing facility’s rate if the facility occupancy percentage is 95 percent or greater.
	(2)	Not be made if a facility’s occupancy percentage is less than 95 percent.
	(3)	Be made at 42 percent of the nursing facility’s rate for special population facilities.
	g. 	Payment for residents determined by utilization review to require the residential level of care shall be made at the maximum state supplementary assistance rate. This rate is effective as of the date of final notice by utilization review that the lower level of care is required.
	h. 	In-state nursing facilities serving Medicaid eligible patients who require a ventilator at least six hours every day, are inappropriate for home care, and have medical needs that require skilled care as determined by the peer review organization shall receive reimbursement for the care of these patients equal to the sum of the Medicare-certified hospital-based nursing facility direct care rate component limit plus the Medicare-certified hospital-based nursing facility non-direct care rate component limit factor pursuant to subparagraph 81.6(16)“f”(3). Facilities may continue to receive reimbursement at this rate for 30 days for any person weaned from a respirator who continues to reside in the facility and continues to meet skilled care criteria for those 30 days.
	81.10(5) Supplementation. Only the amount of client participation may be billed to the resident for the cost of care and the facility must accept the combination of client participation and payment made through the Iowa Medicaid program as payment in full for the care of a resident. No additional charges shall be made to residents or family members for any supplies or services required in the facility-developed plan of care for the resident.
Residents may choose to spend their personal funds on items of personal care such as professional beauty or barber services but the facility shall not require this expenditure and shall not routinely obligate residents to any use of their personal funds.
	a. 	Supplies or services which the facility shall provide:
	(1)	Nursing services, social work services, activity programs, individual and group therapy, rehabilitation or habilitation programs provided by facility staff in order to carry out the plan of care for the resident.
	(2)	Services related to the nutrition, comfort, cleanliness and grooming of a resident as required under state licensure and Medicaid survey regulations.
	(3)	Medical equipment and supplies including wheelchairs, medical supplies except for those listed in 441—paragraph 78.10(4)“b,” oxygen except under circumstances specified in 441—paragraph 78.10(2)“a,” and other items required in the facility-developed plan of care.
	(4)	Nonprescription drugs ordered by the physician except for those specified in 441—78.1(2)“f.”
	(5)	Fees charged by medical professionals for services requested by the facility which do not meet criteria for direct Medicaid payment.
	b. 	The facility shall arrange for transportation to receive necessary medical services outside the facility. If a family member, friend, or volunteer is not available to provide the transportation at no charge, the facility shall arrange and pay for the medically necessary transportation.
	c. 	The Medicaid program will provide direct payment to relieve the facility of payment responsibility for certain medical equipment and services which meet the Medicare definition of medical necessity and are provided by vendors enrolled in the Medicaid programs including:
	(1)	Physician services.
	(2)	Ambulance services.
	(3)	Hospital services.
	(4)	Hearing aids, braces and prosthetic devices.
	(5)	Therapy services.
	d. 	Other supplies or services for which direct Medicaid payment may be available include:
	(1)	Drugs covered pursuant to 441—78.1(2).
	(2)	Dental services.
	(3)	Optician and optometrist services.
	(4)	Repair of medical equipment and appliances which belong to the resident.
	(5)	Transportation to receive medical services outside the community subject to limitations specified in rule 441—78.13(249A).
	(6)	Other medical services specified in 441—Chapter 78.
	e. 	The following supplementation is permitted:
	(1)	The resident, the resident’s family, or friends may pay to hold the resident’s bed in cases where a resident who is not discharged from the facility spends over 18 days per year on visits (or longer under 81.10(4)“d”) or spends over 10 days per calendar month on a hospital stay. These supplementation payments shall not exceed the amount the department would pay to hold the bed under paragraph 81.10(4)“f.”
When the resident is discharged, the facility may handle the holding of the bed in the same manner as for a private paying resident.
	(2)	Payments made by the resident’s family toward cost of care of the resident shall not be considered as supplementation so long as the payments are included in client participation and are not over and above the payment made by the state for care of the resident.
	(3)	If a physician does not order a nonprescription drug by brand name, the facility may offer a generic. If a resident or family member requests a brand name, the resident or family member may pay for the brand-name nonprescription drug.
	81.10(6) Payment for out-of-state care. Rescinded IAB 9/5/90, effective 11/1/90.
	81.10(7) Comparative charges between private pay and Medicaid residents. Rescinded IAB 2/6/02, effective 4/1/02.
[ARC 8344B, IAB 12/2/09, effective 12/1/09]
441—81.11(249A) Billing procedures.
	81.11(1) Claims. Claims for service must be sent to the Iowa Medicaid enterprise after the month of service and within 365 days of the date of service. Claims may be submitted electronically on software provided by the Iowa Medicaid enterprise or in writing on Form 470-0039.
	a. 	When payment is made, the facility will receive a copy of Form 470-0039, Iowa Medicaid Long-Term Care Claim. The white copy of the form shall be signed and returned to the Iowa Medicaid enterprise as a claim for the next month. If the claim is submitted electronically, the facility will receive remittance advice of the claims paid.
	b. 	When there has been a new admission or a discharge, the facility shall submit Form 470-0039 with the changes noted. When a change is necessary to adjust a previously paid claim, the facility shall submit Form 470-0040, Credit/Adjustment Request. Adjustments to electronically submitted claims may be made electronically as provided for by the Iowa Medicaid enterprise. A request for an adjustment to a paid claim must be received by the Iowa Medicaid enterprise within one year from the date the claim was paid in accordance with rule 441—80.4(249A).
	81.11(2) Reserved.
This rule is intended to implement Iowa Code sections 249A.2(6) and 249A.3(2)“a.”
441—81.12(249A) Closing of facility. When a facility is planning on closing, the department shall be notified at least 60 days in advance of the closing. Plans for the transfer of residents receiving medical assistance shall be approved by the local office of the department.
This rule is intended to implement Iowa Code sections 249A.2(6) and 249A.3(2)“a.”
441—81.13(249A) Conditions of participation for nursing facilities. All nursing facilities shall enter into a contractual agreement with the department which sets forth the terms under which they will participate in the program.
	81.13(1) Procedures for establishing health care facilities as Medicaid facilities. All survey procedures and certification process shall be in accordance with Department of Health and Human Services publication “State Operations Manual.”
	a. 	The facility shall obtain the applicable license from the department of inspections and appeals and must be recommended for certification by the department of inspections and appeals.
	b. 	The facility shall request an application, Form 470-0254, Iowa Medicaid Provider Enrollment Application, from the Iowa Medicaid enterprise provider services unit.
	c. 	The Iowa Medicaid enterprise provider services unit shall transmit an application form and a copy of the nursing facility provider manual to the facility.
	d. 	The facility shall complete its portion of the application form and submit it to the Iowa Medicaid enterprise provider services unit.
	e. 	The Iowa Medicaid enterprise provider services unit shall review the application form and verify with the department of inspections and appeals that the facility is licensed and has been recommended for certification.
	f. 	Prior to requesting enrollment, the facility shall contact the department of inspections and appeals to schedule a survey. The department of inspections and appeals shall schedule and complete a survey of the facility.
	g. 	The department of inspections and appeals shall notify the facility of any deficiencies and ask for a plan for the correction of the deficiencies.
	h. 	The facility shall submit a plan of correction within ten days after receipt of written deficiencies from the health facilities division department of inspections and appeals. This plan must be approved before the facility can be certified.
	i. 	The department of inspections and appeals shall evaluate the survey findings and plan of correction and either recommend the facility for certification or recommend denial of certification. The date of certification will be the date of approval of the plan of corrections.
	j. 	When certification is recommended, the department of inspections and appeals shall notify the department recommending a provider agreement.
	k. 	Rescinded IAB 12/6/95, effective 2/1/96.
	81.13(2) Medicaid provider agreements. The health care facility shall be recommended for certification by the department of inspections and appeals for participation as a nursing facility before a provider agreement may be issued. All survey procedures and certification process shall be in accordance with Department of Health and Human Services publication “Providers Certification State Operations Manual.” The effective date of a provider agreement may not be earlier than the date of certification.
	a. 	Rescinded IAB 2/3/93, effective 4/1/93.
	b. 	Rescinded IAB 2/3/93, effective 4/1/93.
	c. 	Rescinded IAB 2/3/93, effective 4/1/93.
	d. 	Rescinded IAB 2/3/93, effective 4/1/93.
	e. 	When it becomes necessary for the department to cancel or refuse to renew a Title XIX provider agreement, federal financial participation may continue for 30 days beyond the date of cancellation, if the extension is necessary to ensure the orderly transfer of residents.
	f. 	Rescinded IAB 2/3/93, effective 4/1/93.
	81.13(3) Distinct part requirement. All facilities which provide nursing facility care and also provide other types of care shall set aside a distinct or identifiable part for the provision of the nursing facility care.
	a. 	The distinct part shall meet the following conditions:
	(1)	The distinct part shall meet all requirements for a nursing facility.
	(2)	The distinct part shall be identifiable as a unit such as a designated group of rooms, an entire ward or contiguous wards, wings, floor, or building. It shall consist of all beds and related facilities in the unit for whom payment is being made for nursing facility services. It shall be clearly identified and licensed by the department of inspections and appeals.
	(3)	The appropriate personnel shall be assigned to the identifiable unit and shall work regularly therein. Immediate supervision of staff shall be provided in the unit at all times by qualified personnel as required for licensure.
	(4)	The distinct part may share such central services and facilities as management services, dietary services, building maintenance and laundry with other units.
	(5)	When members of the staff share time between units of the facility, written records shall be maintained of the time assigned to each unit.
	b. 	Hospitals participating as nursing facilities shall meet all of the same conditions applicable to freestanding nursing facilities.
	c. 	Nothing herein shall be construed as requiring transfer of a resident within or between facilities when in the opinion of the attending physician the transfer might be harmful to the physical or mental health of the resident. The opinion of the physician shall be recorded on the resident’s medical chart and stands as a continuing order unless the circumstances requiring the exception change.
	81.13(4) Civil rights. The nursing facility shall comply with Title VI of the Civil Rights Act of 1964 in all areas of administration including admissions, records, services and physical facilities, room assignments and transfers, attending physicians’ privileges and referrals. Written statements of compliance shall be available to residents, employees, attending physicians and other members of the public.
	81.13(5) Resident rights. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility shall protect and promote the rights of each resident, including each of the following rights:
	a. 	Exercise of rights.
	(1)	The resident has the right to exercise rights as a resident of the facility and as a citizen of the United States.
	(2)	The resident has the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights.
	(3)	In the case of a resident adjudged incompetent under the laws of a state, by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under state law to act on the resident’s behalf.
	(4)	In the case of a resident who has not been adjudged incompetent by the state court, any legal-surrogate designated in accordance with state law may exercise the resident’s rights to the extent provided by state law.
	b. 	Notice of rights and services.
	(1)	The facility shall inform the resident, both orally and in writing in a language that the resident understands, of the resident’s rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility shall also provide the resident with the pamphlet “Medicaid for People in Nursing Homes and Other Care Facilities,” Comm. 52. This notification shall be made prior to or upon admission and during the resident’s stay. Receipt of this information, and any amendments to it, must be acknowledged in writing.
	(2)	The resident or the resident’s legal representative has the right, upon an oral or written request, to access all records pertaining to the resident including clinical records within 24 hours (excluding weekends and holidays); and after receipt of the records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and two working days’ advance notice to the facility.
	(3)	The resident has the right to be fully informed in language that the resident can understand of the resident’s total health status, including, but not limited to, medical condition.
	(4)	The resident has the right to refuse treatment and to refuse to participate in experimental research.
	(5)	The facility shall:
	1.	Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or when the resident becomes eligible for Medicaid, of the items and services that are included in nursing facility services under the state plan and for which the resident may not be charged and of those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services.
	2.	Inform each resident when changes are made to the items and services specified in number “1” of this subparagraph.
	(6)	The facility shall inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility’s per diem rate.
	(7)	The facility shall furnish a written description of legal rights which includes:
	1.	A description of the manner of protecting personal funds.
	2.	A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment which determines the extent of a couple’s nonexempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse’s medical care in the resident’s process of spending down to Medicaid eligibility levels.
	3.	A posting of names, addresses, and telephone numbers of all pertinent state client advocacy groups such as the state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit.
	4.	A statement that the resident may file a complaint with the state survey and certification agency concerning resident abuse, neglect and misappropriation of resident property in the facility.
	(8)	The facility shall inform each resident of the name, specialty and way of contacting the physician responsible for the resident’s care.
	(9)	The facility shall prominently display in the facility written information and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by these benefits.
	(10)	Notification of changes.
	1.	A facility shall immediately inform the resident, consult with the resident’s physician, and, if known, notify the resident’s legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility.
	2.	The facility shall also promptly notify the resident and, if known, the resident’s legal representative or interested family member when there is a change in room or roommate assignment or a change in resident rights under federal or state law or regulations.
	3.	The facility shall record and periodically update the address and telephone number of the resident’s legal representative or interested family member.
	c. 	Protection of resident funds.
	(1)	The resident has the right to manage the resident’s financial affairs and the facility may not require residents to deposit their personal funds with the facility.
	(2)	Management of personal funds. Upon written authorization of a resident, the facility shall hold, safeguard, manage and account for the personal funds of the resident deposited with the facility, as specified in subparagraphs (3) to (8) of this paragraph.
	(3)	Deposit of funds. The facility shall deposit any residents’ personal funds in excess of $50 in an interest-bearing account that is separate from any of the facility’s operating accounts, and that credits all interest earned on the resident’s funds to that account. In pooled accounts, there must be a separate accounting for each resident’s share.
The facility shall maintain a resident’s personal funds that do not exceed $50 in a non-interest-bearing account, an interest-bearing account, or petty cash fund.
	(4)	Accounting and records. The facility shall establish and maintain a system that ensures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident’s personal funds entrusted to the facility on the resident’s behalf.
	1.	The system shall preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
	2.	The individual financial record shall be available through quarterly statements and on request to the resident or the resident’s legal representative.
	(5)	Notice of certain balances. The facility shall notify each resident that receives Medicaid benefits:
	1.	When the amount in the resident’s account reaches $200 less than the SSI resource limit for one person.
	2.	That, if the amount in the account, in addition to the value of the resident’s other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.
	(6)	Conveyance upon death. Upon the death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident’s funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident’s estate.
	(7)	Assurance of financial security. The facility shall purchase a surety bond, or otherwise provide assurance satisfactory to the department of inspections and appeals and the department of human services, to ensure the security of all personal funds of residents deposited with the facility.
	(8)	Limitation on charges to personal funds. The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare.
	d. 	Free choice. The resident has the right to:
	(1)	Choose a personal attending physician.
	(2)	Be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident’s well-being.
	(3)	Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the state, participate in planning care and treatment or changes in care and treatment.
	e. 	Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of personal and clinical records.
	(1)	Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room.
	(2)	Except as provided in subparagraph (3) below, the resident may approve or refuse the release of personal and clinical records to any person outside the facility.
	(3)	The resident’s right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution or record release is required by law.
	f. 	Grievances. A resident has the right to:
	(1)	Voice grievances without discrimination or reprisal for voicing the grievances. The grievances include those with respect to treatment which has been furnished as well as that which has not been furnished.
	(2)	Prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.
	g. 	Examination of survey results. A resident has the right to:
	(1)	Examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability.
	(2)	Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.
	h. 	Work. The resident has the right to:
	(1)	Refuse to perform services for the facility.
	(2)	Perform services for the facility if the resident chooses, when:
	1.	The facility has documented the need or desire for work in the plan of care.
	2.	The plan specifies the nature of the services performed and whether the services are voluntary or paid.
	3.	Compensation for paid services is at or above prevailing rates.
	4.	The resident agrees to the work arrangement described in the plan of care.
	5.	Rescinded IAB 3/4/92, effective 4/8/92.
	i. 	Mail. The resident has the right to privacy in written communications, including the right to send and receive mail promptly that is unopened and to have access to stationery, postage and writing implements at the resident’s own expense.
	j. 	Access and visitation rights.
	(1)	The resident has the right and the facility shall provide immediate access to any resident by the following:
	1.	Any representative of the secretary of the Department of Health and Human Services.
	2.	Any representative of the state.
	3.	The resident’s individual physician.
	4.	The state long-term care ombudsman.
	5.	The agency responsible for the protection and advocacy system for developmentally disabled individuals.
	6.	The agency responsible for the protection and advocacy system for mentally ill individuals.
	7.	Immediate family or other relatives of the resident subject to the resident’s right to deny or withdraw consent at any time.
	8.	Others who are visiting with the consent of the resident subject to reasonable restrictions and to the resident’s right to deny or withdraw consent at any time.
	(2)	The facility shall provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident’s right to deny or withdraw consent at any time.
	(3)	The facility shall allow representatives of the state ombudsman to examine a resident’s clinical records with the permission of the resident or the resident’s legal representative, and consistent with state law.
	k. 	Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard.
	l. 	Personal property. The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
	m. 	Married couples. The resident has the right to share a room with the resident’s spouse when married residents live in the same facility and both spouses consent to the arrangement.
	n. 	Self-administration of drugs. An individual resident has the right to self-administer drugs if the interdisciplinary team has determined that this practice is safe.
	o. 	Refusal of certain transfers.
	(1)	A person has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate a resident of a skilled nursing facility from the distinct part of the institution that is a skilled nursing facility to a part of the institution that is not a skilled nursing facility or, if a resident of a nursing facility, from the distinct part of the institution that is a nursing facility to a distinct part of the institution that is a skilled nursing facility.
	(2)	A resident’s exercise of the right to refuse transfer under subparagraph (1) does not affect the resident’s eligibility or entitlement to Medicare or Medicaid benefits.
	p. 	Advance directives.
	(1)	The nursing facility, at the time of admission, shall provide written information to each resident which explains the resident’s rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives and the nursing facility’s policies regarding the implementation of these rights.
	(2)	The nursing facility shall document in the resident’s medical record whether or not the resident has executed an advance directive.
	(3)	The nursing facility shall not condition the provision of care or otherwise discriminate against a resident based on whether or not the resident has executed an advance directive.
	(4)	The nursing facility shall ensure compliance with requirements of state law regarding advance directives.
	(5)	The nursing facility shall provide for education for staff and the community on issues concerning advance directives.
Nothing in this paragraph shall be construed to prohibit the application of a state law which allows for an objection on the basis of conscience for any nursing facility which as a matter of conscience cannot implement an advance directive.
	81.13(6) Admission, transfer and discharge rights.
	a. 	Transfer and discharge.
	(1)	Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.
	(2)	Transfer or discharge requirements. The facility shall permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless:
	1.	The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility.
	2.	The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility.
	3.	The safety of persons in the facility is endangered.
	4.	The health of persons in the facility would otherwise be endangered.
	5.	The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid.
	6.	The facility ceases to operate.
	(3)	Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in subparagraph (2), numbers 1 through 5 above, the resident’s clinical record shall be documented. The documentation shall be made by:
	1.	The resident’s physician when transfer or discharge is necessary under subparagraph (2), number 1 or 2.
	2.	A physician when transfer or discharge is necessary under subparagraph (2), number 4.
	(4)	Notice before transfer. Before a facility transfers or discharges a resident, the facility shall:
	1.	Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.
	2.	Record the reasons in the resident’s clinical record.
	3.	Include in the notice the items in subparagraph (6) below.
	(5)	Timing of the notice. The notice of transfer or discharge shall be made by the facility at least 30 days before the resident is transferred or discharged except that notice shall be made as soon as practicable before transfer or discharge when:
	1.	The safety of persons in the facility would be endangered.
	2.	The health of persons in the facility would be endangered.
	3.	The resident’s health improves sufficiently to allow a more immediate transfer or discharge.
	4.	An immediate transfer or discharge is required by the resident’s urgent medical needs.
	5.	A resident has not resided in the facility for 30 days.
	(6)	Contents of the notice. The written notice shall including the following:
	1.	The reason for transfer or discharge.
	2.	The effective date of transfer or discharge.
	3.	The location to which the resident is transferred or discharged.
	4.	A statement that the resident has the right to appeal the action to the department.
	5.	The name, address, and telephone number of the state long-term care ombudsman.
	6.	The mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals for residents with developmental disabilities.
	7.	The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals for residents who are mentally ill.
	(7)	Orientation for transfer or discharge. A facility shall provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.
	b. 	Notice of bed-hold policy and readmission.
	(1)	Notice before transfer. Before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the facility shall provide written information to the resident and a family member or legal representative that specifies:
	1.	The duration of the bed-hold policy under the state plan during which the resident is permitted to return and resume residence in the facility.
	2.	The facility’s policies regarding bed-hold periods, which shall be consistent with subparagraph (3) below, permitting a resident to return.
	(2)	Notice upon transfer. At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility shall provide written notice to the resident and a family member or legal representative, which specifies the duration of the bed-hold policy described in subparagraph (1) above.
	(3)	Permitting resident to return to facility. A nursing facility shall establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the state plan, is readmitted to the facility immediately upon the first availability of a bed in a semiprivate room if the resident requires the services provided by the facility and is eligible for Medicaid nursing facility services.
	c. 	Equal access to quality care.
	(1)	A facility shall establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the state plan for all persons regardless of source of payment.
	(2)	The facility may charge any amount for services furnished to non-Medicaid residents consistent with the notice requirement in 81.13(1)“a”(5).
	(3)	The state is not required to offer additional services on behalf of a resident other than services provided in the state plan.
	d. 	Admissions policy.
	(1)	The facility shall not require residents or potential residents to:
	1.	Waive their rights to Medicare or Medicaid; or
	2.	Give oral or written assurance that they are not eligible for, or will not apply for, Medicare or Medicaid benefits. However, a continuing care retirement community or a life care community that is licensed, registered, certified, or the equivalent by the state, including a nursing facility that is part of such a community, may require in its contract for admission that before a resident applies for medical assistance, the resources that the resident declared for the purposes of admission must be spent on the resident’s care, subject to 441—subrule 75.5(3), 441—paragraph 75.5(4)“a,” and 441—subrule 75.16(2).
	(2)	The facility shall not require a third-party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require a person who has legal access to a resident’s income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident’s income or resources.
	(3)	In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the state plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However:
	1.	A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the state plan as included in the term “nursing facility services” so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident’s admission or continued stay on the request for and receipt of these additional services.
	2.	A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid-eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid-eligible resident.
	(4)	States or political subdivisions may apply stricter admission standards under state or local laws than are specified in these rules, to prohibit discrimination against persons entitled to Medicaid.
	81.13(7) Resident behavior and facility practices.
	a. 	Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.
	b. 	Abuse. The resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion.
	c. 	Staff treatment of residents. The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
	*(1)	Facility staff shall not use verbal, mental, sexual, or physical abuse, including corporal punishment, or involuntary seclusion of residents. The facility shall not employ persons who have been found guilty by a court of law of abusing, neglecting or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property.
The facility shall report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the state nurse aide registry or licensing authorities.
*See Objection filed 8/25/92 published herein at end of 441—Chapter 81.
	(2)	The facility shall ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility or to other officials (including the department of inspections and appeals) in accordance with state law through established procedures.
	(3)	The facility shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.
	(4)	The results of all investigations conducted by facility staff shall be reported to the administrator or the administrator’s designated representative or to other officials (including the department of inspections and appeals) in accordance with state law within five working days of the incident and if the alleged violation is verified, take appropriate corrective action.
	81.13(8) Quality of life. A facility shall care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life.
	a. 	Dignity. The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of the resident’s individuality.
	b. 	Self-determination and participation. The resident has the right to:
	(1)	Choose activities, schedules, and health care consistent with the resident’s interests, assessments and plans of care.
	(2)	Interact with members of the community both inside and outside the facility.
	(3)	Make choices about aspects of life in the facility that are significant to the resident.
	c. 	Participation in resident and family groups.
	(1)	A resident has the right to organize and participate in resident groups in the facility.
	(2)	A resident’s family has the right to meet in the facility with the families of other residents in the facility.
	(3)	The facility shall provide a resident or family group, if one exists, with private space.
	(4)	Staff or visitors may attend meetings at the group’s invitation.
	(5)	The facility shall provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings.
	(6)	When a resident or family group exists, the facility shall listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.
	d. 	Participation in other activities. A resident has the right to participate in social, religious, and community activities that do not interfere with the rights of other residents in the facility.
	e. 	Accommodation of needs. A resident has the right to:
	(1)	Reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.
	(2)	Receive notice before the resident’s room or roommate in the facility is changed.
	f. 	Activities.
	(1)	The facility shall provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.
	(2)	The activities program shall be directed by a qualified professional who meets one of the following criteria:
	1.	Is a qualified therapeutic recreation specialist or an activities professional who is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990.
	2.	Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting.
	3.	Is a qualified occupational therapist or occupational therapy assistant.
	4.	Has completed a training course approved by the state.
	g. 	Social services.
	(1)	The facility shall provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident.
	(2)	A facility with more than 120 beds shall employ a qualified social worker on a full-time basis.
	(3)	Qualifications of social worker. A qualified social worker is a person who meets both of the following criteria:
	1.	A bachelor’s degree in social work or a bachelor’s degree in a human services field including, but not limited to, sociology, special education, rehabilitation, counseling and psychology.
	2.	One year of supervised social work experience in a health care setting working directly with individuals.
	h. 	Environment. The facility shall provide:
	(1)	A safe, clean, comfortable and homelike environment, allowing the resident to use personal belongings to the extent possible.
	(2)	Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior.
	(3)	Clean bed and bath linens that are in good condition.
	(4)	Private closet space in each resident room.
	(5)	Adequate and comfortable lighting levels in all areas.
	(6)	Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, shall maintain a temperature range of 71 to 81 degrees Fahrenheit.
	(7)	For the maintenance of comfortable sound levels.
	81.13(9) Resident assessment. The facility shall conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional ability.
	a. 	Admission orders. At the time each resident is admitted, the facility shall have physician orders for the resident’s immediate care.
	b. 	Comprehensive assessments.
	(1)	The facility shall make a comprehensive assessment of a resident’s needs which is based on the minimum data set (MDS) specified by the department of inspections and appeals, which describes the resident’s capability to perform daily life functions and significant impairments in functional capacity.
	(2)	The assessment process shall include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. The comprehensive assessment shall include at least the following information:
	1.	Identification and demographic information.
	2.	Customary routine.
	3.	Cognitive patterns.
	4.	Communication.
	5.	Vision.
	6.	Mood and behavior patterns.
	7.	Psychosocial well-being.
	8.	Physical functioning and structural problems.
	9.	Continence.
	10.	Disease diagnoses and health conditions.
	11.	Dental and nutritional status.
	12.	Skin condition.
	13.	Activity pursuit.
	14.	Medications.
	15.	Special treatments and procedures.
	16.	Discharge potential.
	17.	Documentation of summary information regarding the additional assessment performed through the resident assessment protocols.
	18.	Documentation of participation in assessment.
	19.	Additional specification relating to resident status as required in Section S of the MDS.
	(3)	Frequency. Assessments shall be conducted:
	1.	Within 14 calendar days after admission or readmission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. “Readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.
	2.	Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. A “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and that requires either interdisciplinary review, revision of the care plan, or both.
	3.	In no case less often than once every 12 months.
	(4)	Review of assessments. The facility shall examine each resident no less than once every three months, and as appropriate, revise the resident’s assessment to ensure the continued accuracy of the assessment.
	(5)	Maintenance and use. A facility shall maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results to develop, review and revise the resident’s comprehensive plan of care.
	(6)	Coordination. The facility shall coordinate assessments with any state-required preadmission screening program to the maximum extent practicable to avoid duplicative testing and effort.
	(7)	Automated data processing requirement.
	1.	Entering data. Within seven days after a facility completes a resident’s assessment, a facility shall enter the following information for the resident into a computerized format that meets the specifications defined in numbered paragraphs “2” and “4” below.
	●	Admission assessment.
	●	Annual assessment updates.
	●	Significant change in status assessments.
	●	Quarterly review assessments.
	●	A subset of items upon a resident’s transfer, reentry, discharge, and death.
	●	Background (face sheet) information, if there is no admission assessment.
	2.	Transmitting data. Within seven days after a facility completes a resident’s assessment, a facility shall be capable of transmitting to the state each resident’s assessment information contained in the MDS in a format that conforms to standard record layouts and data dictionaries and that passes edits that ensure accurate and consistent coding of the MDS data as defined by the Centers for Medicare and Medicaid Services (CMS) and the department of human services or the department of inspections and appeals.
	3.	Monthly transmittal requirements. On at least a monthly basis, a facility shall input and electronically transmit accurate and complete MDS data for all assessments conducted during the previous month, including the following:
	●	Admission assessment.
	●	Annual assessment.
	●	Significant correction of prior full assessment.
	●	Significant correction of prior quarterly assessment.
	●	Quarterly review.
	●	A subset of items upon a resident’s transfer, reentry, discharge, and death.
	●	Background (face sheet) information, for an initial transmission of MDS data on a resident who does not have an admission assessment.
	4.	The facility must transmit MDS data in the ASCII format specified by CMS.
	(8)	Resident-identifiable information. A facility shall not release information that is resident-identifiable to the public. The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
	c. 	Accuracy of assessments. The assessment shall accurately reflect the resident’s status.
	(1)	Coordination. Each assessment shall be conducted or coordinated with the appropriate participation of health professionals. Each assessment shall be conducted or coordinated by a registered nurse.
	(2)	Certification. Each person who completes a portion of the assessment shall sign and certify the accuracy of that portion of the assessment. A registered nurse shall sign and certify that the assessment is completed.
	(3)	Penalty for falsification. An individual who willfully and knowingly certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment. An individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.
Clinical disagreement does not constitute a material and false statement.
	(4)	Use of independent assessors. If the department of human services or the department of inspections and appeals determines, under a survey or otherwise, that there has been a knowing and willful certification of false statements under subparagraph (3) above, the department of human services or the department of inspections and appeals may require that resident assessments under this paragraph be conducted and certified by individuals who are independent of the facility and who are approved by the department of human services or the department of inspections and appeals for a period specified by the agency.
	d. 	Comprehensive care plans.
	(1)	The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
The care plan shall describe the following:
	1.	The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under subrule 81.13(10).
	2.	Any services that would otherwise be required under subrule 81.13(10), but are not provided due to the resident’s exercise of rights under subrule 81.13(5), including the right to refuse treatment under subrule 81.13(5), paragraph “b,” subparagraph (4).
	(2)	A comprehensive care plan shall be developed within seven days after completion of the comprehensive assessment by an interdisciplinary team and with the participation of the resident, the resident’s family or legal representative to the extent practicable, and shall be periodically reviewed and revised by a team of qualified persons after each assessment.
The interdisciplinary team shall include the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs.
	(3)	The services provided or arranged by the facility shall meet professional standards of quality and be provided by qualified persons in accordance with each resident’s written plan of care.
	e. 	Discharge summary. When the facility anticipates discharges, a resident shall have a discharge summary that includes:
	(1)	A recapitulation of the resident’s stay.
	(2)	A final summary of the resident’s status to include items in paragraph “b,” subparagraph (2) above, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative.
	(3)	A postdischarge plan of care developed with the participation of the resident and resident’s family which will assist the resident to adjust to a new living environment.
	f. 	Preadmission screening for mentally ill individuals and individuals with mental retardation.
	(1)	A nursing facility shall not admit a new resident with mental illness or mental retardation unless the division of mental health, mental retardation, and developmental disabilities has approved the admission, based on an independent physical and mental health evaluation. This evaluation shall be reviewed by the Iowa Foundation for Medical Care prior to admission to determine whether the individual requires the level of services provided by the facility because of the physical and mental condition of the individual. If the individual requires nursing facility level of services, the individual shall receive specialized services for mental illness or mental retardation.
	(2)	Definition. For purposes of this rule:
	1.	An individual is considered to have “mental illness” if the individual has a primary or secondary diagnosis of mental disorder (as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition) and does not have a primary diagnosis of dementia (including Alzheimer’s disease or a related disorder).
	2.	An individual is considered to be “mentally retarded” if the individual is mentally retarded or a person with a related condition as described in 42 CFR 435.1009.
	g. 	Preadmission resident assessment. The facility shall conduct prior to admission a resident assessment of all persons seeking nursing facility placement. The assessment information gathered shall be similar to the data in the minimum data set (MDS) resident assessment tool.
	81.13(10) Quality of care. Each resident shall receive and the facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
	a. 	Activities of daily living. Based on the comprehensive assessment of a resident, the facility shall ensure that:
	(1)	A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to bathe, dress and groom; transfer and ambulate; toilet; eat, and to use speech, language or other functional communication systems.
	(2)	A resident is given the appropriate treatment and services to maintain or improve the resident’s abilities specified in subparagraph (1) above.
	(3)	A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
	b. 	Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility shall, if necessary, assist the resident:
	(1)	In making appointments.
	(2)	By arranging for transportation to and from the office of a medical practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
	c. 	Pressure sores. Based on the comprehensive assessment of a resident, the facility shall ensure that:
	(1)	A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.
	(2)	A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
	d. 	Urinary incontinence. Based on the resident’s comprehensive assessment, the facility shall ensure that:
	(1)	A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary.
	(2)	A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
	e. 	Range of motion. Based on the comprehensive assessment of a resident, the facility shall ensure that:
	(1)	A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident’s clinical condition demonstrates that a reduction in range of motion is unavoidable.
	(2)	A resident with a limited range of motion receives appropriate treatment and services to increase range of motion to prevent further decrease in range of motion.
	f. 	Mental and psychosocial functioning. Based on the comprehensive assessment of a resident, the facility shall ensure that:
	(1)	A resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem.
	(2)	A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction or increased withdrawn, angry or depressive behaviors, unless the resident’s clinical condition demonstrates that such a pattern was unavoidable.
	g. 	Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility shall ensure that:
	(1)	A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident’s clinical condition demonstrates that use of a naso-gastric tube was unavoidable.
	(2)	A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasalpharyngeal ulcers and to restore, if possible, normal eating skills.
	h. 	Accidents. The facility shall ensure that:
	(1)	The resident environment remains as free of accident hazards as is possible.
	(2)	Each resident receives adequate supervision and assistive devices to prevent accidents.
	i. 	Nutrition. Based on a resident’s comprehensive assessment, the facility shall ensure that a resident:
	(1)	Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible.
	(2)	Receives a therapeutic diet when there is a nutritional problem.
	j. 	Hydration. The facility shall provide each resident with sufficient fluid intake to maintain proper hydration and health.
	k. 	Special needs. The facility shall ensure that residents receive proper treatment and care for the following special services:
	(1)	Injections.
	(2)	Parenteral and enteral fluids.
	(3)	Colostomy, ureterostomy or ileostomy care.
	(4)	Tracheostomy care.
	(5)	Tracheal suctioning.
	(6)	Respiratory care.
	(7)	Foot care.
	(8)	Prostheses.
	l. 	Unnecessary drugs.
	(1)	General. Each resident’s drug regimen shall be free from unnecessary drugs. An unnecessary drug is any drug when used:
	1.	In excessive dose including duplicate drug therapy; or
	2.	For excessive duration; or
	3.	Without adequate monitoring; or
	4.	Without adequate indications for its use; or
	5.	In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
	6.	Any combinations of the reasons above.
	(2)	Antipsychotic drugs. Based on a comprehensive assessment of a resident, the facility shall ensure that:
	1.	Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.
	2.	Residents who use antipsychotic drugs receive gradual dose reductions and behavioral programming, unless clinically contraindicated in an effort to discontinue these drugs.
	m. 	Medication errors. The facility shall ensure that:
	(1)	It is free of significant medication error rates of 5 percent or greater.
	(2)	Residents are free of any significant medication errors.
	81.13(11) Nursing services. The facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.
	a. 	Sufficient staff.
	(1)	The facility shall provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
	1.	Except when waived under paragraph “c,” licensed nurses.
	2.	Other nursing personnel.
	(2)	Except when waived under paragraph “c,” the facility shall designate a licensed nurse to serve as a charge nurse on each tour of duty.
	b. 	Registered nurse.
	(1)	Except when waived under paragraph “c,” the facility shall use the services of a registered nurse for at least eight consecutive hours a day, seven days a week.
	(2)	Except when waived under paragraph “c,” the facility shall designate a registered nurse to serve as the director of nursing on a full-time basis.
	(3)	The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
	c. 	Nursing facilities. Waiver of requirement to provide licensed nurses on a 24-hour basis. A facility may request a waiver from either the requirement that a nursing facility provide a registered nurse for at least eight consecutive hours a day, seven days a week, as specified in paragraph “b,” or the requirement that a nursing facility provide licensed nurses on a 24-hour basis, including a charge nurse as specified in paragraph “a,” if the following conditions are met:
	(1)	The facility demonstrates to the satisfaction of the state that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel.
	(2)	The department of inspections and appeals determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility.
	(3)	The department of inspections and appeals finds that, for any periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility.
	(4)	A waiver granted under the conditions listed in paragraph “c” is subject to annual department of inspections and appeals review.
	(5)	In granting or renewing a waiver, a facility may be required by the department of inspections and appeals to use other qualified, licensed personnel.
	(6)	The department of inspections and appeals shall provide notice of a waiver granted under this paragraph to the state long-term care ombudsman established under Section 307(a)(12) of the Older Americans Act of 1965 and the protection and advocacy system in the state for the mentally ill and mentally retarded.
	(7)	The nursing facility that is granted a waiver under this paragraph shall notify residents of the facility or, where appropriate, the guardians or legal representatives of the residents and members of their immediate families of the waiver.
	81.13(12) Dietary services. The facility shall provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.
	a. 	Staffing. The facility shall employ a qualified dietitian either full-time, part-time or on a consultant basis.
	(1)	If a qualified dietitian is not employed full-time, the facility shall designate a person to serve as the director of food services who receives frequently scheduled consultation from a qualified dietitian.
	(2)	A qualified dietitian is one who is licensed by the state according to Iowa Code chapter 152A.
	b. 	Sufficient staff. The facility shall employ sufficient support personnel competent to carry out the functions of the dietary service.
	c. 	Menus and nutritional adequacy. Menus shall:
	(1)	Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.
	(2)	Be prepared in advance.
	(3)	Be followed.
	d. 	Food. Each resident receives and the facility provides:
	(1)	Food prepared by methods that conserve nutritive value, flavor and appearances.
	(2)	Food that is palatable, attractive and at the proper temperature.
	(3)	Food prepared in a form designed to meet individual needs.
	(4)	Substitutes offered of similar nutritive value to residents who refuse food served.
	e. 	Therapeutic diets. Therapeutic diets shall be prescribed by the attending physician.
	f. 	Frequency of meals.
	(1)	Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.
	(2)	There shall be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in subparagraph (4) below.
	(3)	The facility shall offer snacks at bedtime daily.
	(4)	When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.
	g. 	Assistive devices. The facility shall provide special eating equipment and utensils for residents who need them.
	h. 	Sanitary conditions. The facility shall:
	(1)	Procure food from sources approved or considered satisfactory by federal, state or local authorities.
	(2)	Store, prepare, distribute and serve food under sanitary conditions.
	(3)	Dispose of garbage and refuse properly.
	81.13(13) Physician services. A physician shall personally approve in writing a recommendation that an individual be admitted to a facility. Each resident shall remain under the care of a physician.
	a. 	Physician supervision. The facility shall ensure that:
	(1)	The medical care of each resident is supervised by a physician.
	(2)	Another physician supervises the medical care of residents when their attending physician is unavailable.
	b. 	Physician visits. The physician shall:
	(1)	Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph “c” below.
	(2)	Write, sign and date progress notes at each visit.
	(3)	Sign and date all orders.
	c. 	Frequency of physician visits.
	(1)	The resident shall be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
	(2)	A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.
	(3)	Except as provided in paragraph “e,” all required physician visits shall be made by the physician personally.
	d. 	Availability of physicians for emergency care. The facility shall provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.
	e. 	Performance of physician tasks in nursing facilities. Any required physician task in a nursing facility (including tasks which the rules specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility, but who is working in collaboration with a physician except where prohibited by state law.
	81.13(14) Specialized rehabilitative services.
	a. 	Provision of services. If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and mental retardation, are required in the resident’s comprehensive plan of care, the facility shall:
	(1)	Provide the required services; or
	(2)	Obtain the required services from an outside provider of specialized rehabilitative services.
	b. 	Qualifications. Specialized rehabilitative services shall be provided under the written order of a physician by qualified personnel.
	81.13(15) Dental services. The facility shall assist residents in obtaining routine and 24-hour emergency dental care. The facility shall:
	a. 	Provide or obtain from an outside resource the following dental services to meet the needs of each resident:
	(1)	Routine dental services to the extent covered under the state plan.
	(2)	Emergency dental services.
	b. 	If necessary, assist the resident in making appointments; and by arranging for transportation to and from the dentist’s office.
	c. 	Promptly refer residents with lost or damaged dentures to a dentist.
	81.13(16) Pharmacy services. The facility shall provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement. The nursing facility may permit a certified medication aide to administer drugs, but only under the general supervision of a licensed nurse.
	a. 	Procedures. A facility shall provide pharmaceutical services (including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
	b. 	Service consultation. The facility shall employ or obtain the services of a licensed pharmacist who:
	(1)	Provides consultation on all aspects of the provision of pharmacy services in the facility.
	(2)	Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.
	(3)	Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
	c. 	Drug regimen review.
	(1)	The drug regimen of each resident shall be reviewed at least once a month by a licensed pharmacist.
	(2)	The pharmacist shall report any irregularities to the attending physician and the director of nursing, and these reports shall be acted upon.
	d. 	Labeling of drugs and biologicals. Drugs and biologicals used in the facility shall be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
	e. 	Storage of drugs and biologicals.
	(1)	In accordance with state and federal laws, the facility shall store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys.
	(2)	The facility shall provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
	f. 	Consultant pharmacists. When the facility does not employ a licensed pharmacist, it shall have formal arrangements with a licensed pharmacist to provide consultation on methods and procedures for ordering, storage, administration and disposal and record keeping of drugs and biologicals. The formal arrangements with the licensed pharmacist shall include separate written contracts for pharmaceutical vendor services and consultant pharmacist services. The consultant’s visits are scheduled to be of sufficient duration and at a time convenient to work with nursing staff on the resident care plan, consult with the administrator and others on developing and implementing policies and procedures, and planning in-service training and staff development for employees. The consultant shall provide monthly drug regimen review reports. The facility shall provide reimbursement for consultant pharmacists based on fair market value. Documentation of consultation shall be available for review in the facility.
	81.13(17) Infection control. The facility shall establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection.
	a. 	Infection control program. The facility shall establish an infection control program under which it:
	(1)	Investigates, controls and prevents infections in the facility.
	(2)	Decides what procedures, such as isolation, should be applied to an individual resident.
	(3)	Maintains a record of incidents and corrective actions related to infections.
	b. 	Preventing spread of infection.
	(1)	When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility shall isolate the resident.
	(2)	The facility shall prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.
	(3)	The facility shall require staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice.
	c. 	Linens. Personnel shall handle, store, process, and transport linens so as to prevent the spread of infection.
	81.13(18) Physical environment. The facility shall be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public.
	a. 	Life safety from fire. Except as provided in subparagraph (1) or (3) below, the facility shall meet the applicable provisions of the 1985 edition of the Life Safety Code of the National Fire Protection Association.
	(1)	A facility is considered to be in compliance with this requirement as long as the facility:
	1.	On November 26, 1982, complied with or without waivers with the requirements of the 1967 or 1973 editions of the Life Safety Code and continues to remain in compliance with those editions of the code; or
	2.	On May 9, 1988, complied, with or without waivers, with the 1981 edition of the Life Safety Code and continues to remain in compliance with that edition of the Code.
	(2)	When Medicaid nursing facilities and Medicaid distinct part nursing facility providers request a waiver of Life Safety Code requirements in accordance with Subsection 1919(d)(2)(B)(i) of the Social Security Act, the department of inspections and appeals shall forward the requests to the Centers for Medicare and Medicaid Services Regional Office for review and approval.
	(3)	The provisions of the Life Safety Code do not apply in a state where the Centers for Medicare and Medicaid Services finds that a fire and safety code imposed by state law adequately protects patients, residents and personnel in long-term care facilities.
	b. 	Emergency power.
	(1)	An emergency electrical power system shall supply power adequate at least for lighting all entrances and exits, equipment to maintain the fire detection, alarm and extinguishing systems, and life support systems in the event the normal electrical supply is interrupted.
	(2)	When life support systems are used that have no nonelectrical backup, the facility shall provide emergency electrical power with an emergency generator, as defined in NFPA 99, Health Care Facilities, that is located on the premises.
	c. 	Space and equipment. The facility shall:
	(1)	Provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident’s plan of care.
	(2)	Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.
	d. 	Resident rooms. Resident rooms shall be designed and equipped for adequate nursing care, comfort and privacy of residents.
	(1)	Bedrooms shall:
	1.	Accommodate no more than four residents.
	2.	Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms.
	3.	Have direct access to an exit corridor.
	4.	Be designed or equipped to ensure full visual privacy for each resident.
	5.	In facilities initially certified after March 31, 1992, except in private rooms, each bed shall have ceiling-suspended curtains, which extend around the bed to provide total visual privacy, in combination with adjacent walls and curtains.
	6.	Have at least one window to the outside.
	7.	Have a floor at or above grade level.
	(2)	The facility shall provide each resident with:
	1.	A separate bed of proper size and height for the convenience of the resident.
	2.	A clean, comfortable mattress.
	3.	Bedding appropriate to the weather and climate.
	4.	Functional furniture appropriate to the resident’s needs and individual closet space in the resident’s bedroom with clothes racks and shelves accessible to the resident.
	(3)	The department of inspections and appeals may permit variations in requirements specified in paragraph “d,” subparagraph (1), numbers 1 and 2 above relating to rooms in individual cases when the facility demonstrates in writing that the variations are required by the special needs of the residents and will not adversely affect residents’ health and safety.
	e. 	Toilet facilities. Each resident room shall be equipped with or located adjacent to toilet facilities unless a waiver is granted by the department of inspections and appeals. Additionally, each resident room shall be equipped with or located adjacent to bathing facilities.
	f. 	Resident call system. The nurse’s station shall be equipped to receive resident calls through a communication system from:
	(1)	Resident rooms.
	(2)	Toilet and bathing facilities.
	g. 	Dining and resident activities. The facility shall provide one or more rooms designated for resident dining and activities. These rooms shall:
	(1)	Be well lighted.
	(2)	Be well ventilated, with nonsmoking areas identified.
	(3)	Be adequately furnished.
	(4)	Have sufficient space to accommodate all activities.
	h. 	Other environmental conditions. The facility shall provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The facility shall:
	(1)	Establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply.
	(2)	Have adequate outside ventilation by means of windows or mechanical ventilation or a combination of the two.
	(3)	Equip corridors with firmly secured handrails on each side.
	(4)	Maintain an effective pest control program so that the facility is free of pests and rodents.
	81.13(19) Administration. A facility shall be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
	a. 	Licensure. A facility shall be licensed under applicable state and federal law.
	b. 	Compliance with federal, state and local laws and professional standards. The facility shall operate and provide services in compliance with all applicable federal, state, and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.
	c. 	Relationship to other Department of Health and Human Services (HHS) regulations. In addition to compliance with these rules, facilities shall meet the applicable provisions of other HHS regulations, including, but not limited to, those pertaining to nondiscrimination on the basis of race, color, or national origin, nondiscrimination on the basis of handicap, nondiscrimination on the basis of age, protection of human subjects of research, and fraud and abuse. Although these regulations are not in themselves considered requirements under these rules, their violation may result in the termination or suspension of, or the refusal to grant or continue payment with federal funds.
	d. 	Governing body.
	(1)	The facility shall have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility.
	(2)	The governing body appoints the administrator who is:
	1.	Licensed by the state.
	2.	Responsible for management of the facility.
	e. 	Required training of nurse aides.
	(1)	Definitions.
“Licensed health professional” means a physician; physician assistant; nurse practitioner; physical, speech or occupational therapist; registered professional nurse; licensed practical nurse; or licensed or certified social worker.
“Nurse aide” means any person providing nursing or nursing-related services to residents in a facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide these services without pay.
	(2)	General rule. A facility shall not use any person working in the facility as a nurse aide for more than four months, on a permanent basis, unless:
	1.	That person is competent to provide nursing and nursing-related services.
	2.	That person has completed a training and competency evaluation program or a competency evaluation program approved by the department of inspections and appeals; or that person has been deemed or determined competent by the department of inspections and appeals.
	(3)	Nonpermanent employees. A facility shall not use on a temporary, per diem, leased, or any basis other than a permanent employee any person who does not meet the requirements in subparagraph (2).
	(4)	Competency. A facility shall not use any person who has worked less than four months as a nurse aide in that facility unless the person:
	1.	Is a permanent employee and is in a nurse aide training and competency evaluation program approved by the department of inspections and appeals;
	2.	Has demonstrated competence through satisfactory participation in a nurse aide training and competency evaluation program or competency evaluation program approved by the department of inspections and appeals; or
	3.	Has been deemed or determined competent by the department of inspections and appeals.
	(5)	Registry verification. Before allowing a person to serve as a nurse aide, a facility shall receive registry verification that the person has met competency evaluation requirements unless:
	1.	The person is a permanent employee and is in a training and competency evaluation program approved by the department of inspections and appeals; or
	2.	The person can prove that the person has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the department of inspections and appeals and has not yet been included in the registry. Facilities shall follow up to ensure that such a person actually becomes registered.
	(6)	Multistate registry verification. Before allowing a person to serve as a nurse aide, a facility shall seek information from every state registry the facility believes will include information on the person.
	(7)	Required retraining. If since October 1, 1990, there has been a continuous period of 24 consecutive months during none of which the person provided nursing or nursing-related services for monetary compensation, the person shall complete a new training and competency evaluation program or a new competency evaluation program.
	(8)	Regular in-service education. The facility shall complete a performance review of every nurse aide at least once every 12 months and shall provide regular in-service education based on the outcome of these reviews. The in-service training shall:
	1.	Be sufficient to ensure the continuing competencies of nurse aides, but shall be no less than 12 hours per year.
	2.	Address areas of weakness as determined in nurse aides’ performance reviews and may address the special needs of residents as determined by the facility staff.
	3.	For nurse aides providing services to persons with cognitive impairments, also address the care of the cognitively impaired.
	f. 	Proficiency of nurse aides. The facility shall ensure that nurse aides are able to demonstrate competency in skills and technique necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.
	g. 	Staff qualifications.
	(1)	The facility shall employ on a full-time, part-time, or consultant basis those professionals necessary to carry out the provisions of these conditions of participation.
	(2)	Professional staff shall be licensed, certified or registered in accordance with applicable state laws.
	h. 	Use of outside resources.
	(1)	If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility shall have that service furnished to residents by a person or agency outside the facility under an arrangement described in Section 1861(w) of the Omnibus Budget Reconciliation Act of 1987 or an agreement described in subparagraph (2) below.
	(2)	Arrangements or agreements pertaining to services furnished by outside resources shall specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility and for the timeliness of the services.
	i. 	Medical director.
	(1)	The facility shall designate a physician to serve as medical director.
	(2)	The medical director is responsible for implementation of resident care policies and the coordination of medical care in the facility.
	j. 	Laboratory services.
	(1)	The facility shall provide or obtain clinical laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
	1.	If the facility provides its own laboratory services, the services shall meet the applicable conditions for coverage of the services furnished by laboratories specified in 42 CFR Part 493 as amended to October 1, 1990.
	2.	If the facility provides blood bank and transfusion services, it shall meet the requirements for laboratories specified in 42 CFR Part 493 as amended to October 1, 1990.
	3.	If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory shall be approved or licensed to test specimens in the appropriate specialties or subspecialties of service in accordance with 42 CFR Part 493 as amended to October 1, 1990.
	4.	If the facility does not provide laboratory services on site, it shall have an agreement to obtain these services only from a laboratory that meets the requirements of 42 CFR Part 493 as amended to October 1, 1990, or from a physician’s office.
	(2)	The facility shall:
	1.	Provide or obtain laboratory services only when ordered by the attending physician.
	2.	Promptly notify the attending physician of the findings.
	3.	Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance.
	4.	File in the resident’s clinical record signed and dated reports of clinical laboratory services.
	k. 	Radiology and other diagnostic services.
	(1)	The facility shall provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
	1.	If the facility provides its own diagnostic services, the services shall meet the applicable conditions of participation for hospitals.
	2.	If the facility does not provide its own diagnostic services, it shall have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.
	(2)	The facility shall:
	1.	Provide or obtain radiology and other diagnostic services only when ordered by the attending physician.
	2.	Promptly notify the attending physician of the findings.
	3.	Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance.
	4.	File in the resident’s clinical record signed and dated reports of X-ray and other diagnostic services.
	l. 	Clinical records.
	(1)	The facility shall maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible, and systematically organized.
	(2)	Clinical records shall be retained for:
	1.	The period of time required by state law.
	2.	Five years from the date of discharge when there is no requirement in state law.
	3.	For a minor, three years after a resident reaches legal age under state law.
	(3)	The facility shall safeguard clinical record information against loss, destruction, or unauthorized use.
	(4)	The facility shall keep confidential all information contained in the resident’s records, regardless of the form or storage method of the records, except when release is required by:
	1.	Transfer to another health care institution.
	2.	Law.
	3.	Third-party payment contract.
	4.	The resident.
	(5)	The clinical record shall contain:
	1.	Sufficient information to identify the resident.
	2.	A record of the resident’s assessments.
	3.	The plan of care and services provided.
	4.	The results of any preadmission screening conducted by the state.
	5.	Progress notes.
	m. 	Disaster and emergency preparedness.
	(1)	The facility shall have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.
	(2)	The facility shall train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out staff drills using those procedures.
	n. 	Transfer agreement.
	(1)	The facility shall have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs that reasonably ensures that:
	1.	Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician.
	2.	Medical and other information needed for care and treatment of residents, and, when the transferring facility deems it appropriate, for determining whether the residents can be adequately cared for in a less expensive setting than either the facility or the hospital, will be exchanged between the institutions.
	(2)	The facility is considered to have a transfer agreement in effect if the facility has attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible.
	o. 	Quality assessment and assurance.
	(1)	A facility shall maintain a quality assessment and assurance committee consisting of the director of nursing services, a physician designated by the facility, and at least three other members of the facility’s staff.
	(2)	The quality assessment and assurance committee:
	1.	Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary.
	2.	Develops and implements appropriate plans of action to correct identified quality deficiencies.
	(3)	The state or the Secretary of the Department of Health and Human Services may not require disclosure of the records of the committee except insofar as the disclosure is related to the compliance of the committee with the requirements of this paragraph.
	(4)	Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
	p. 	Disclosure of ownership.
	(1)	The facility shall comply with the disclosure requirements of 42 CFR 420.206 and 455.104.
	(2)	The facility shall provide written notice to the department of inspections and appeals at the time of change, if a change occurs in:
	1.	Persons with an ownership or control interest.
	2.	The officers, directors, agents, or managing employees.
	3.	The corporation, association, or other company responsible for the management of the facility.
	4.	The facility’s administrator or director of nursing.
	(3)	The notice specified in subparagraph (2) above shall include the identity of each new individual or company.
This rule is intended to implement Iowa Code sections 249A.2, 249A.3(2)“a,” and 249A.4.
441—81.14(249A) Audits.
	81.14(1) Audit of financial and statistical report. Authorized representatives of the department or the Department of Health and Human Services shall have the right, upon proper identification, to audit, using generally accepted auditing procedures, the general financial records of a facility to determine if expenses reported on the Financial and Statistical Report, Form 470-0030, are reasonable and proper according to the rules set forth in 441—81.6(249A). The aforementioned audits may be done either on the basis of an on-site visit to the facility, their central accounting office, or office(s) of their agent(s).
	a. 	When a proper per diem rate cannot be determined, through generally accepted and customary auditing procedures, the auditor shall examine and adjust the report to arrive at what appears to be an acceptable rate and shall recommend to the department that the indicated per diem should be reduced to 75 percent of the established payment rate for the ensuing six-month period and if the situation is not remedied on the subsequent Financial and Statistical Report, Form 470-0030, the health facility shall be suspended and eventually canceled from the nursing facility program, or
	b. 	When a health facility continues to include as an item of cost an item or items which had in a prior audit been removed by an adjustment in the total audited costs, the auditor shall recommend to the department that the per diem be reduced to 75 percent of the current payment rate for the ensuing six-month period. The department may, after considering the seriousness of the exception, make the reduction.
	81.14(2) Audit of proper billing and handling of patient funds.
	a. 	Field auditors of the department of inspections and appeals, or representatives of Health and Human Services, upon proper identification, shall have the right to audit billings to the department and receipts of client participation, to ensure the facility is not receiving payment in excess of the contractual agreement and that all other aspects of the contractual agreement are being followed, as deemed necessary.
	b. 	Field auditors of the department of inspections and appeals or representatives of Health and Human Services, upon proper identification, shall have the right to audit records of the facility to determine proper handling of patient funds in compliance with subrule 81.4(3).
	c. 	The auditor shall recommend and the department shall request repayment by the facility to either the department or the resident(s) involved, any sums inappropriately billed to the department or collected from the resident.
	d. 	The facility shall have 60 days to review the audit and repay the requested funds or present supporting documentation which would indicate that the requested refund amount, or part thereof, is not justified.
	e. 	When the facility fails to comply with paragraph “d,” the requested refunds may be withheld from future payments to the facility. The withholding shall not be more than 25 percent of the average of the last six monthly payments to the facility. The withholding shall continue until the entire requested refund amount is recovered. If in the event the audit results indicate significant problems, the audit results may be referred to the attorney general’s office for whatever action may be deemed appropriate.
	f. 	When exceptions are taken during the scope of an audit which are similar in nature to the exceptions taken in a prior audit, the auditor shall recommend and the department may, after considering the seriousness of the exceptions, reduce payment to the facility to 75 percent of the current payment rate.
This rule is intended to implement Iowa Code sections 249A.2, 249A.3(2)“a” and 249A.4.
441—81.15(249A) Nurse aide training and testing programs. Rescinded IAB 12/9/92, effective 2/1/93.
441—81.16(249A) Nurse aide requirements and training and testing programs.
	81.16(1) Deemed meeting of requirements. A nurse aide is deemed to satisfy the requirement of completing a training and competency evaluation approved by the department of inspections and appeals if the nurse aide successfully completed a training and competency evaluation program before July 1, 1989. The aide would have satisfied this requirement if:
	a. 	At least 60 hours were substituted for 75 hours; and
	b. 	The aide has made up at least the difference in the number of hours in the program the aide completed and 75 hours in supervised practical nurse aide training or in regular in-service nurse education; or
	c. 	The person was found to be competent (whether or not by the state) after completion of a nurse aide training of at least 100 hours’ duration; or
	d. 	The person can demonstrate that the person served as a nurse aide at one or more facilities of the same employer in Iowa for at least 24 consecutive months before December 19, 1989; or
	e. 	The person completed, before July 1, 1989, a nurse aide training and competency evaluation program that the department of inspections and appeals determines would have met the requirements for approval at the time it was offered.
	81.16(2) State review and approval of nurse aide training and competency evaluation programs or competency evaluation programs.
	a. 	The department of inspections and appeals shall, in the course of all surveys, determine whether the nurse aide training and evaluation requirements of 81.13(19)“e” and 81.16(1) are met.
	b. 	Requirements for approval of programs.
	(1)	Before the department of inspections and appeals approves a nurse aide training and competency evaluation program or competency evaluation program, the department of inspections and appeals shall determine whether:
	1.	A nurse aide training and competency evaluation program meets the course requirements of 81.16(3).
	2.	A nurse aide competency evaluation program meets the requirements of 81.16(4).
	(2)	Except as provided by paragraph 81.16(2)“f,” the department of inspections and appeals shall not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in a facility which, in the previous two years:
	1.	Has operated under a nurse staffing waiver for a period in excess of 48 hours per week; or
	2.	Has been subject to an extended or partial extended survey; or
	3.	Has been assessed a civil money penalty of not less than $5,000; or
	4.	Has operated under temporary management appointed to oversee the operation of the facility and to ensure the health and safety of the facility’s residents; or
	5.	Pursuant to state action, was closed or had its residents transferred; or
	6.	Has been terminated from participation in the Medicaid or Medicare program; or
	7.	Has been denied payment under subrule 81.40(1) or 81.40(2).
	(3)	Rescinded IAB 10/7/98, effective 12/1/98.
	c. 	Application process. Applications shall be submitted to the department of inspections and appeals before a new program begins and every two years thereafter on Form 427-0517, Application for Nurse Aide Training. The department of inspections and appeals shall, within 90 days of the date of a request or receipt of additional information from the requester:
	(1)	Advise the requester whether or not the program has been approved; or
	(2)	Request additional information from the requesting entity.
	d. 	Duration of approval. The department of inspections and appeals shall not grant approval of a nurse aide training and competency evaluation program for a period longer than two years. A program shall notify the department of inspections and appeals and the department of inspections and appeals shall review that program when there are substantive changes made to that program within the two-year period.
	e. 	Withdrawal of approval.
	(1)	The department of inspections and appeals shall withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program offered by or in a facility described in 81.16(2)“b”(2).
	(2)	The department of inspections and appeals may withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program if the department of inspections and appeals determines that any of the applicable requirements for approval or registry, as set out in subrule 81.16(3) or 81.16(4), are not met.
	(3)	The department of inspections and appeals shall withdraw approval of a nurse aide training and competency evaluation program or a nurse aide competency evaluation program if the entity providing the program refuses to permit unannounced visits by the department of inspections and appeals.
	(4)	If the department of inspections and appeals withdraws approval of a nurse aide training and competency evaluation program or competency evaluation program, the department of inspections and appeals shall notify the program in writing, indicating the reasons for withdrawal of approval of the program. Students who have started a training and competency evaluation program from which approval has been withdrawn shall be allowed to complete the course.
	f. 	An exception to subparagraph 81.16(2)“b”(2) may be granted by the department of inspections and appeals (DIA) for 75-hour nurse aide training courses offered in (but not by) a facility under the following conditions:
	(1)	The facility has submitted Form 470-3494, Nurse Aide Education Program Waiver Request, to the DIA to request a waiver for each 75-hour nurse aide training course to be offered in (but not by) the facility.
	(2)	The 75-hour nurse aide training is offered in a facility by an approved nurse aide training and competency evaluation program (NATCEP).
	(3)	No other NATCEP program is offered within 30 minutes’ travel from the facility, unless the facility can demonstrate the distance or program would create a hardship for program participants.
	(4)	The facility is in substantial compliance with the federal requirements related to nursing care and services.
	(5)	The facility is not a poor performing facility.
	(6)	Employees of the facility do not function as instructors for the program unless specifically approved by DIA.
	(7)	The NATCEP sponsoring the 75-hour nursing aide training course is responsible for program administration and for ensuring that program requirements are met.
	(8)	The NATCEP has submitted an evaluation to the DIA indicating that an adequate teaching and learning environment exists for conducting the course.
	(9)	The NATCEP has developed policies for communicating and resolving problems encountered during the course, including notice by the facility to the program instructor and students on how to contact the DIA to register any concerns encountered during the course.
	(10)	The NATCEP shall require the program instructor and students to complete an evaluation of the course. The instructor shall return the completed evaluations to the NATCEP which shall return the evaluations to DIA.
	81.16(3) Requirements for approval of a nurse aide training and competency evaluation program. The department has designated the department of inspections and appeals to approve required nurse aide training and testing programs. Policies and procedures governing approval of the programs are set forth in these rules.
	a. 	For a nurse aide training and competency evaluation program to be approved by the department of inspections and appeals, it shall, at a minimum:
	(1)	Consist of no less than 75 clock hours of training.
	(2)	Include at least the subjects specified in 81.16(3).
	(3)	Include at least 15 hours of laboratory experience, 30 hours of classroom instruction (the first 16 hours of which must occur before the nurse aide has resident contact) and 30 hours of supervised clinical training. Supervised clinical training means training in a setting in which the trainee demonstrates knowledge while performing tasks on a resident under the general supervision of a registered nurse or licensed practical nurse.
	(4)	Ensure that students do not independently perform any services for which they have not been trained and found proficient by the instructor. It shall also ensure that students who are providing services to residents are under the general supervision of a licensed nurse or a registered nurse.
	(5)	Meet the following requirements for instructors who train nurse aides:
	1.	The training of nurse aides shall be performed by or under the general supervision of a registered nurse who possesses a minimum of two years of nursing experience, at least one year of which shall be in the provision of long-term care facility services.
	2.	Instructors shall be registered nurses and shall have completed a course in teaching adults or have experience teaching adults or supervising nurse aides.
	3.	In a facility-based program, when the director of nursing is a registered nurse, the training of nurse aides may be performed under the general supervision of the director of nursing for the facility. The director of nursing is prohibited from performing the actual training.
	4.	Other personnel from the health professions may supplement the instructor. Supplemental personnel shall have at least one year of experience in their fields.
	5.	The ratio of qualified trainers to students shall not exceed one instructor for every ten students in the clinical setting.
	(6)	Contain information regarding competency evaluation through written or oral and skills testing.
	b. 	The curriculum of the nurse aide training program shall include:
	(1)	At least a total of 16 hours of training in the following areas prior to any direct contact with a resident:
	1.	Communication and interpersonal skills.
	2.	Infection control.
	3.	Safety and emergency procedures including the Heimlich maneuver.
	4.	Promoting residents’ independence.
	5.	Respecting residents’ rights.
	(2)	Basic nursing skills:
	1.	Taking and recording vital signs.
	2.	Measuring and recording height and weight.
	3.	Caring for the residents’ environment.
	4.	Recognizing abnormal changes in body functioning and the importance of reporting these changes to a supervisor.
	5.	Caring for residents when death is imminent.
	(3)	Personal care skills, including, but not limited to:
	1.	Bathing.
	2.	Grooming, including mouth care.
	3.	Dressing.
	4.	Toileting.
	5.	Assisting with eating and hydration.
	6.	Proper feeding techniques.
	7.	Skin care.
	8.	Transfers, positioning, and turning.
	(4)	Mental health and social service needs:
	1.	Modifying aide’s behavior in response to residents’ behavior.
	2.	Awareness of developmental tasks associated with the aging process.
	3.	How to respond to resident behavior.
	4.	Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident’s dignity.
	5.	Using the resident’s family as a source of emotional support.
	(5)	Care of cognitively impaired residents:
	1.	Techniques for addressing the unique needs and behaviors of persons with dementia (Alzheimer’s and others).
	2.	Communicating with cognitively impaired residents.
	3.	Understanding the behavior of cognitively impaired residents.
	4.	Appropriate responses to the behavior of cognitively impaired residents.
	5.	Methods of reducing the effects of cognitive impairments.
	(6)	Basic restorative services:
	1.	Training the resident in self-care according to the resident’s ability.
	2.	Use of assistive devices in transferring, ambulation, eating and dressing.
	3.	Maintenance of range of motion.
	4.	Proper turning and positioning in bed and chair.
	5.	Bowel and bladder training.
	6.	Care and use of prosthetic and orthotic devices.
	(7)	Residents’ rights:
	1.	Providing privacy and maintenance of confidentiality.
	2.	Promoting the residents’ rights to make personal choices to accommodate their needs.
	3.	Giving assistance in resolving grievances and disputes.
	4.	Providing needed assistance in getting to and participating in resident and family groups and other activities.
	5.	Maintaining care and security of residents’ personal possessions.
	6.	Promoting the residents’ rights to be free from abuse, mistreatment, and neglect and the need to report any instances of this type of treatment to appropriate facility staff.
	7.	Avoiding the need for restraints in accordance with current professional standards.
	c. 	Prohibition of charges.
	(1)	No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program or competency evaluation program may be charged for any portion of the program including any fees for textbooks or other required evaluation or course materials.
	(2)	If a person who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility not later than 12 months after completing a nurse aide training and competency evaluation program or competency evaluation program, the facility shall reimburse the nurse aide for costs incurred in completing the program or competency evaluation on a pro rata basis during the period in which the person is employed as a nurse aide. The formula for paying the nurse aides on a pro rata basis shall be as follows:
	1.	Add all costs incurred by the aides for the course, books, and tests.
	2.	Divide the total arrived at in No.	1 above by 12 to prorate the costs over a one-year period and establish a monthly rate.
	3.	The aide shall be reimbursed the monthly rate each month the aide works at the facility until one year from the time the aide completed the course.
	d. 	Setting and equipment. The classroom shall have appropriate equipment, be of adequate size, and not interfere with resident activities.
	e. 	Records and reports. Nurse aide education programs approved by the department of inspections and appeals shall:
	(1)	Notify the department of inspections and appeals:
	1.	Of dates of classroom and clinical sessions as well as location of classrooms and clinical practice sites before each course begins and if the course is canceled.
	2.	When a facility or other training entity will no longer be offering nurse aide training courses.
	3.	Whenever the person coordinating the training program is hired or terminates employment.
	(2)	Keep a list of faculty members and their qualifications available for department review.
	(3)	Provide each nurse aide a record of skills for which the nurse aide has been found competent during the course and which may be performed before completion of the competency evaluation.
	(4)	Complete a lesson plan for each unit which includes behavioral objectives, a topic outline and student activities and experiences.
	(5)	Provide the student, within 30 days of the last class period, evidence of having successfully completed the course.
	81.16(4) Nurse aide competency evaluation. A competency evaluation program shall contain a written or oral portion and a skills demonstration portion.
	a. 	Notification to person. The department of inspections and appeals shall advise in advance any person who takes the competency evaluation that a record of the successful completion of the evaluation will be included in the state’s nurse aide registry.
	b. 	Content of the competency evaluation program.
	(1)	Written or oral examinations. The competency evaluation shall:
	1.	Allow an aide to choose between a written and oral examination.
	2.	Address each of the course requirements listed in 81.16(3)“b.”
	3.	Be developed from a pool of test questions, only a portion of which is used in any one examination.
	4.	Use a system that prevents disclosure of both the pool of questions and the individual competency evaluations.
	5.	If oral, be read from a prepared text in a neutral manner.
	6.	Be tested for reliability and validity using a nationally recognized standard as determined by the department of education.
	7.	Be in English, unless the prevailing language used in the facility where a nurse aide will be working is other than English.
	(2)	Demonstration of skills. The skills demonstration evaluation shall consist of a demonstration of randomly selected items drawn from a pool consisting of tasks generally performed by nurse aides. This pool of skills shall include all of the personal care skills listed in 81.16(3)“b”(3).
	c. 	Administration of the competency evaluation.
	(1)	The competency examination shall be administered and evaluated only by an entity approved by the department of inspections and appeals, which is neither a skilled nursing facility that participates in Medicare nor a nursing facility that participates in Medicaid.
	(2)	Charging nurse aides for competency testing is prohibited in accordance with 81.16(3)“c.”
	(3)	The skills demonstration part of the evaluation shall be performed in a facility or laboratory setting comparable to the setting in which the person will function as a nurse aide and shall be administered and evaluated by a registered nurse with at least one year’s experience in providing care for the elderly or the chronically ill of any age.
	d. 	Facility proctoring of the competency evaluation.
	(1)	The competency evaluation may, at the nurse aide’s option, be conducted at the facility in which the nurse aide is or will be employed unless the facility is prohibited from being a competency evaluation site.
	(2)	The department of inspections and appeals may permit the competency evaluation to be proctored by facility personnel if the department of inspections and appeals finds that the procedure adopted by the facility ensures that the competency evaluation program:
	1.	Is secure from tampering.
	2.	Is standardized and scored by a testing, educational, or other organization approved by the department of inspections and appeals.
	3.	Requires no scoring by facility personnel.
	(3)	The department of inspections and appeals shall retract the right to proctor nurse aide competency evaluations from facilities in which the department of inspections and appeals finds any evidence of impropriety, including evidence of tampering by facility staff.
	e. 	Successful completion of the competency evaluation program.
	(1)	A score of 70 percent or above is passing for both the written or oral and skills demonstration parts of the test.
	(2)	A record of successful completion of the competency evaluation shall be included in the nurse aide registry within 30 days of the date the person is found to be competent.
	(3)	The competency testing entity shall inform the nurse aide of the test score within 30 calendar days of the completion of the test and shall inform the nurse aide registry of the nurse aide’s scores within 20 calendar days after the test is administered.
	f. 	Unsuccessful completion of the competency evaluation program.
	(1)	If the person does not complete the evaluation satisfactorily, the person shall be advised in writing within ten working days after the test is scored:
	1.	Of the areas which the person did not pass.
	2.	That the person has three opportunities to take the evaluation.
	(2)	Each person shall have three opportunities to pass each part of the test. If one part of the test is failed, only that part need be taken a second or third time. If either part of the test is failed three times, the 75-hour course shall be taken or retaken before the test can be taken again.
	g. 	Storage of evaluation instrument. The person responsible for administering a competency evaluation shall provide secure storage of the evaluation instruments when they are not being administered or processed.
	h. 	Application process. Entities wishing to secure approval for a competency evaluation program shall submit a copy of the evaluation plan and procedures to the department of inspections and appeals. The department of inspections and appeals shall notify the applicant of its decision within 90 days of receipt of the application. The notification shall include the reason for not giving approval if approval is denied and the applicable rule citation.
	81.16(5) Registry of nurse aides.
	a. 	Establishment of registry. The department of inspections and appeals shall establish and maintain a registry of nurse aides that meets the following requirements. The registry:
	(1)	Shall include, at a minimum, the information required in 81.16(5)“c.”
	(2)	Shall be sufficiently accessible to meet the needs of the public and health care providers promptly.
	(3)	Shall provide that any response to an inquiry that includes a finding of abuse, neglect, mistreatment of a resident or misappropriation of property also include any statement made by the nurse aide which disputes the finding.
	b. 	Registry operation.
	(1)	Only the department of inspections and appeals may place on the registry findings of abuse, neglect, mistreatment of a resident or misappropriation of property.
	(2)	The department of inspections and appeals shall determine which persons:
	1.	Have successfully completed a nurse aide training and competency evaluation program or nurse aide competency evaluation program.
	2.	Have been deemed as meeting these requirements.
	3.	Do not qualify to remain on the registry because they have performed no nursing or nursing-related services for monetary compensation during a period of 24 consecutive months.
	(3)	The department of inspections and appeals shall not impose any charges related to registration on persons listed in the registry.
	(4)	The department of inspections and appeals shall provide information on the registry promptly.
	c. 	Registry content.
	(1)	The registry shall contain at least the following information on each person who has successfully completed a nurse aide training and competency evaluation program or competency evaluation program which was approved by the department of inspections and appeals or who may function as a nurse aide because of having been deemed competent:
	1.	The person’s full name.
	2.	Information necessary to identify each person.
	3.	The date the person became eligible for placement in the registry through successfully completing a nurse aide training and competency evaluation program or competency evaluation or by being deemed competent.
	4.	The following information on any finding by the department of inspections and appeals of abuse, neglect, mistreatment of residents or misappropriation of property by the person: documentation of the department of inspections and appeals’ investigation, including the nature of the allegation and the evidence that led the department of inspections and appeals to conclude that the allegation was valid; the date of the hearing, if the person chose to have one, and its outcome; and a statement by the person disputing the allegation, if the person chooses to make one. This information must be included in the registry within ten working days of the finding and shall remain in the registry permanently, unless the finding was made in error, the person was found not guilty in a court of law, or the department of inspections and appeals is notified of the person’s death.
	5.	A record of known convictions by a court of law of a person convicted of abuse, neglect, mistreatment or misappropriation of resident property.
	(2)	The registry shall remove entries for persons who have performed no nursing or nursing-related services for monetary compensation for a period of 24 consecutive months unless the person’s registry entry includes documented findings or convictions by a court of law of abuse, neglect, mistreatment or misappropriation of property.
	d. 	Disclosure of information. The department of inspections and appeals shall:
	(1)	Disclose all of the information listed in 81.16(5)“c”(1), (3), and (4) to all requesters and may disclose additional information it deems necessary.
	(2)	Promptly provide persons with all information contained in the registry about them when adverse findings are placed on the registry and upon request. Persons on the registry shall have sufficient opportunity to correct any misstatements or inaccuracies contained in the registry.
	e. 	Placement of names on nurse aide registry. The facility shall ensure that the name of each person employed as a nurse aide in a Medicare- or Medicaid-certified nursing facility in Iowa is submitted to the registry. The telephone number of the registry is (515)281-4963. The address is Nurse Aide Registry, Lucas State Office Building, Des Moines, Iowa 50319-0083.
	(1)	Persons employed as nurse aides shall complete Form 427-0496, Nurse Aide Registry Application, within the first 30 days of employment. This form shall be submitted to the department of inspections and appeals. Form 427-0496 may be obtained by calling or writing the nurse aide registry.
	(2)	A nurse aide who is not employed may apply for inclusion on the registry by submitting a copy of completed Form 427-0496 to the nurse aide registry.
	(3)	When the registry has received a signed application and entered the required training and testing information on the registry, a letter will be sent to the nurse aide that includes all the information the registry has on the nurse aide. A nurse aide may obtain a copy of the information on the registry by writing the nurse aide registry and requesting the information. The letter requesting the information must include the nurse aide’s social security number, current or last facility of employment, date of birth and current mailing address and must be signed by the nurse aide.
	81.16(6) Hearing. When there is an allegation of abuse against a nurse aide, the department of inspections and appeals shall investigate that allegation. When the investigation by the department of inspections and appeals makes a finding of an act of abuse, the nurse aide named will be notified of this finding and the right to a hearing. The nurse aide shall have 30 days to request a hearing. The request shall be in writing and shall be sent to the department of inspections and appeals. The hearing shall be held pursuant to department of inspections and appeals rules 481—Chapter 10. After 30 days, if the nurse aide fails to appeal, or when all appeals are exhausted, the nurse aide registry will include a notation that the nurse aide has a founded abuse report on record if the final decision indicates the nurse aide performed an abusive act.
	81.16(7)  Appeals. Adverse decisions made by the department of inspections and appeals in administering these rules may be appealed pursuant to department of inspections and appeals rules 481—Chapter 10.
This rule is intended to implement Iowa Code section 249A.4.
441—81.17(249A) Termination procedures. Rescinded IAB 5/10/95, effective 7/1/95.
441—81.18(249A) Sanctions.
	81.18(1) Penalty for falsification of a resident assessment. An individual, who willfully and knowingly certifies a material and false statement in a resident assessment, is subject to a civil money penalty of not less than $100 or more than $1,000 for each falsified assessment. An individual who willfully and knowingly causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not less than $500 nor more than $5,000 for each falsified assessment. These fines shall be administratively assessed by the department of inspections and appeals.
	a. 	Factors determining the size of fine. In determining the monetary amount of the penalty, the director of the department of inspections and appeals or the director’s designee may consider evidence of the circumstances surrounding the violation, including, but not limited to, the following factors:
	(1)	The number of assessments willingly and knowingly falsified.
	(2)	The history of the individual relative to previous assessment falsifications.
	(3)	The intent of the individual who falsifies an assessment or causes an assessment to be falsified.
	(4)	The areas of assessment falsified or caused to be falsified and the potential for harm to the resident.
	(5)	The relationship of the falsification of assessment to falsification of other records at the time of the visit.
	b. 	Notification of a fine imposed for falsification of assessments or causing another individual to falsify an assessment shall be served upon the individual personally or by certified mail.
	c. 	Appeals of fines. Notice of intent to formally contest the fine shall be given to the department of inspections and appeals in writing and be postmarked within 20 working days after receipt of the notification of the fine. An administrative hearing will be conducted pursuant to Iowa Code chapter 17A and department of inspections and appeals rules 481—Chapter 10. An individual who has exhausted all administrative remedies and is aggrieved by the final action of the department of inspections and appeals may petition for judicial review in the manner provided by Iowa Code chapter 17A.
	81.18(2) Use of independent assessors. If the department of inspections and appeals determines that there has been a knowing and willful certification of false assessments, or the causation of knowing and willful false assessments, the department of inspections and appeals may require that resident assessments be conducted and certified by individuals independent of the facility and who are approved by the state.
	a. 	Criteria used to determine the need for independent assessors shall include:
	(1)	The involvement of facility management in the falsification of or causing resident assessments to be falsified.
	(2)	The facility’s response to the falsification of or causing resident assessments to be falsified.
	(3)	The method used to prepare facility staff to do resident assessments.
	(4)	The number of individuals involved in the falsification.
	(5)	The number of falsified resident assessments.
	(6)	The extent of harm to residents caused by the falsifications.
	b. 	The department of inspections and appeals will specify the length of time that these independent assessments will be conducted and when they will begin. This determination will be based on the extent of assessments and reassessments needed and the plan submitted by the facility to ensure falsifications will not occur in the future.
	c. 	The individuals or agency chosen by the facility to conduct the independent assessments shall be approved by the department of inspections and appeals before conducting any assessments. The approval will be based on the ability of the individual or agency to conduct resident assessments in accordance with the applicable rules. Any costs incurred shall be the responsibility of the facility.
	d. 	Notice of the requirement to obtain independent assessments will be in writing and sent to the facility by certified mail or personal service. The notice shall include the date independent assessors are to begin assessments, information on how independent assessors are to be approved and the anticipated length of time independent assessors will be needed.
	e. 	Criteria for removal of the requirement for independent assessors.
	(1)	Independent assessors shall be utilized until all residents assessed by the disciplines involved have been reassessed by the independent assessor.
	(2)	The facility shall submit a plan to the department of inspections and appeals for completing its own assessments.
	(3)	The department of inspections and appeals will evaluate the facility’s proposal for ensuring assessments will not be falsified in the future.
	f. 	Appeal procedures.
	(1)	A written notice to appeal shall be postmarked or personally served to the department of inspections and appeals within five working days after receipt of the notice requiring independent assessors.
	(2)	An evidentiary hearing shall be held pursuant to department of inspections and appeals rules 481—Chapter 10 no later than 15 working days after receipt of the appeal.
	(3)	The written decision shall be rendered no later than ten working days after the hearing.
	(4)	The decision rendered is a proposed decision which may be appealed to the director of the department of inspections and appeals pursuant to department of inspections and appeals rules 481—Chapter 50.
	(5)	A notice of appeal stays the effective date of the requirement for independent assessments pending a final agency decision.
	(6)	Final agency action may be appealed pursuant to Iowa Code chapter 17A.
	81.18(3) Penalty for notification of time or date of survey. Any individual who notifies, or causes to be notified, a nursing facility of the time or date on which a survey is scheduled to be conducted shall be subject to a fine not to exceed $2,000.
	81.18(4)  Failure to meet requirements for participation. Rescinded IAB 5/10/95, effective 7/1/95.
This rule is intended to implement Iowa Code section 249A.4.
441—81.19(249A) Criteria related to the specific sanctions. Rescinded IAB 5/10/95, effective 7/1/95.
441—81.20(249A) Out-of-state facilities. Payment will be made for care in out-of-state nursing facilities. Out-of-state facilities shall abide by the same policies as in-state facilities with the following exceptions:
	81.20(1) Out-of-state providers. Except for Medicare-certified hospital-based nursing facilities and special population nursing facilities, out-of-state providers shall be reimbursed at the same nursing facility rate they would receive from the Medicaid program in their state of residence or an amount equal to the sum of the Iowa non-state-operated nursing facility direct care rate component limit pursuant to subparagraph 81.6(16)“f”(1) plus the non-direct care rate limit pursuant to subparagraph 81.6(16)“f”(1), whichever is lower.
	a. 	Medicare-certified hospital-based nursing facilities providing skilled care in other states shall be reimbursed at an amount equal to the sum of the Iowa Medicare-certified hospital-based nursing facility direct care rate component limit pursuant to subparagraph 81.6(16)“f”(3) plus the non-direct care rate component limit pursuant to subparagraph 81.6(16)“f”(3) if one of the following criteria is met:
	(1)	The placement is recommended because moving the resident back to Iowa would endanger the resident’s health, because services are not readily available in Iowa, or because the out-of-state placement is cost-effective.
	(2)	The placement is temporary until services are available to the resident in Iowa or until the program of treatment is completed.
	b. 	Special population nursing facilities shall be reimbursed at the same nursing facility rate they would receive from Medicaid in their state of residence or, if not participating in the Medicaid program in their state, they shall be reimbursed pursuant to subparagraph 81.6(16)“e”(2), if one of the following criteria is met:
	(1)	The placement is recommended because moving the resident back to Iowa would endanger the resident’s health, because services are not readily available in Iowa, or because the out-of-state placement is cost-effective.
	(2)	The placement is temporary until services are available to the resident in Iowa or until the program of treatment is completed.
	81.20(2) Out-of-state facilities shall not submit financial and statistical reports as required in rule 441—81.6(249A).
	81.20(3) Payment for periods when residents are absent for visitation or hospitalization will be made to out-of-state facilities at 75 percent of the rate paid to the facility by the Iowa Medicaid program.
	81.20(4) Rescinded IAB 3/20/91, effective 3/1/91.
This rule is intended to implement Iowa Code section 249A.4.
441—81.21(249A) Outpatient services. Medicaid outpatient services provided by certified skilled nursing facilities are defined in the same way as the Medicare program.
This rule is intended to implement Iowa Code section 249A.4 and 1991 Iowa Acts, House File 479, section 132, subsection 1, paragraph “i.”
441—81.22(249A) Rates for Medicaid eligibles.
	81.22(1) Maximum client participation. A nursing facility may not charge more client participation for Medicaid-eligible clients as determined in rule 441—75.16(249A) than the maximum monthly allowable payment for their facility as determined according to subrule 79.1(9) or rule 441—81.6(249A). When the department makes a retroactive increase in the maximum daily rate, the nursing facility can charge the client the increased amount for the retroactive period.
	81.22(2) Beginning date of payment. When a resident becomes eligible for Medicaid payments for facility care, the facility shall accept Medicaid rates effective when the resident’s Medicaid eligibility begins. A nursing facility is required to refund any payment received from a resident or family member for any period of time during which the resident is determined to be eligible for Medicaid.
Any refund owing shall be made no later than 15 days after the nursing facility first receives Medicaid payment for the resident for any period of time. Facilities may deduct the resident’s client participation for the month from a refund of the amount paid for a month of Medicaid eligibility.
The beginning date of eligibility is given on the Facility Card, Form 470-0371. When the beginning Medicaid eligibility date is a future month, the facility shall accept the Medicaid rate effective the first of that future month.
This rule is intended to implement Iowa Code section 249A.4.
441—81.23(249A) State-funded personal needs supplement. A Medicaid member living in a nursing facility who has countable income for purposes of rule 441—75.16(249A) of less than $50 per month shall receive a state-funded payment from the department for the difference between that countable income and $50 if the legislature has appropriated funding specifically for this purpose. This payment shall not be considered a benefit under Title XIX of the Social Security Act.
This rule is intended to implement Iowa Code Supplement section 249A.30A.
441—81.24 to 81.30 Reserved.
DIVISION II
ENFORCEMENT OF COMPLIANCE
Preamble
These rules specify remedies that may by used when a nursing facility is not in substantial compliance with the requirements for participation in the Medicaid program. These rules also provide for ensuring prompt compliance and specify that these remedies are in addition to any others available under state or federal law.
441—81.31(249A) Definitions.
“CMS” means the Centers for Medicare and Medicaid Services of the federal Department of Health and Human Services.
“Deficiency” means a nursing facility’s failure to meet a participation requirement.
“Department” means the Iowa department of human services.
“Immediate jeopardy” means a situation in which immediate corrective action is necessary because the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.
“New admission” means a resident who is admitted to the facility on or after the effective date of a denial of payment remedy and, if previously admitted, has been discharged before that effective date. Residents admitted before the effective date of the denial of payment, and taking temporary leave, are not considered new admissions, nor are they subject to the denial of payment.
“Noncompliance” means any deficiency that causes a facility to not be in substantial compliance.
“Plan of correction” means a plan developed by the facility and approved by the department of inspections and appeals which describes the actions the facility shall take to correct deficiencies and specifies the date by which those deficiencies shall be corrected.
“Standard survey” means a periodic, resident-centered inspection which gathers information about the quality of service furnished in a facility to determine compliance with the requirements for participation.
“Substandard quality of care” means one or more deficiencies related to the participation requirements for resident behavior and facility practices, quality of life, or quality of care which constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm.
“Substantial compliance” means a level of compliance with the requirements of participation such that any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm.
“Temporary management” means the temporary appointment by the department of inspections and appeals of a substitute facility manager or administrator with authority to hire, terminate or reassign staff, obligate facility funds, alter facility procedures, and manage the facility to correct deficiencies identified in the facility’s operation.
441—81.32(249A) General provisions.
	81.32(1) Purpose of remedies. The purpose of remedies is to ensure prompt compliance with program requirements.
	81.32(2) Basis for imposition and duration of remedies. The department of inspections and appeals, as the state survey agency under contract with the department, determines the remedy to be applied for noncompliance with program requirements. When the department of inspections and appeals chooses to apply one or more remedies specified in rule 441—81.34(249A), the remedies are applied on the basis of noncompliance found during surveys conducted by the department of inspections and appeals.
	81.32(3) Number of remedies. The department of inspections and appeals may apply one or more remedies for each deficiency constituting noncompliance or for all deficiencies constituting noncompliance.
	81.32(4) Plan of correction requirement.
	a. 	Except as specified in paragraph “b,” regardless of which remedy is applied, each facility that has deficiencies with respect to program requirements shall submit a plan of correction for approval by the department of inspections and appeals.
	b. 	A facility is not required to submit a plan of correction when the department of inspections and appeals determines the facility has deficiencies that are isolated and have a potential for minimal harm, but no actual harm has occurred.
	81.32(5) Disagreement regarding remedies. If the department of inspections and appeals and CMS disagree on the decision to impose a remedy, the disagreement shall be resolved in accordance with rule 441—81.55(249A).
	81.32(6) Notification requirements.
	a. 	The department of inspections and appeals shall give the provider written notice of remedy, including the:
	(1)	Nature of the noncompliance.
	(2)	Which remedy is imposed.
	(3)	Effective date of the remedy.
	(4)	Right to appeal the determination leading to the remedy.
	b. 	Except for civil money penalties and state monitoring imposed when there is immediate jeopardy, for all remedies specified in rule 441—81.34(249A) imposed when there is immediate jeopardy, the notice shall be given at least two calendar days before the effective date of the enforcement action.
	c. 	Except for civil money penalties and state monitoring, notice shall be given at least 15 calendar days before the effective date of the enforcement action in situations where there is no immediate jeopardy.
	d. 	The 2- and 15-day notice periods begin when the facility receives the notice, but in no event will the effective date of the enforcement action be later than 20 calendar days after the notice is sent.
	e. 	For civil money penalties, the notices shall be given in accordance with rules 441—81.48(249A) and 441—81.51(249A).
	f. 	For state monitoring imposed when there is immediate jeopardy, no prior notice is required.
	81.32(7) Informal dispute resolution.
	a. 	Opportunity to refute survey findings.
	(1)	For nonfederal surveys, the department of inspections and appeals (DIA) shall offer a facility an informal opportunity, at the facility’s request, to dispute survey findings upon the facility’s receipt of the official statement of deficiencies.
	(2)	For a federal survey, the Centers for Medicare and Medicaid Services (CMS) offers a facility an informal opportunity, at the facility’s request, to dispute survey findings upon the facility’s receipt of the official statement of deficiencies.
	b. 	Delay of enforcement action.
	(1)	Failure of DIA or CMS, as appropriate, to complete informal dispute resolution timely cannot delay the effective date of any enforcement action against the facility.
	(2)	A facility may not seek a delay of any enforcement action against it on the grounds that informal dispute resolution has not been completed before the effective date of the enforcement action.
	c. 	If a provider is subsequently successful, during the informal dispute resolution process, at demonstrating that deficiencies should not have been cited, the deficiencies are removed from the statement of deficiencies and any enforcement actions imposed solely as a result of those cited deficiencies are rescinded.
	d. 	Notification. DIA shall provide the facility with written notification of the informal dispute resolution process.
441—81.33(249A) Factors to be considered in selecting remedies.
	81.33(1) Initial assessment. In order to select the appropriate remedy, if any, to apply to a facility with deficiencies, the department of inspections and appeals shall determine the seriousness of the deficiencies.
	81.33(2) Determining seriousness of deficiencies. To determine the seriousness of the deficiency, the department of inspections and appeals shall consider at least the following factors:
	a. 	Whether a facility’s deficiencies constitute:
	(1)	No actual harm with a potential for minimal harm.
	(2)	No actual harm with a potential for more than minimal harm, but not immediate jeopardy.
	(3)	Actual harm that is not immediate jeopardy.
	(4)	Immediate jeopardy to resident health or safety.
	b. 	Whether the deficiencies:
	(1)	Are isolated.
	(2)	Constitute a pattern.
	(3)	Are widespread.
	81.33(3) Other factors which may be considered in choosing a remedy within a remedy category. Following the initial assessment, the department of inspections and appeals may consider other factors, which may include, but are not limited to, the following:
	a. 	The relationship of the one deficiency to other deficiencies resulting in noncompliance.
	b. 	The facility’s prior history of noncompliance in general and specifically with reference to the cited deficiencies.
441—81.34(249A) Available remedies. In addition to the remedy of termination of the provider agreement, the following remedies are available:
	1.	Temporary management.
	2.	Denial of payment for all new admissions.
	3.	Civil money penalties.
	4.	State monitoring.
	5.	Closure of the facility in emergency situations or transfer of residents, or both.
	6.	Directed plan of correction.
	7.	Directed in-service training.
441—81.35(249A) Selection of remedies.
	81.35(1) Categories of remedies. Remedies specified in rule 441—81.34(249A) are grouped into categories and applied to deficiencies according to the severity of noncompliance.
	81.35(2) Application of remedies. After considering the factors specified in rule 441—81.33(249A), if the department of inspections and appeals applies remedies, as provided in paragraphs 81.35(3)“a,” 81.35(4)“a,” and 81.35(5)“a,” for facility noncompliance, instead of, or in addition to, termination of the provider agreement, the department of inspections and appeals shall follow the criteria set forth in 81.35(3)“b,”81.35(4)“b,” and 81.35(5)“b,” as applicable.
	81.35(3) Category 1.
	a. 	Category 1 remedies include the following:
	(1)	Directed plan of correction.
	(2)	State monitoring.
	(3)	Directed in-services training.
	b. 	The department of inspections and appeals shall apply one or more of the remedies in Category 1 when there:
	(1)	Are isolated deficiencies that constitute no actual harm with a potential for more than minimal harm but not immediate jeopardy; or
	(2)	Is a pattern of deficiencies that constitutes no actual harm with a potential for more than minimal harm but not immediate jeopardy.
	c. 	Except when the facility is in substantial compliance, the department of inspections and appeals may apply one or more of the remedies in Category 1 to any deficiency.
	81.35(4) Category 2.
	a. 	Category 2 remedies include the following:
	(1)	Denial of payment for new admissions.
	(2)	Civil money penalties of $50 to $3,000 per day.
	b. 	The department of inspections and appeals shall apply one or more of the remedies in Category 2 when there are:
	(1)	Widespread deficiencies that constitute no actual harm with a potential for more than minimal harm but not immediate jeopardy; or
	(2)	One or more deficiencies that constitute actual harm that is not immediate jeopardy.
	c. 	Except when the facility is in substantial compliance, the department of inspections and appeals may apply one or more of the remedies in Category 2 to any deficiency.
	81.35(5) Category 3.
	a. 	Category 3 remedies include the following:
	(1)	Temporary management.
	(2)	Immediate termination.
	(3)	Civil money penalties of $3,050 to $10,000 per day.
	b. 	When there is one or more deficiencies that constitute immediate jeopardy to resident health or safety, one or both of the following remedies shall be applied:
	(1)	Temporary management.
	(2)	Termination of the provider agreement.
In addition the department of inspections and appeals may impose a civil money penalty of $3,050 to $10,000 per day.
	c. 	When there are widespread deficiencies that constitute actual harm that is not immediate jeopardy, the department of inspections and appeals may impose temporary management, in addition to Category 2 remedies.
	81.35(6) Plan of correction.
	a. 	Except as specified in paragraph “b,” each facility that has a deficiency with regard to a requirement for long-term care facilities shall submit a plan of correction for approval by the department of inspections and appeals, regardless of:
	(1)	Which remedies are applied.
	(2)	The seriousness of the deficiencies.
	b. 	When there are only isolated deficiencies that the department of inspections and appeals determines constitute no actual harm with a potential for minimal harm, the facility need not submit a plan of correction.
	81.35(7) Appeal of a determination of noncompliance.
	a. 	A facility may request a hearing on a determination of noncompliance leading to an enforcement remedy. The affected nursing facility, or its legal representative or other authorized official, shall file the request for hearing in writing to the department of inspections and appeals within 60 days from receipt of the notice of the proposed denial, termination, or nonrenewal of participation, or imposition of a civil money penalty or other remedies.
	(1)	A request for a hearing shall be made in writing to the department of inspections and appeals within 60 days from receipt of the notice.
	(2)	Hearings shall be conducted pursuant to department of inspections and appeals rules 481—Chapter 10 and rule 481—50.6(10A), with an administrative law judge appointed as the presiding officer and with the department of inspections and appeals as the final decision maker, with subject matter jurisdiction.
	b. 	A facility may not appeal the choice of remedy, including the factors considered by the department of inspections and appeals in selecting the remedy.
	c. 	A facility may not challenge the level of noncompliance found by the department of inspections and appeals, except that in the case of a civil money penalty, a facility may challenge the level of noncompliance found by the department of inspections and appeals only if a successful challenge on this issue would affect the range of civil money penalty amounts that the department could collect.
	d. 	Except when a civil remedy penalty is imposed, the imposition of a remedy shall not be stayed pending an appeal hearing.
441—81.36(249A) Action when there is immediate jeopardy.
	81.36(1) Terminate agreement or appoint temporary manager. If there is immediate jeopardy to resident health or safety, the department of inspections and appeals shall appoint a temporary manager to remove the immediate jeopardy or the provider agreement shall be terminated within 23 calendar days of the last date of the survey.
The rules for appointment of a temporary manager in an immediate jeopardy situation are as follows:
	a. 	The department of inspections and appeals shall notify the facility that a temporary manager is being appointed.
	b. 	If the facility fails to relinquish control to the temporary manager, the provider agreement shall be terminated within 23 calendar days of the last day of the survey if the immediate jeopardy is not removed. In these cases, state monitoring may be imposed pending termination.
	c. 	If the facility relinquishes control to the temporary manager, the department of inspections and appeals shall notify the facility that, unless it removes the immediate jeopardy, its provider agreement shall be terminated within 23 calendar days of the last day of the survey.
	d. 	The provider agreement shall be terminated within 23 calendar days of the last day of survey if the immediate jeopardy has not been removed.
	81.36(2) Other remedies. The department of inspections and appeals may also impose other remedies, as appropriate.
	81.36(3) Notification of CMS. In a nursing facility or dually participating facility, if the department of inspections and appeals finds that a facility’s noncompliance poses immediate jeopardy to resident health or safety, the department of inspections and appeals shall notify CMS of the finding.
	81.36(4) Transfer of residents. The department shall provide for the safe and orderly transfer of residents when the facility is terminated from participation.
	81.36(5) Notification of physicians and state board. If the immediate jeopardy is also substandard quality of care, the department of inspections and appeals shall notify attending physicians and the Iowa board of nursing home administrators of the finding of substandard quality of care.
441—81.37(249A) Action when there is no immediate jeopardy.
	81.37(1) Termination of agreement or limitation of participation. If a facility’s deficiencies do not pose immediate jeopardy to residents’ health or safety, and the facility is not in substantial compliance, the facility’s provider agreement may be terminated or the facility may be allowed to continue to participate for no longer than six months from the last day of the survey if:
	a. 	The department of inspections and appeals finds that it is more appropriate to impose alternative remedies than to terminate the facility’s provider agreement;
	b. 	The department of inspections and appeals has submitted a plan of correction approved by CMS; and
	c. 	The facility agrees to repay payments received after the last day of the survey that first identified the deficiencies if corrective action is not taken in accordance with the approved plan of correction and posts bond acceptable to the department to guarantee the repayment.
	81.37(2) Termination. If a facility does not meet the criteria for continuation of payment under subrule 81.37(1), the facility’s provider agreement shall be terminated.
	81.37(3) Denial of payment. Payment shall be denied for new admissions when the facility is not in substantial compliance three months after the last day of the survey.
	81.37(4) Failure to comply. The provider agreement shall be terminated and all payments stopped to a facility for which participation was continued under subrule 81.37(1) if the facility is not in substantial compliance within six months of the last day of the survey.
441—81.38(249A) Action when there is repeated substandard quality of care.
	81.38(1) General. If a facility has been found to have provided substandard quality of care on the last three consecutive standard surveys, regardless of other remedies provided:
	a. 	Payment for all new admissions shall be denied, as specified in rule 441—81.40(249A).
	b. 	The department of inspections and appeals shall impose state monitoring, as specified in rule 441—81.42(249A) until the facility has demonstrated to the satisfaction of the department of inspections and appeals that it is in substantial compliance with all requirements and will remain in substantial compliance with all requirements.
	81.38(2) Repeated noncompliance. For purposes of this rule, repeated noncompliance is based on the repeated finding of substandard quality of care and not on the basis that the substance of the deficiency or the exact deficiency was repeated.
	81.38(3) Standard surveys to which this provision applies. Standard surveys completed by the department of inspections and appeals on or after October 1, 1990, are used to determine whether the threshold of three consecutive standard surveys is met.
	81.38(4) Program participation.
	a. 	The determination that a certified facility has repeated instances of substandard quality of care is made without regard to any variances in the facility’s program participation (that is, any standard survey completed for Medicare, Medicaid or both programs will be considered).
	b. 	Termination would allow the count of repeated substandard quality of care surveys to start over.
	c. 	Change of ownership.
	(1)	A facility may not avoid a remedy on the basis that it underwent a change of ownership.
	(2)	In a facility that has undergone a change of ownership, the department of inspections and appeals may not restart the count of repeated substandard quality of care surveys unless the new owner can demonstrate to the department of inspections and appeals that the poor past performance no longer is a factor due to the change in ownership.
	81.38(5) Compliance. Facility alleges corrections or achieves compliance after repeated substandard quality of care is identified.
	a. 	If a penalty is imposed for repeated substandard quality of care, it will continue until the facility has demonstrated to the satisfaction of the department of inspections and appeals that it is in substantial compliance with the requirements and that it will remain in substantial compliance for a period of time specified by the department of inspections and appeals.
	b. 	A facility will not avoid the imposition of remedies or the obligation to demonstrate that it will remain in compliance when it:
	(1)	Alleges correction of the deficiencies cited in the most recent standard survey; or
	(2)	Achieves compliance before the effective date of the remedies.
441—81.39(249A) Temporary management. The department of inspections and appeals may appoint a temporary manager from qualified applicants.
	81.39(1) Qualifications. The temporary manager must:
	a. 	Be qualified to oversee correction of deficiencies on the basis of experience and education, as determined by the department of inspections and appeals.
	b. 	Not have been found guilty of misconduct by any licensing board or professional society in any state.
	c. 	Have, or a member of the manager’s immediate family have, no financial ownership interest in the facility.
	d. 	Not currently serve or, within the past two years, have served as a member of the staff of the facility.
	81.39(2) Payment of salary. The temporary manager’s salary:
	a. 	Is paid directly by the facility while the temporary manager is assigned to that facility.
	b. 	Shall be at least equivalent to the sum of the following:
	(1)	The prevailing salary paid by providers for positions of this type in the facility’s geographic area.
	(2)	Additional costs that would have reasonably been incurred by the provider if the person had been in an employment relationship.
	(3)	Any other transportation and lodging costs incurred by the person in furnishing services under the arrangement up to the maximum per diem for state employees.
	c. 	May exceed the amount specified in paragraph “b” if the department of inspections and appeals is otherwise unable to attract a qualified temporary manager.
	81.39(3) Failure to relinquish authority to temporary management.
	a. 	If a facility fails to relinquish authority to the temporary manager, the provider agreement shall be terminated in accordance with rule 441—81.57(249A).
	b. 	A facility’s failure to pay the salary of the temporary manager is considered a failure to relinquish authority to temporary management.
	81.39(4) Duration of temporary management. Temporary management ends when the facility meets any of the conditions specified in subrule 81.56(3).
441—81.40(249A) Denial of payment for all new admissions.
	81.40(1) Optional denial of payment. Except as specified in subrule 81.40(2), the denial of payment for all new admissions may be imposed when a facility is not in substantial compliance with the requirements.
	81.40(2) Required denial of payment. Payment for all new admissions shall be denied when:
	a. 	The facility is not in substantial compliance three months after the last day of the survey identifying the noncompliance; or
	b. 	The department of inspections and appeals has cited a facility with substandard quality of care on the last three consecutive standard surveys.
	81.40(3) Resumption of payments. Repeated instances of substandard quality of care. When a facility has repeated instances of substandard quality of care, payments to the facility resume on the date that:
	a. 	The facility achieves substantial compliance as indicated by a revisit or written credible evidence acceptable to the department of inspections and appeals.
	b. 	The department of inspections and appeals determines that the facility is capable of remaining in substantial compliance.
	81.40(4) Resumption of payments. No repeated instances of substandard quality of care. When a facility does not have repeated instances of substandard quality of care, payments to the facility resume prospectively on the date that the facility achieves substantial compliance, as indicated by a revisit or written credible evidence acceptable to the department of inspections and appeals.
	81.40(5) Restriction. No payments to a facility are made for the period between the date that the denial of payment remedy is imposed and the date the facility achieves substantial compliance, as determined by the department of inspections and appeals.
441—81.41(249A) Secretarial authority to deny all payments.
	81.41(1) CMS option to deny all payment. If a facility has not met a requirement, in addition to the authority to deny payment for all new admissions as specified in rule 441—81.40(249A), CMS may deny any further payment to the state for all Medicaid residents in the facility. When CMS denies payment to the state, the department shall deny payment to the facility.
	81.41(2) Resumption of payment. When CMS resumes payment to the state, the department shall also resume payment to the facility. The department shall make payments to the facility for the same periods for which payment is made to the state.
441—81.42(249A) State monitoring.
	81.42(1) State monitor. A state monitor:
	a. 	Oversees the correction of deficiencies specified by the department of inspections and appeals at the facility site and protects the facility’s residents from harm.
	b. 	Is an employee or a contractor of the department of inspections and appeals.
	c. 	Is identified by the department of inspections and appeals as an appropriate professional to monitor cited deficiencies.
	d. 	Is not an employee of the facility.
	e. 	Does not function as a consultant to the facility.
	f. 	Does not have an immediate family member who is a resident of the facility to be monitored.
	81.42(2) Use of state monitor. A state monitor shall be used when the department of inspections and appeals has cited a facility with substandard quality of care deficiencies on the last three consecutive standard surveys.
	81.42(3) Discontinuance of state monitor. State monitoring is discontinued when:
	a. 	The facility has demonstrated that it is in substantial compliance with the requirement, and it will remain in compliance for a period of time specified by the department of inspections and appeals.
	b. 	Termination procedures are completed.
441—81.43(249A) Directed plan of correction. The department of inspections and appeals or the temporary manager (with department of inspections and appeals’ approval) may develop a plan of correction and require a facility to take action within specified time frames.
441—81.44(249A) Directed in-service training.
	81.44(1) Required training. The department of inspections and appeals may require the staff of a facility to attend an in-service training program if:
	a. 	The facility has a pattern of deficiencies that indicate noncompliance; and
	b. 	Education is likely to correct the deficiencies.
	81.44(2) Action following training. After the staff has received in-service training, if the facility has not achieved substantial compliance, the department of inspections and appeals may impose one or more other remedies.
	81.44(3) Payment. The facility is responsible for the payment for the directed in-service training.
441—81.45(249A) Closure of a facility or transfer of residents, or both.
	81.45(1) Closure during an emergency. In an emergency, the department and the department of inspections and appeals have the authority to:
	a. 	Transfer Medicaid and Medicare residents to another facility; or
	b. 	Close the facility and transfer the Medicaid and Medicare residents to another facility.
	81.45(2) Required transfer in immediate jeopardy situations. When a facility’s provider agreement is terminated for a deficiency that constitutes immediate jeopardy, the department arranges for the safe and orderly transfer of all Medicaid and Medicare residents to another facility.
	81.45(3) All other situations. Except for immediate jeopardy situations, as specified in subrule 81.45(2), when a facility’s provider agreement is terminated, the department arranges for the safe and orderly transfer of all Medicare and Medicaid residents to another facility.
441—81.46(249A) Civil money penalties—basis for imposing penalty. The department of inspections and appeals may impose a civil money penalty for the number of days a facility is not in substantial compliance with one or more participation requirements, regardless of whether or not the deficiencies constitute immediate jeopardy.
The department of inspections and appeals may impose a civil money penalty for the number of days of past noncompliance since the last standard survey, including the number of days of immediate jeopardy.
441—81.47(249A) Civil money penalties—when penalty is collected.
	81.47(1) When facility requests a hearing.
	a. 	A facility shall request a hearing on the determination of the noncompliance that is the basis for imposition of the civil money penalty within the time limit specified in subrule 81.35(7).
	b. 	If a facility requests a hearing within the time specified in subrule 81.35(7), the department of inspections and appeals initiates collection of the penalty when there is a final administrative decision that upholds the department of inspections and appeals’ determination of noncompliance after the facility achieves substantial compliance or is terminated.
	81.47(2) When facility does not request a hearing. If a facility does not request a hearing, in accordance with subrule 81.47(1), the department of inspections and appeals initiates collection of the penalty when the facility:
	a. 	Achieves substantial compliance; or
	b. 	Is terminated.
	81.47(3) When facility waives a hearing. If a facility waives its right to a hearing in writing, as specified in rule 441—81.49(249A), the department of inspections and appeals initiates collection of the penalty when the facility:
	a. 	Achieves substantial compliance; or
	b. 	Is terminated.
	81.47(4) Accrual and computation of penalties. Accrual and computation of penalties for a facility that:
	a. 	Requests a hearing or does not request a hearing as specified in rule 441—81.50(249A);
	b. 	Waives its right to a hearing in writing, as specified in subrule 81.49(2) and rule 441—81.50(249A).
	81.47(5)  Collection. The collection of civil money penalties is made as provided in rule 441—81.52(249A).
441—81.48(249A) Civil money penalties—notice of penalty. The department of inspections and appeals shall notify the facility of intent to impose a civil money penalty in writing. The notice shall include, at a minimum, the following information:
	1.	The nature of the noncompliance.
	2.	The statutory basis for the penalty.
	3.	The amount of penalty per day of noncompliance.
	4.	Any factors specified in subrule 81.50(6) that were considered when determining the amount of the penalty.
	5.	The date on which the penalty begins to accrue.
	6.	When the penalty stops accruing.
	7.	When the penalty is collected.
	8.	Instructions for responding to the notice, including a statement of the facility’s right to a hearing, and the implication of waiving a hearing, as provided in rule 441—81.49(249A).
441—81.49(249A) Civil money penalties—waiver of hearing, reduction of penalty amount.
	81.49(1) Waiver of a hearing. The facility may waive the right to a hearing, in writing, within 60 days from the date of the notice of intent to impose the civil money penalty.
	81.49(2) Reduction of penalty amount.
	a. 	If the facility waives its right to a hearing, the department of inspections and appeals reduces the civil money penalty amount by 35 percent.
	b. 	If the facility does not waive its right to a hearing, the civil money penalty is not reduced by 35 percent.
441—81.50(249A) Civil money penalties—amount of penalty.
	81.50(1) Amount of penalty. The penalties are within the following ranges, set at $50 increments:
	a. 	Upper range—$3,050 to $10,000. Penalties in the range of $3,050 to $10,000 per day are imposed for deficiencies constituting immediate jeopardy, as specified in 81.50(4)“b.”
	b. 	Lower range—$50 to $3,000. Penalties in the range of $50 to $3,000 per day are imposed for deficiencies that do not constitute immediate jeopardy, but either caused actual harm, or caused no actual harm, but have the potential for more than minimal harm.
	81.50(2) Basis for penalty amount. The amount of penalty is based on the department of inspections and appeals’ assessment of factors listed in subrule 81.50(6).
	81.50(3) Decreased penalty amounts. Except as specified in 81.50(4)“b,” if immediate jeopardy is removed, but the noncompliance continues, the department of inspections and appeals shall shift the penalty amount to the lower range.
	81.50(4) Increased penalty amounts.
	a. 	Before the hearing, the department of inspections and appeals may propose to increase the penalty amount for facility noncompliance which, after imposition of a lower level penalty amount, becomes sufficiently serious to pose immediate jeopardy.
	b. 	The department of inspections and appeals shall increase the penalty amount for any repeated deficiencies for which a lower level penalty amount was previously imposed, regardless of whether the increased penalty amount would exceed the range otherwise reserved for nonimmediate jeopardy deficiencies.
	c. 	Repeated deficiencies are deficiencies in the same regulatory grouping of requirements found at the last survey, subsequently corrected, and found again at the next survey.
	81.50(5) Review of the penalty. When an administrative law judge (or director of the department of inspections and appeals) finds that the basis for imposing a civil money penalty exists, the administrative law judge (or director) may not:
	a. 	Set a penalty of zero or reduce a penalty to zero.
	b. 	Review the exercise of discretion by the department of inspections and appeals to impose a civil money penalty.
	c. 	Consider any factors in reviewing the amount of the penalty other than those specified in subrule 81.50(6).
	81.50(6) Factors affecting the amount of penalty. In determining the amount of penalty, the department of inspections and appeals shall take into account the following factors:
	a. 	The facility’s history of noncompliance, including repeated deficiencies.
	b. 	The facility’s financial condition.
	c. 	The factors specified in rule 441—81.33(249A).
	d. 	The facility’s degree of culpability. Culpability includes, but is not limited to, neglect, indifference, or disregard for resident care, comfort or safety. The absence of culpability is not a mitigating circumstance in reducing the amount of the penalty.
441—81.51(249A) Civil money penalties—effective date and duration of penalty.
	81.51(1) When penalty begins to accrue. The civil money penalty may start accruing as early as the date the facility was first out of compliance, as determined by the department of inspections and appeals.
	81.51(2) Duration of penalty. The civil money penalty is computed and collectible, as specified in rules 441—81.47(249A) and 441—81.52(249A), for the number of days of noncompliance until the date the facility achieves substantial compliance or, if applicable, the date of termination when:
	a. 	The department of inspections and appeals’ decision of noncompliance is upheld after a final administrative decision;
	b. 	The facility waives its right to a hearing in accordance with rule 441—81.49(249A); or
	c. 	The time for requesting a hearing has expired and the department of inspections and appeals has not received a hearing request from the facility.
	81.51(3)  Penalty due. The entire accrued penalty is due and collectible, as specified in the notice sent to the provider under subrules 81.51(4) and 81.54(5).
	81.51(4) Notice after facility achieves compliance. When a facility achieves substantial compliance, the department of inspections and appeals shall send a separate notice to the facility containing:
	a. 	The amount of penalty per day;
	b. 	The number of days involved;
	c. 	The total amount due;
	d. 	The due date of the penalty; and
	e. 	The rate of interest assessed on the unpaid balance beginning on the due date, as provided in rule 441—81.52(249A).
	81.51(5) Notice to terminated facility. In the case of a terminated facility, the department of inspections and appeals shall send this penalty information after the:
	a. 	Final administrative decision is made;
	b. 	Facility has waived its right to a hearing in accordance with rule 441—81.49(249A); or
	c. 	Time for requesting a hearing has expired and the department of inspections and appeals has not received a hearing request from the facility.
	81.51(6) Accrual of penalties when there is no immediate jeopardy.
	a. 	In the case of noncompliance that does not pose immediate jeopardy, the daily accrual of civil money penalties is imposed for the days of noncompliance prior to the notice specified in rule 441—81.48(249A) and an additional period of no longer than six months following the last day of the survey.
	b. 	After the period specified in paragraph “a,” if the facility has not achieved substantial compliance, the provider agreement may be terminated.
	81.51(7) Accrual of penalties when there is immediate jeopardy.
	a. 	When a facility has deficiencies that pose immediate jeopardy, the provider agreement shall be terminated within 23 calendar days after the last day of the survey if the immediate jeopardy remains.
	b. 	The accrual of the civil money penalty stops on the day the provider agreement is terminated.
	81.51(8) Documenting substantial compliance.
	a. 	If an on-site revisit is necessary to confirm substantial compliance and the provider can supply documentation acceptable to the department of inspections and appeals that substantial compliance was achieved on a date preceding the revisit, penalties only accrue until that date of correction for which there is written credible evidence.
	b. 	If an on-site revisit is not necessary to confirm substantial compliance, penalties only accrue until the date of correction for which the department of inspections and appeals receives and accepts written credible evidence.
441—81.52(249A) Civil money penalties—due date for payment of penalty.
	81.52(1) When payments are due.
	a. 	A civil money penalty payment is due 15 days after a final administrative decision is made when:
	(1)	The facility achieves substantial compliance before the final administrative decision; or
	(2)	The effective date of termination occurs before the final administrative decision.
	b. 	A civil money penalty is due 15 days after the time period for requesting a hearing has expired and a hearing request was not received when:
	(1)	The facility achieves substantial compliance before the hearing request was due; or
	(2)	The effective date of termination occurs before the hearing request was due.
	c. 	A civil money penalty payment is due 15 days after receipt of the written request to waive a hearing when:
	(1)	The facility achieved substantial compliance before the department of inspections and appeals received the written waiver of hearing; or
	(2)	The effective date of termination occurs before the department of inspections and appeals received the written waiver of hearing.
	d. 	A civil money penalty payment is due 15 days after substantial compliance is achieved when:
	(1)	The final administrative decision is made before the facility came into compliance;
	(2)	The facility did not file a timely hearing request before it came into substantial compliance; or
	(3)	The facility waived its right to a hearing before it came into substantial compliance.
	e. 	A civil money penalty payment is due 15 days after the effective date of termination, if before the effective date of termination:
	(1)	The final administrative decision was made;
	(2)	The time for requesting a hearing has expired and the facility did not request a hearing; or
	(3)	The facility waived its right to a hearing.
	f. 	In the cases specified in paragraph “d,” the period of noncompliance may not extend beyond six months from the last day of the survey.
	81.52(2) Deduction of penalty from amount owed. The amount of the penalty, when determined, may be deducted from any sum then or later owing by the department to the facility.
	81.52(3) Interest. Interest of 10 percent per year is assessed on the unpaid balance of the penalty, beginning on the due date.
	81.52(4) Penalties collected by the department.
	a. 	Civil money penalties collected by the department shall be applied to the protection of the health or property of residents of facilities that the department of inspections and appeals finds deficient, such as:
	(1)	Payment for the cost of relocating residents to other facilities;
	(2)	State costs related to the operation of a facility pending correction of deficiencies or closure; and
	(3)	Reimbursement of residents for personal funds or property lost at a facility as a result of actions by the facility or by individuals used by the facility to provide services to residents.
	b. 	Reserved.
441—81.53(249A) Civil money penalties—settlement of penalties. The department of inspections and appeals has the authority to settle cases at any time prior to the evidentiary hearing decision.
441—81.54(249A) Continuation of payments to a facility with deficiencies.
	81.54(1) Criteria.
	a. 	The department may continue payments to a facility that is not in substantial compliance for the periods specified in subrule 81.54(3) if the following criteria are met:
	(1)	The department of inspections and appeals finds that it is more appropriate to impose alternative remedies than to terminate the facility;
	(2)	The department of inspections and appeals has submitted a plan and timetable for corrective action approved by CMS; and
	(3)	The facility agrees to repay the department for all payments received under this provision if corrective action is not taken in accordance with the approved plan and timetable for corrective action and posts a bond acceptable to the department to guarantee agreement to repay.
	b. 	The facility provider agreement may be terminated before the end of the correction period if the criteria in 81.54(1)“a” are not met.
	81.54(2) Cessation of payments. If termination is not sought, either by itself or along with another remedy or remedies, or any of the criteria in 81.54(1)“a” are not met or agreed to by either the facility or the department, the facility shall receive no payments, as applicable, from the last day of the survey.
	81.54(3) Period of continued payments. If the conditions in 81.54(1)“a” are met, the department may continue payments to a facility with noncompliance that does not constitute immediate jeopardy for up to six months from the last day of the survey.
	81.54(4) Failure to achieve substantial compliance. If the facility does not achieve substantial compliance by the end of the period specified in subrule 81.54(3), the provider agreement for the facility may be terminated.
441—81.55(249A) State and federal disagreements involving findings not in agreement when there is no immediate jeopardy. This rule applies when CMS and the department of inspections and appeals disagree over findings of noncompliance or application of remedies.
	81.55(1) Disagreement over whether facility has met requirements.
	a. 	The department of inspections and appeals’ finding of noncompliance takes precedence when:
	(1)	CMS finds the facility is in substantial compliance with the participation requirements; and
	(2)	The department of inspections and appeals finds the facility has not achieved substantial compliance.
	b. 	CMS’s findings of noncompliance take precedence when:
	(1)	CMS finds that a facility has not achieved substantial compliance; and
	(2)	The department of inspections and appeals finds the facility is in substantial compliance with the participation requirements.
	c. 	When CMS’s survey findings take precedence, CMS may:
	(1)	Impose any of the alternative remedies specified in rule 441—81.34(249A);
	(2)	Terminate the provider agreement subject to the applicable conditions of rule 441—81.54(249A); and
	(3)	Stop federal financial participation to the department for a nursing facility.
	81.55(2) Disagreement over decision to terminate.
	a. 	CMS’s decision to terminate the participation of a facility takes precedence when:
	(1)	Both CMS and the department of inspections and appeals find that the facility has not achieved substantial compliance; and
	(2)	CMS, but not the department of inspections and appeals, finds that the facility’s participation should be terminated. CMS will permit continuation of payment during the period prior to the effective date of termination, not to exceed six months, if the applicable conditions of rule 441—81.54(249A) are met.
	b. 	The department of inspections and appeals’ decision to terminate a facility’s participation and the procedures for appealing the termination take precedence when:
	(1)	The department of inspections and appeals, but not CMS, finds that a facility’s participation should be terminated; and
	(2)	The department of inspections and appeals’ effective date for the termination of the nursing facility’s provider agreement is no later than six months after the last day of survey.
	81.55(3) Disagreement over timing of termination of facility. The department of inspections and appeals’ timing of termination takes precedence if it does not occur later than six months after the last day of the survey when both CMS and the department of inspections and appeals find that:
	a. 	A facility is not in substantial compliance; and
	b. 	The facility’s participation should be terminated.
	81.55(4) Disagreement over remedies.
	a. 	When CMS or the department of inspections and appeals, but not both, establishes one or more remedies, in addition to or as an alternative to termination, the additional or alternative remedies will also apply when:
	(1)	Both CMS and the department of inspections and appeals find that a facility has not achieved substantial compliance; and
	(2)	Both CMS and the department of inspections and appeals find that no immediate jeopardy exists.
	b. 	When CMS and the department of inspections and appeals establish one or more remedies, in addition to or as an alternative to termination, only the CMS remedies apply when both CMS and the department of inspections and appeals find that a facility has not achieved substantial compliance.
	81.55(5) One decision. Regardless of whether CMS’s or the department of inspections and appeals’ decision controls, only one noncompliance and enforcement decision is applied to the Medicaid agreement, and for a dually participating facility, that same decision will apply to the Medicare agreement.
441—81.56(249A) Duration of remedies.
	81.56(1) Remedies continue. Except as specified in subrule 81.56(2), alternative remedies continue until:
	a. 	The facility has achieved substantial compliance as determined by the department of inspections and appeals based upon a revisit or after an examination of credible written evidence that it can verify without an on-site visit; or
	b. 	The provider agreement is terminated.
	81.56(2) State monitoring. In the cases of state monitoring and denial of payment imposed for repeated substandard quality of care, remedies continue until:
	a. 	The department of inspections and appeals determines that the facility has achieved substantial compliance and is capable of remaining in substantial compliance; or
	b. 	The provider agreement is terminated.
	81.56(3) Temporary management. In the case of temporary management, the remedy continues until:
	a. 	The department of inspections and appeals determines that the facility has achieved substantial compliance and is capable of remaining in substantial compliance;
	b. 	The provider agreement is terminated; or
	c. 	The facility which has not achieved substantial compliance reassumes management control. In this case, the department of inspections and appeals initiates termination of the provider agreement and may impose additional remedies.
	81.56(4) Facility in compliance. If the facility can supply documentation acceptable to the department of inspections and appeals that it was in substantial compliance, and was capable of remaining in substantial compliance, if necessary, on a date preceding that of the revisit, the remedies terminate on the date that the department of inspections and appeals can verify as the date that substantial compliance was achieved.
441—81.57(249A) Termination of provider agreement.
	81.57(1) Effect of termination. Termination of the provider agreement ends payment to the facility and any alternative remedy.
	81.57(2) Basis of termination.
	a. 	A facility’s provider agreement may be terminated if a facility:
	(1)	Is not in substantial compliance with the requirements of participation, regardless of whether or not immediate jeopardy is present; or
	(2)	Fails to submit an acceptable plan of correction within the time frame specified by the department of inspections and appeals.
	b. 	A facility’s provider agreement shall be terminated if a facility:
	(1)	Fails to relinquish control to the temporary manager, if that remedy is imposed by the department of inspections and appeals; or
	(2)	Does not meet the eligibility criteria for continuation of payment as set forth in 81.37(1)“a.”
	81.57(3) Notice of termination. Before a provider agreement is terminated, the department of inspections and appeals shall notify the facility and the public:
	a. 	At least two calendar days before the effective date of termination for a facility with immediate jeopardy deficiencies; and
	b. 	At least 15 calendar days before the effective date of termination for a facility with nonimmediate jeopardy deficiencies that constitute noncompliance.
These rules are intended to implement Iowa Code section 249A.4.
[Filed June 21, 1973; amended June 3, 1975]
[Filed 6/25/76, Notice 5/17/76—published 7/12/76, effective 8/16/76]
[Filed 2/25/77, Notice 1/12/77—published 3/23/77, effective 5/1/77]
[Filed 6/10/77, Notice 5/4/77—published 6/29/77, effective 8/3/77]
[Filed 10/24/77, Notice 9/7/77—published 11/16/77, effective 12/21/77]
[Filed 11/7/78, Notice 4/19/78—published 11/29/78, effective 1/3/79]
[Filed 6/5/79, Notice 4/4/79—published 6/27/79, effective 8/1/79]
[Filed 8/2/79, Notice 2/21/79—published 8/22/79, effective 9/26/79]
[Filed 9/27/79, Notice 7/25/79—published 10/17/79, effective 11/21/79]
[Filed 10/24/79, Notice 5/30/79—published 11/14/79, effective 12/19/79]
[Filed 10/24/79, Notice 9/5/79—published 11/14/79, effective 12/19/79]
[Filed 2/14/80, Notice 8/22/79—published 3/5/80, effective 4/9/80]
[Filed 4/4/80, Notice 1/23/80—published 4/30/80, effective 6/4/80]
[Filed 6/4/80, Notice 4/2/80—published 6/25/80, effective 7/30/80]
[Filed 7/3/80, Notice 4/16/80—published 7/23/80, effective 8/27/80]
[Filed 12/19/80, Notice 10/29/80—published 1/7/81, effective 2/11/81]
[Filed 2/12/81, Notice 1/7/81—published 3/4/81, effective 4/8/81]
[Filed 6/30/81, Notice 4/29/81—published 7/22/81, effective 9/1/81]
[Filed 7/23/81, Notice 5/27/81—published 8/19/81, effective 9/23/81]
[Filed 11/20/81, Notice 10/14/81—published 12/9/81, effective 2/1/82]
[Filed emergency 3/26/82—published 4/14/82, effective 4/1/82]
[Filed 4/29/82, Notice 12/9/81—published 5/26/82, effective 7/1/82]
[Filed 7/1/82, Notice 4/28/82—published 7/21/82, effective 9/1/82]
[Filed 8/20/82, Notice 6/23/82—published 9/15/82, effective 10/20/82]
[Filed 9/23/82, Notice 8/4/82—published 10/13/82, effective 12/1/82]
[Filed emergency 1/14/83—published 2/2/83, effective 1/14/83]
[Filed 3/25/83, Notice 1/19/83—published 4/13/83, effective 6/1/83]
[Filed 5/20/83, Notice 4/13/83—published 6/8/83, effective 8/1/83]
[Filed emergency 6/17/83—published 7/6/83, effective 7/1/83]
[Filed 9/19/83, Notice 4/27/83—published 10/12/83, effective 12/1/83]
[Filed emergency 10/7/83—published 10/26/83, effective 11/1/83]
[Filed without Notice 10/7/83—published 10/26/83, effective 12/1/83]
[Filed 11/18/83, Notice 10/12/83—published 12/7/83, effective 2/1/84]
[Filed 12/16/83, Notice 11/9/83—published 1/4/84, effective 3/1/84]
[Filed emergency 6/15/84—published 7/4/84, effective 7/1/84]
[Filed emergency 8/31/84—published 9/26/84, effective 10/1/84]
[Filed 11/1/84, Notice 9/12/84—published 11/21/84, effective 1/1/85]
[Filed emergency 6/14/85—published 7/3/85, effective 7/1/85]
[Filed 6/14/85, Notice 5/8/85—published 7/3/85, effective 9/1/85]
[Filed 8/23/85, Notice 7/3/85—published 9/11/85, effective 11/1/85]
[Filed emergency 10/1/85—published 10/23/85, effective 11/1/85]
[Filed without Notice 10/1/85—published 10/23/85, effective 12/1/85]
[Filed 10/18/85, Notice 8/28/85—published 11/6/85, effective 1/1/86]
[Filed 12/2/85, Notice 10/23/85—published 12/18/85, effective 2/1/86]
[Filed emergency 6/26/86—published 7/16/86, effective 7/1/86]
[Filed 9/26/86, Notice 8/13/86—published 10/22/86, effective 12/1/86]
[Filed 12/22/86, Notice 10/22/86—published 1/14/87, effective 3/1/87]
[Filed emergency 1/15/87—published 2/11/87, effective 1/15/87]
[Filed emergency 6/19/87—published 7/15/87, effective 7/1/87]
[Filed 10/23/87, Notice 7/15/87—published 11/18/87, effective 1/1/88]
[Filed 4/22/88, Notice 3/9/88—published 5/18/88, effective 7/1/88]
[Filed emergency 6/9/88—published 6/29/88, effective 7/1/88]
[Filed 6/9/88, Notice 4/20/88—published 6/29/88, effective 9/1/88]
[Filed 10/27/88, Notice 8/24/88—published 11/16/88, effective 1/1/89]
[Filed emergency 11/16/88 after Notice 10/5/88—published 12/14/88, effective 1/1/89]
[Filed emergency 6/8/89 after Notice 2/22/89—published 6/28/89, effective 7/1/89]
[Filed emergency 6/9/89—published 6/28/89, effective 7/1/89]
[Filed 7/14/89, Notices 4/19/89, 5/31/89—published 8/9/89, effective 10/1/89]
[Filed 8/17/89, Notice 6/28/89—published 9/6/89, effective 11/1/89]
[Filed emergency 2/14/90—published 3/7/90, effective 2/14/90]
[Filed 3/16/90, Notice 11/15/90—published 4/4/90, effective 6/1/90]
[Filed emergency 6/19/90—published 7/11/90, effective 7/1/90]
[Filed 7/13/90, Notices 3/7/90, 5/30/90—published 8/8/90, effective 10/1/901]
[Filed 8/16/90, Notice 6/27/90—published 9/5/90, effective 11/1/90]
[Filed 9/28/90, Notices 7/11/90, 8/8/90—published 10/17/90, effective 12/1/902]
[Filed emergency 11/14/90—published 12/12/90, effective 12/1/90]
[Filed emergency 2/22/91—published 3/20/91, effective 3/1/91]
[Filed emergency 6/14/91—published 7/10/91, effective 7/1/91]
[Filed 6/14/91, Notices 3/20/91, 5/1/91—published 7/10/91, effective 9/1/91]
[Filed 7/10/91, Notice 5/29/91—published 8/7/91, effective 10/1/91]
[Filed 9/18/91, Notices 7/10/91, 7/24/91—published 10/16/91, effective 12/1/91]
[Filed 10/10/91, Notice 8/21/91—published 10/30/91, effective 1/1/92]
[Filed 2/13/92, Notice 1/8/92—published 3/4/92, effective 4/8/92]
[Filed without Notice 5/14/92—published 6/10/92, effective 7/15/923]
[Filed emergency 6/12/92—published 7/8/92, effective 7/1/92]
[Filed 8/14/92, Notice 7/8/92—published 9/2/92, effective 11/1/92]
[Filed 11/10/92, Notice 9/30/92—published 12/9/92, effective 2/1/93]
[Filed 1/14/93, Notice 12/9/92—published 2/3/93, effective 4/1/93]
[Filed 3/11/93, Notice 1/20/93—published 3/31/93, effective 6/1/934]
[Filed emergency 6/11/93—published 7/7/93, effective 7/1/93]
[Filed 8/12/93, Notice 7/7/93—published 9/1/93, effective 11/1/93]
[Filed emergency 6/16/94—published 7/6/94, effective 7/1/94]
[Filed 9/15/94, Notice 7/6/94—published 10/12/94, effective 12/1/94]
[Filed emergency 4/12/95—published 5/10/95, effective 4/12/95]
[Filed 4/13/95, Notice 3/1/95—published 5/10/95, effective 7/1/95]
[Filed emergency 6/7/95—published 7/5/95, effective 7/1/95]
[Filed 8/10/95, Notice 7/5/95—published 8/30/95, effective 11/1/95]
[Filed 11/16/95, Notice 9/27/95—published 12/6/95, effective 2/1/96]
[Filed emergency 6/13/96—published 7/3/96, effective 7/1/96]
[Filed 8/15/96, Notice 7/3/96—published 9/11/96, effective 11/1/96]
[Filed 4/11/97, Notice 2/12/97—published 5/7/97, effective 7/1/97]
[Filed emergency 6/12/97—published 7/2/97, effective 7/1/97]
[Filed 9/16/97, Notice 7/2/97—published 10/8/97, effective 12/1/97]
[Filed emergency 5/13/98—published 6/3/98, effective 6/22/98]
[Filed emergency 6/10/98—published 7/1/98, effective 7/1/98]
[Filed 7/15/98, Notice 6/3/98—published 8/12/98, effective 10/1/98]
[Filed emergency 8/12/98—published 9/9/98, effective 8/12/98]
[Filed 8/12/98, Notice 7/1/98—published 9/9/98, effective 11/1/98]
[Filed 9/15/98, Notice 7/29/98—published 10/7/98, effective 12/1/98]
[Filed 10/14/98, Notice 9/9/98—published 11/4/98, effective 1/1/99]
[Filed 11/10/98, Notice 8/26/98—published 12/2/98, effective 2/1/99]
[Filed emergency 6/10/99—published 6/30/99, effective 7/1/99]
[Filed 8/12/99, Notices 5/5/99, 6/30/99—published 9/8/99, effective 11/1/99]
[Filed 11/10/99, Notice 9/22/99—published 12/1/99, effective 2/1/00]
[Filed 4/12/00, Notice 3/8/00—published 5/3/00, effective 7/1/00]
[Filed emergency 6/8/00—published 6/28/00, effective 7/1/00]
[Filed 8/9/00, Notice 6/14/00—published 9/6/00, effective 11/1/00]
[Filed emergency 6/13/01—published 7/11/01, effective 7/1/01]
[Filed 7/11/01, Notice 5/16/01—published 8/8/01, effective 10/1/01]
[Filed 12/12/01, Notice 10/17/01—published 1/9/02, effective 3/1/02]
[Filed 1/9/02, Notice 10/31/01—published 2/6/02, effective 3/13/02]
[Filed 1/9/02, Notice 11/28/01—published 2/6/02, effective 4/1/02]
[Filed emergency 1/16/02—published 2/6/02, effective 2/1/025]
[Filed emergency 4/12/02—published 5/1/02, effective 4/12/02]
[Filed 2/13/03, Notice 12/25/02—published 3/5/03, effective 5/1/03]
[Filed 5/16/03, Notice 4/2/03—published 6/11/03, effective 7/16/03]
[Filed emergency 6/12/03—published 7/9/03, effective 7/1/03]
[Filed 9/22/03, Notice 7/9/03—published 10/15/03, effective 12/1/03]
[Filed emergency 11/19/03—published 12/10/03, effective 12/1/03]
[Filed emergency 6/14/04—published 7/7/04, effective 7/1/04]
[Filed 9/23/04, Notice 7/7/04—published 10/13/04, effective 11/17/04]
[Filed without Notice 5/4/05—published 5/25/05, effective 7/1/05]
[Filed emergency 6/17/05—published 7/6/05, effective 7/1/05]
[Filed 10/21/05, Notice 7/6/05—published 11/9/05, effective 12/14/05]
[Filed 10/21/05, Notice 8/31/05—published 11/9/05, effective 1/1/06]
[Filed emergency 5/12/06—published 6/7/06, effective 6/1/06]
[Filed emergency 6/16/06—published 7/5/06, effective 7/1/06]
[Filed 7/14/06, Notice 6/7/06—published 8/2/06, effective 9/6/06]
[Filed 11/8/06, Notice 7/5/06—published 12/6/06, effective 1/10/07]
[Filed 2/15/07, Notice 12/20/06—published 3/14/07, effective 5/1/07]
[Filed 8/9/07, Notice 6/20/07—published 8/29/07, effective 11/1/07]
[Filed emergency 11/14/07 after Notice 9/26/07—published 12/5/07, effective 11/15/07]
[Filed 4/10/08, Notice 1/30/08—published 5/7/08, effective 7/1/08]
[Filed without Notice 7/9/08—published 7/30/08, effective 9/3/08]
[Filed 10/14/08, Notice 7/30/08—published 11/5/08, effective 12/10/08]
[Filed ARC 8258B (Notice ARC 8086B, IAB 8/26/09), IAB 11/4/09, effective 1/1/10]
[Filed Emergency ARC 8344B, IAB 12/2/09, effective 12/1/09]
1	Effective date of 81.16(4) delayed 30 days by the Administrative Rules Review Committee at its September 12, 1990, meeting; at the October 9, 1990, meeting the delay was extended to 70 days. Amendment effective 12/1/90 superseded the 70-day delay.
2	Effective date of 81.10(5) delayed until adjournment of the 1991 session of the General Assembly by the Administrative Rules Review Committee at its November 13, 1990, meeting.
3	Effective date of 81.13(7)“c”(1) delayed 70 days by the Administrative Rules Review Committee at its meeting held July 14, 1992; delay lifted by the Committee at its meeting held August 11, 1992, effective August 12, 1992.
4	Effective date of 81.6(3), first unnumbered paragraph, delayed 70 days by the Administrative Rules Review Committee at its meeting held April 5, 1993.
5	At a special meeting held January 24, 2002, the Administrative Rules Review Committee voted to delay until adjournment of the 2002 Session of the General Assembly the effective date of amendments published in the February 6, 2002, Iowa Administrative Bulletin as ARC 1365B.
Objection
At its meeting held August 11, 1992, the Administrative Rules Review Committee voted to object to the amendments published in ARC 3069A on the grounds the amendments are unreasonable. This filing is published in IAB Vol. XIV No.	253 (06-10-92). It is codified as an amendment to paragraph 441 IAC 81.13(7)“c”(1).
In brief, this filing provides that care facilities shall not employ persons who have been found guilty in a court of law of abusing, neglecting or mistreating facility residents, or who have had a “finding” entered into the state nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property. Additionally, the filing eliminates a previous provision which allowed the Department of Inspections and Appeals some discretion in deciding whether the lifetime ban on employment should be applied.
This language originated in the federal government which mandated that the department adopt these provisions or possibly face sanctions. The Committee does not believe these amendments are an improvement to Iowa’s system and has the following objection. The Committee believes that the amendments published in ARC 3069A are unreasonable because of the inconsistency in the burdens of proof and the levels of procedural safeguards in the two proceedings. A facility employee may either be found guilty in a court of law or have an administrative finding entered into the registry. In either case the result is the same, the employee is permanently banned from further employment in a care facility; however, the two paths to the result are significantly different. The first proceeding is a criminal tribunal in which the burden of proof is “beyond a reasonable doubt.” The second proceeding is a simple administrative hearing in which the burden is “preponderance of the evidence.” The two proceedings also differ in the level of many other due process protections accorded to the individual. A criminal proceeding provides the accused with the opportunity for a trial by jury, competent legal counsel, strict rules of evidence and many procedural protections not present in administrative hearings. It should also be noted that the penalty in this situation—a lifetime ban on employment—is more serious than is usually imposed in contested cases. In licensee discipline cases, a license can be revoked, but the possibility of reinstatement exists; under this new rule no reinstatement is allowed, the facility employee is banned from employment no matter how serious or minor the offense or how far in the past it occurred. Because of the magnitude of this penalty, the Committee believes that the accused should be provided with greater procedural protections than are generally found in administrative hearings.
The Committee also believes this filing is unreasonable because it eliminates the discretion accorded to the Department of Inspections and Appeals to not apply the lifetime ban on employment. Under the previous rule, the department’s discretion in applying the employment ban acted as a safeguard against unjust results. It recognized that a person would make amends for past offenses and earn a second chance. The provision was a genuine improvement in the process; it recognized that flexibility was needed in government decision making and that some decisions should be made on a case-by-case basis. There does not appear to be any rational basis to justify the elimination of this safeguard and, therefore, the Committee believes this action to be unreasonable.