481—70.4 (231D) Nonaccredited program—application content. An application for certification or recertification of a nonaccredited program shall include the following:
	 70.4(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 and of the designated manager, as well as stockholders, partners or any individuals who have greater than a 5 percent equity interest in the program. The program shall notify the department of any changes in the list within ten working days of the change.
	 70.4(2) A statement affirming that the individuals listed in subrule 70.4(1) have not been convicted of a felony or serious misdemeanor or found in violation of the dependent adult abuse code in any state.
	 70.4(3) A statement disclosing whether any of the individuals listed in subrule 70.4(1) have or have had an ownership interest in an adult day services program, assisted living 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 or a boarding home as defined in 2009 Iowa Acts, Senate File 484, section 3 (to be codified as Iowa Code Supplement section 135O.1), which has been closed in any state due to removal of program, agency, or facility licensure or certification or due to involuntary termination from participation in either the Medicaid or Medicare program; or have been found to have failed to provide adequate protection or services for participants to prevent abuse or neglect.
	 70.4(4) The policy and procedure for evaluation of each participant. A copy of the evaluation tool or tools to be used to identify the functional, cognitive and health status of each participant shall be included.
	 70.4(5) The policy and procedure for service plans.
	 70.4(6) The policy and procedure for addressing medication needs of participants.
	 70.4(7) The policy and procedure for accidents and emergency response.
	 70.4(8) The policies and procedures for food service, including those relating to staffing, nutrition, menu planning, therapeutic diets, and food preparation, service and storage.
	 70.4(9) The policy and procedure for activities.
	 70.4(10) The policy and procedure for transportation.
	 70.4(11) The policy and procedure for staffing and training.
	 70.4(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.
	 70.4(13) The policy and procedure for managing risk and upholding participant autonomy when participant decision making results in poor outcomes for the participant or others.
	 70.4(14) The policy and procedure for reporting incidents including dependent adult abuse as required in rule 481—67.2(231B,231C,231D).
	 70.4(15) The policy and procedure related to life safety requirements for a dementia-specific program as required by subrule 70.32(2).
	 70.4(16) The participant contractual agreement and all attachments.
	 70.4(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.
	 70.4(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.
	 70.4(19) The fee set forth in Iowa Code section 231D.4.
[ARC 8177B, IAB 9/23/09, effective 1/1/10]