441—77.25 (249A) Home- and community-based habilitation services. To be eligible to participate in the Medicaid program as an approved provider of home- and community-based habilitation services, a provider shall be an enrolled provider of habilitation with the Iowa Plan for Behavioral Health and meet the general requirements in subrules 77.25(2), 77.25(3), and 77.25(4) and shall meet the requirements in the subrules applicable to the individual services being provided.
	   77.25(1) Definitions.
“Guardian” means a guardian appointed in probate or juvenile court.
“Major incident” means an occurrence involving a member during service provision that:
	      1. 	  Results in a physical injury to or by the member that requires a physician’s treatment or admission to a hospital;
	      2. 	  Results in the death of any person;
	      3. 	  Requires emergency mental health treatment for the member;
	      4. 	  Requires the intervention of law enforcement;
	      5. 	  Requires a report of child abuse pursuant to Iowa Code section 232.69 or a report of dependent adult abuse pursuant to Iowa Code section 235B.3;
	      6. 	  Constitutes a prescription medication error or a pattern of medication errors that leads to the outcome in paragraph “1,” “2,” or “3”; or
	      7. 	  Involves a member’s location being unknown by provider staff who are assigned protective oversight.
“Member” means a person who has been determined to be eligible for Medicaid under 441—Chapter 75.
“Minor incident” means an occurrence involving a member during service provision that is not a major incident and that:
	      1. 	  Results in the application of basic first aid;
	      2. 	  Results in bruising;
	      3. 	  Results in seizure activity;
	      4. 	  Results in injury to self, to others, or to property; or
	      5. 	  Constitutes a prescription medication error.
	   77.25(2) Organization and staff.
	      a.    	 The prospective provider shall demonstrate the fiscal capacity to initiate and operate the specified programs on an ongoing basis.
	      b.    	 The provider shall complete child abuse, dependent adult abuse, and criminal background screenings pursuant to Iowa Code section 249A.29 before employing a person who will provide direct care.
	      c.    	 A person providing direct care shall be at least 16 years of age.
	      d.    	 A person providing direct care shall not be an immediate family member of the member.
	   77.25(3) Incident management and reporting. As a condition of participation in the medical assistance program, HCBS habilitation service providers must comply with the requirements of Iowa Code sections 232.69 and 235B.3 regarding the reporting of child abuse and dependent adult abuse and with the incident management and reporting requirements in this subrule.
	      a.    	  Reporting procedure for minor incidents. Minor incidents may be reported in any format designated by the provider. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident. The completed report shall be maintained in a centralized file with a notation in the member’s file.
	      b.    	  Reporting procedure for major incidents. When a major incident occurs or a staff member becomes aware of a major incident:
	       (1)  	 The staff member involved shall notify the following persons of the incident by the end of the next calendar day after the incident:
	      1. 	  The staff member’s supervisor.
	      2. 	  The member or the member’s legal guardian. Exception: Notification to the member is required only if the incident took place outside of the provider’s service provision. Notification to the guardian, if any, is always required.
	      3. 	  The member’s case manager.
	       (2)  	 By the end of the next calendar day after the incident, the staff member who observed or first became aware of the incident shall also report as much information as is known about the incident to the department’s bureau of long-term care either:
	      1. 	  By direct data entry into the Iowa Medicaid Provider Access System, or
	      2. 	  By faxing or mailing Form 470-4698, Critical Incident Report, according to the directions on the form.
	       (3)  	 The following information shall be reported:
	      1. 	  The name of the member involved.
	      2. 	  The date and time the incident occurred.
	      3. 	  A description of the incident.
	      4. 	  The names of all provider staff and others who were present at the time of the incident or who responded after becoming aware of the incident. The confidentiality of other members or nonmembers who were present must be maintained by the use of initials or other means.
	      5. 	  The action that the provider staff took to manage the incident.
	      6. 	  The resolution of or follow-up to the incident.
	      7. 	  The date the report is made and the handwritten or electronic signature of the person making the report.
	       (4)  	 Submission of the initial report will generate a workflow in the Individualized Services Information System (ISIS) for follow-up by the case manager. When complete information about the incident is not available at the time of the initial report, the provider must submit follow-up reports until the case manager is satisfied with the incident resolution and follow-up. The completed report shall be maintained in a centralized file with a notation in the member’s file.
	      c.    	  Tracking and analysis. The provider shall track incident data and analyze trends to assess the health and safety of members served and determine if changes need to be made for service implementation or if staff training is needed to reduce the number or severity of incidents.
	   77.25(4) Restraint, restriction, and behavioral intervention. The provider shall have in place a system for the review, approval, and implementation of ethical, safe, humane, and efficient behavioral intervention procedures. All members receiving home- and community-based habilitation services shall be afforded the protections imposed by these rules when any restraint, restriction, or behavioral intervention is implemented.
	      a.    	 The system shall include procedures to inform the member and the member’s legal guardian of the restraint, restriction, and behavioral intervention policy and procedures at the time of service approval and as changes occur.
	      b.    	 Restraint, restriction, and behavioral intervention shall be used only for reducing or eliminating maladaptive target behaviors that are identified in the member’s restraint, restriction, or behavioral intervention program.
	      c.    	 Restraint, restriction, and behavioral intervention procedures shall be designed and implemented only for the benefit of the member and shall never be used as punishment, for the convenience of the staff, or as a substitute for a nonaversive program.
	      d.    	 Restraint, restriction, and behavioral intervention programs shall be time-limited and shall be reviewed at least quarterly.
	      e.    	 Corporal punishment and verbal or physical abuse are prohibited.
	   77.25(5) Case management. The department of human services, a county or consortium of counties, or a provider under subcontract to the department or to a county or consortium of counties is eligible to participate in the home- and community-based habilitation services program as a provider of case management services provided that the agency meets the standards in 441—Chapter 24.
	   77.25(6) Day habilitation. The following providers may provide day habilitation:
	      a.    	 An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide services that qualify as day habilitation under 441—subrule 78.27(8).
	      b.    	 An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities to provide other services and began providing services that qualify as day habilitation under 441—subrule 78.27(8) since the agency’s last accreditation survey. The agency may provide day habilitation services until the current accreditation expires. When the current accreditation expires, the agency must qualify under paragraph “a,” “d,” “g,” or “h.”
	      c.    	 An agency that is not accredited by the Commission on Accreditation of Rehabilitation Facilities but has applied to the Commission within the last 12 months for accreditation to provide services that qualify as day habilitation under 441—subrule 78.27(8). An agency that has not received accreditation within 12 months after application to the Commission is no longer a qualified provider.
	      d.    	 An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
	      e.    	 An agency that has applied to the Council on Quality and Leadership in Supports for People with Disabilities for accreditation within the last 12 months. An agency that has not received accreditation within 12 months after application to the Council is no longer a qualified provider.
	      f.    	 An agency that is accredited under 441—Chapter 24 to provide day treatment or supported community living services.
	      g.    	 An agency that is certified by the department to provide day habilitation services under the home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A).
	      h.    	 An agency that is accredited by the International Center for Clubhouse Development.
	      i.    	 An agency that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
	      j.    	 A residential care facility of more than 16 beds that is licensed by the Iowa department of inspections and appeals, was enrolled as a provider of rehabilitation services for adults with chronic mental illness before December 31, 2006, and has applied for accreditation through one of the accrediting bodies listed in this subrule.
	       (1)  	 The facility must have policies in place by June 30, 2007, consistent with the accreditation being sought.
	       (2)  	 A facility that has not received accreditation within 12 months after application for accreditation is no longer a qualified provider.
	   77.25(7) Home-based habilitation. The following agencies may provide home-based habilitation services:
	      a.    	 An agency that is certified by the department to provide supported community living services under:
	       (1)  	 The home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A); or
	       (2)  	 The home- and community-based services brain injury waiver pursuant to rule 441—77.39(249A).
	      b.    	 An agency that is accredited under 441—Chapter 24 to provide supported community living services.
	      c.    	 An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as a community housing or supported living service provider.
	      d.    	 An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
	      e.    	 An agency that is accredited by the Council on Accreditation of Services for Families and Children.
	      f.    	 An agency that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
	      g.    	 A residential care facility of 16 or fewer beds that is licensed by the Iowa department of inspections and appeals, was enrolled as a provider of rehabilitation services for adults with chronic mental illness before December 31, 2006, and has applied for accreditation through one of the accrediting bodies listed in this subrule.
	       (1)  	 The facility must have policies in place by June 30, 2007, consistent with the accreditation being sought.
	       (2)  	 A facility that has not received accreditation within 12 months after application for accreditation is no longer a qualified provider.
	   77.25(8) Prevocational habilitation. The following providers may provide prevocational services:
	      a.    	 An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as an organizational employment service provider or a community employment service provider.
	      b.    	 An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
	      c.    	 An agency that is accredited by the International Center for Clubhouse Development.
	      d.    	 An agency that is certified by the department to provide prevocational services under:
	       (1)  	 The home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A); or
	       (2)  	 The home- and community-based services brain injury waiver pursuant to rule 441—77.39(249A).
	   77.25(9) Supported employment habilitation. The following agencies may provide supported employment services:
	      a.    	 An agency that is certified by the department to provide supported employment services under:
	       (1)  	 The home- and community-based services intellectual disability waiver pursuant to rule 441—77.37(249A); or
	       (2)  	 The home- and community-based services brain injury waiver pursuant to rule 441—77.39(249A).
	      b.    	 An agency that is accredited by the Commission on Accreditation of Rehabilitation Facilities as an organizational employment service provider or a community employment service provider.
	      c.    	 An agency that is accredited by the Council on Accreditation of Services for Families and Children.
	      d.    	 An agency that is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
	      e.    	 An agency that is accredited by the Council on Quality and Leadership in Supports for People with Disabilities.
	      f.    	 An agency that is accredited by the International Center for Clubhouse Development.
	   77.25(10) Provider enrollment. A prospective provider that meets the criteria in this rule and the provider criteria of the Iowa Plan for Behavioral Health contractor must be enrolled through the Iowa Plan for Behavioral Health contractor as an approved provider of a specific component of home- and community-based habilitation services. Enrollment carries no assurance that the approved provider will receive funding. The Iowa Medicaid enterprise will enroll providers with Medicaid only when the provider is enrolled in the Iowa Plan for Behavioral Health. Payment for services will be made to a provider only when the provider is enrolled in the Iowa Plan for Behavioral Health and the provider is authorized to provide the services. This includes payments made by the Iowa Medicaid enterprise for services provided to members who are not eligible to enroll in the Iowa Plan for Behavioral Health.
	      a.    	 The Iowa Plan for Behavioral Health contractor shall review compliance with standards for initial enrollment. Review of a provider may occur at any time.
	      b.    	 The department or the Iowa Plan for Behavioral Health contractor may request any information from the prospective service provider that is pertinent to arriving at an enrollment decision. This information may include:
	       (1)  	 Current accreditations.
	       (2)  	 Evaluations.
	       (3)  	 Inspection reports.
	       (4)  	 Reviews by regulatory and licensing agencies and associations.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 7936B, IAB 7/1/09, effective 9/1/09; ARC 9314B, IAB 12/29/10, effective 3/1/11; ARC 0848C, IAB 7/24/13, effective 7/1/13; ARC 1051C, IAB 10/2/13, effective 11/6/13]