481—69.4 (231C) Nonaccredited program—application content. An application for certification or recertification of a nonaccredited program shall include the following:
	   69.4(1) A list that includes the names, addresses, and percentage of stock, shares, partnership or other equity interest of all officers, members of the board of directors and trustees, as well as stockholders, partners or any individuals who have greater than a 10 percent equity interest in each of the following, as applicable:
	      a.    	 The real estate owner or lessor;
	      b.    	 The lessee; and
	      c.    	 The management company responsible for the day-to-day operation of the program.
The program shall notify the department of any changes in the list no later than ten working days after the effective date of the change.
	   69.4(2) A statement disclosing whether the individuals listed in subrule 69.4(1) have been convicted of a felony or an aggravated or serious misdemeanor or found to be in violation of the child abuse or dependent adult abuse laws of any state.
	   69.4(3) A statement disclosing whether any of the individuals listed in subrule 69.4(1) have or have had an ownership interest in an assisted living program, adult day services program, elder group home, home health agency, licensed health care facility as defined in Iowa Code section 135C.1, or licensed hospital as defined in Iowa Code section 135B.1, which has been closed in any state due to removal of program, agency, or facility licensure, certification, or registration or due to involuntary termination from participation in either the Medicaid or Medicare program; or have been found to have failed to provide adequate protection or services to prevent abuse or neglect of residents, patients, tenants or participants.
	   69.4(4) The policy and procedure for evaluation of each tenant. A copy of the evaluation tool or tools to be used to identify the functional, cognitive and health status of each tenant shall be included.
	   69.4(5) The policy and procedure for service plans.
	   69.4(6) The policy and procedure for addressing medication needs of tenants.
	   69.4(7) The policy and procedure for accidents and emergency response, including provisions related to head injuries.
	   69.4(8) The policies and procedures for food service, including those relating to staffing, nutrition, menu planning, therapeutic diets, and food preparation, service and storage.
	   69.4(9) The policy and procedure for activities.
	   69.4(10) The policy and procedure for transportation.
	   69.4(11) The policy and procedure for staffing and training.
	   69.4(12) The policy and procedure for emergencies, including natural disasters. The policy and procedure shall include an evacuation plan and procedures for notifying legal representatives in emergency situations as applicable.
	   69.4(13) The policy and procedure for managing risk and upholding tenant autonomy when tenant decision making results in poor outcomes for the tenant or others.
	   69.4(14) The policy and procedure for reporting incidents including dependent adult abuse as required in rule 481—67.2(231B,231C,231D).
	   69.4(15) The policy and procedure related to life safety requirements for a dementia-specific program as required by subrule 69.32(2).
	   69.4(16) The tenant occupancy agreement and all attachments.
	   69.4(17) If the program contracts for personal care or health-related care services from a certified home health agency, a mental health center or a licensed health care facility, a copy of that entity’s current license or certification.
	   69.4(18) A copy of the state license for the entity that provides food service, whether the entity is the program or an outside entity or a combination of both.
	   69.4(19) The fee set forth in Iowa Code section 231C.18.
	   69.4(20) The policy and procedure for addressing sexual relationships between tenants and staff or between tenants with dementia greater than Stage 5 on the Global Deterioration Scale.
[ARC 8176B, IAB 9/23/09, effective 1/1/10; ARC 1927C, IAB 4/1/15, effective 5/6/15; ARC 2463C, IAB 3/16/16, effective 4/20/16]