641—155.21 (125,135) General standards for all treatment programs. The following standards shall apply to all treatment programs in the state of Iowa regardless of the category of treatment services provided by such programs. In situations where differences between general standards for all treatment programs and specific standards occur, both general and specific standards must be met.
	 155.21(1) Governing body. Each program shall have a formally designated governing body that is representative of the community being served, complies with Iowa Code chapter 504, and is the ultimate authority for the overall program operations. Persons in private practice as sole practitioners shall be exempt from this subrule except for requirements to have malpractice and liability insurance.
	  a.   	 The governing body shall develop and adopt written bylaws and policies that define the powers and duties of the governing body, its committees, advisory groups, and the executive director. These bylaws shall be reviewed and revised by the governing body as necessary.
	  b.   	 The bylaws shall minimally specify the following:
	 (1) 	 The type of membership;
	 (2) 	 The term of appointment;
	 (3) 	 The frequency of meetings;
	 (4) 	 The attendance requirements; and
	 (5) 	 The quorum necessary to transact business.
	  c.   	 Minutes of all meetings shall be kept and be available for review by the department and shall include, but not necessarily be limited to:
	 (1) 	 Date of the meeting;
	 (2) 	 Names of members attending;
	 (3) 	 Topics discussed; and
	 (4) 	 Decisions reached and actions taken.
	  d.   	 The duties of the governing body shall include, but not necessarily be limited to, the following:
	 (1) 	 Appointment of a qualified executive director who shall have the responsibility and authority for the management of the program in accordance with the governing body’s established policies;
	 (2) 	 Establish an effective control which will ensure that quality services are delivered;
	 (3) 	 Review and approve the program’s annual budget; and
	 (4) 	 Approve all contracts.
	  e.   	 The governing body shall develop and approve policies for the effective operation of the program.
	  f.   	 The governing body shall be responsible for all funds, equipment, supplies and the facility in which the program operates. The governing body shall be responsible for the appropriateness and adequacy of services provided by the program.
	  g.   	 The governing body shall at least annually prepare a report which will include, but not necessarily be limited to, the following items:
	 (1) 	 The name, address, occupation, and place of employment of each governing body member;
	 (2) 	 Any family relationships which a member of the governing body may have to a program staff member; and
	 (3) 	 Where applicable, the name and address of all owners or controlling parties whether they are individuals, partnerships, corporation body, or subdivision of other bodies, such as a public agency, or religious group, fraternity, or other philanthropic organization.
	  h.   	 The governing body shall assume responsibility in seeing that the program has malpractice and liability insurance and a fidelity bond.
	 155.21(2) Executive director. This individual shall have primary responsibility for the overall program operations. The duties of the executive director shall be clearly defined by the governing authority, when applicable, in accordance with the policies established by the governing body.
	 155.21(3) Clinical oversight. The program shall have appropriate clinical oversight to ensure quality of clinical services provided to client/patients. This may be provided in-house or through consultation.
Clinical oversight may include assisting the program in developing policies and procedures relating to the assessment and treatment of psychopathology, assisting in the training of the staff and providing assistance to the clinical staff in assessment or treatment. The executive director or designee shall be ultimately responsible for clinical services and implementation of treatment services to client/patients.
	 155.21(4) Staff development and training. There shall be written policies and procedures that establish staff development. Staff development shall include orientation for staff and opportunities for continuing job-related education. For corporations organized under Iowa Code chapter 496C and sole practitioners, documentation of continuing education to maintain professional license or certification as specified in 155.21(8) will meet the requirements of this subrule.
	  a.   	 Evidence of professional education, certification as specified in 155.21(8), licensing, or orientation which includes the following: psychosocial, medical, pharmacological, confidentiality, and tuberculosis and blood-borne pathogens; an orientation to the program and community resources; counseling skill development; HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) information/education; and the attitudes, values and lifestyles of racially diverse cultures, other cultures and special populations.
	  b.   	 The program shall establish on-site training programs or enter into relationships with outside resources capable of meeting staff training needs.
	  c.   	 The staff development program shall take steps to ensure that staff members are kept informed of new developments in the field of assessment, evaluation, placement, treatment and rehabilitation.
	  d.   	 In-service training programs shall be instituted when program operations or functions are changed and shall be designed to allow staff members to develop new skills so that they may effectively adapt to such changes.
	  e.   	 Staff development activities and participation in state, national and regional training shall be planned and scheduled. These activities shall be documented in order to evaluate their scope, effectiveness, attendance, and amount of time spent on such efforts. The written plan for on-site staff development and activities for professional growth and development of personnel shall be based on the annual needs assessment and shall be available to all personnel.
	  f.   	 Minutes shall be kept of on-site training activities and shall include, but not necessarily be limited to:
	 (1) 	 Date of the meeting;
	 (2) 	 Names of persons attending; and
	 (3) 	 Topics discussed, to include name and title of presenters.
	  g.   	 The individual responsible for supervising staff development activities shall conduct at least an annual needs assessment.
	 155.21(5) Management information system. Programs receiving Medicaid or state funding and programs performing OWI evaluations in accordance with 641—Chapter 157 shall submit client/patient data to the Iowa Department of Public Health, Division of Behavioral Health, Lucas State Office Building, 321 East 12th Street, Des Moines, Iowa 50319-0075, in accordance with reporting system procedures.
	 155.21(6) Procedures manual. All programs shall develop and maintain a procedures manual. This manual shall define the program’s policies and procedures to reflect the program’s activities. Revisions shall be entered with the date, name and title of the individual making the entries. This manual shall contain all of the required written policies, procedures, definitions, and all other documentation outlined throughout these standards. The manual shall contain a working table of contents covering all policies and procedures mandated by this chapter.
	 155.21(7) Fiscal management. The program shall ensure proper fiscal management which shall include the following:
	  a.   	 The preparation and maintenance of an annual written budget which shall be reviewed and approved by the governing body prior to the beginning of the budget year.
	  b.   	 The fiscal management system shall be maintained in accordance with generally accepted accounting principles, including internal controls to reasonably protect agency assets. This shall be verified by an independent fiscal audit of the program by the state auditor’s office or certified public accountant based on an agreement entered into by the governing body. An annual fiscal audit shall not be required for programs with an annual budget of $75,000 or less.
	  c.   	 There shall be an insurance program that provides for the protection of the physical and financial resources of the program which provides coverage for all people, buildings, and equipment. The insurance program shall be reviewed annually by the governing body.
	  d.   	 Assessment and evaluation programs shall make public the OWI evaluation fees, and the client/patient shall be informed of the fee at the time of scheduling the appointment for the evaluation.
	 155.21(8) Personnel. Written personnel policies and procedures shall be developed by all programs except for sole practitioners. All program staff shall subscribe to a code of conduct found in professional certification or licensure as specified in 155.21(8).
	  a.   	 All programs shall have written policies and procedures that address the following areas:
	 (1) 	 Recruitment, selection, and certification of staff members;
	 (2) 	 Recruitment and selection of volunteers;
	 (3) 	 Wage and salary administration;
	 (4) 	 Promotions;
	 (5) 	 Employee benefits;
	 (6) 	 Working hours;
	 (7) 	 Vacation and sick leave;
	 (8) 	 Lines of authority;
	 (9) 	 Rules of conduct;
	 (10) 	 Disciplinary actions and termination of employees;
	 (11) 	 Methods for handling cases of inappropriate client/patient care;
	 (12) 	 Work performance appraisal;
	 (13) 	 Employee accidents and safety;
	 (14) 	 Employee grievances; and
	 (15) 	 Policy on staff persons suspected of using or abusing substances.
	  b.   	 The written personnel policies and practices shall include an equal employment opportunity policy and an affirmative action plan for hiring members of protected classes that minimally comply with Iowa civil rights commission rules and any local ordinances.
	  c.   	 There shall be written job descriptions that reflect the actual duties of the employee.
	  d.   	 Job descriptions shall accurately reflect the actual job situation and shall be reviewed when necessary by the executive director or whenever there is a change in required qualifications or duties.
	  e.   	 All positions shall have job descriptions included in the personnel section of the procedures manual or personnel record of the staff member.
	  f.   	 The written personnel policies and practices shall include a mechanism for written evaluation of personnel performance on at least an annual basis. There shall be evidence that this evaluation is reviewed with the employee and that the employee is given the opportunity to respond to this evaluation.
	  g.   	 There shall be a personnel record kept on each staff member. These records shall contain as applicable:
	 (1) 	 Verification of training, experience, and all professional credentials relevant to the position;
	 (2) 	 Job performance evaluations;
	 (3) 	 Incident reports;
	 (4) 	 Disciplinary actions taken; and
	 (5) 	 Documentation of review and adherence to confidentiality laws and regulations. This review and agreement shall occur prior to assumption of duties.
	  h.   	 There shall be written policies and procedures designed to ensure confidentiality of personnel records and a delineation of authorized personnel who have access to various types of personnel information.
	  i.   	 Appropriately credentialed counselors.
	 (1) 	 Any person providing screening, evaluations, assessments or treatment in accordance with this chapter shall meet at least one of the following conditions:
	  1. 	 Currently maintain a substance abuse- or problem gambling-related credential acceptable to the department for providing treatment according to these rules.
	  2. 	 Currently maintain active status as a licensed marital and family therapist (LMFT) licensed under Iowa Code chapters 154D and 147; a licensed mental health counselor (LMHC) licensed under Iowa Code chapters 154D and 147; a licensed independent social worker (LISW) licensed under Iowa Code chapters 154C and 147; or another licensed professional authorized by the Iowa Code to diagnose and treat DSM-IV disorders.
	  3. 	 Currently maintain active status as a licensed master social worker (LMSW) licensed under Iowa Code chapters 154C and 147.
	  4. 	 For a person beginning employment on or after July 1, 2010, at a program licensed in Iowa pursuant to this chapter who does not currently maintain one of the credentials described in “1” to “3” above, successfully complete and maintain one of those credentials within two years of the date on which the person begins to provide services.
	  5. 	 Be employed before July 1, 2010, as a counselor at a program licensed in Iowa pursuant to this chapter. Those deemed qualified remain qualified only for work for that licensed program.
	 (2) 	 Any person providing screening, evaluations, assessments or treatment in accordance with this chapter shall maintain a minimum of 30 hours of training within the person’s primary scope of practice every two years, including a minimum of three hours of ethics training. In addition to practicing within their primary scope of practice, certified or licensed personnel may practice within a subspecialty in accordance with this chapter by maintaining a minimum of an additional 20 hours of training within the subspecialty every two years.
	  j.   	 The program shall notify the department in writing within ten working days when a certified or licensed staff member has been sanctioned or disciplined by a certifying or licensing body.
	  k.   	 There shall be written policies related to the prohibition of sexual harassment.
	  l.   	 There shall be written policies related to the implementation of the Americans with Disabilities Act.
	 155.21(9) Child abuse/dependent adult abuse/criminal history background check.
	  a.   	 Written policies and procedures shall prohibit mistreatment, neglect, or abuse of children and dependent adults and shall specify reporting and enforcement procedures for the program. Alleged violations shall be reported immediately to the director of the facility and appropriate department of human services personnel. Written policies and procedures on reporting alleged violations regarding substance abuse client/patients shall be in compliance with HIPAA and DHHS, 42 CFR Part 2, regulations on Confidentiality of Alcohol and Drug Abuse Patient Records. Written policies and procedures on reporting alleged violations regarding problem gambling client/patients shall be in compliance with HIPAA and the Iowa Code. Any employee found to be in violation of Iowa Code sections 232.67 through 232.70, as substantiated by a department of human services’ investigation shall be subject to the program’s policies concerning dismissal.
	  b.   	 For each employee working within a juvenile services area as set forth in Iowa Code section 125.14A or with dependent adults as set forth in Iowa Code chapter 235B, the personnel record shall contain at a minimum:
	 (1) 	 Documentation of a criminal history background check with the Iowa division of criminal investigation on all new applicants for employment. The background check shall include asking whether the applicant has been convicted of a crime.
	 (2) 	 A written, signed and dated statement furnished by a new applicant for employment which discloses any substantiated reports of child abuse, neglect or sexual abuse or dependent adult abuse.
	 (3) 	 Documentation of a check after hiring on probationary or temporary status, but prior to permanently employing the individual, with the Iowa central registry for any substantiated reports of child abuse, neglect or sexual abuse pursuant to Iowa Code section 125.14A or substantiated reports of dependent adult abuse for all employees hired on or after July 1, 1994, pursuant to Iowa Code chapter 235B.
	  c.   	 A person who has a record of a criminal conviction or founded child abuse report or founded dependent adult abuse report shall not be employed, unless an evaluation of the crime or founded child abuse or founded dependent adult abuse has been made by the department of human services which concludes that the crime or founded child abuse or founded dependent adult abuse does not merit prohibition of employment. If a record of criminal conviction or founded child abuse or founded dependent adult abuse does exist, the person shall be offered the opportunity to complete and submit Form 470-2310, Record Check Evaluation. In its evaluation, the department of human services shall consider the nature and seriousness of the crime or founded abuse in relation to the position sought, the time elapsed since the commission of the crime or founded abuse, the circumstances under which the crime or founded abuse was committed, the degree of rehabilitation and the number of crimes or founded abuses committed by the person involved.
	  d.   	 Each treatment staff member shall complete two hours of training relating to the identification and reporting of child abuse and dependent adult abuse within six months of initial employment and at least two hours of additional training every five years thereafter.
	 155.21(10) Client/patient case record maintenance. There shall be written policies and procedures governing the compilation, storage and dissemination of individual client/patient case records.
	  a.   	 These policies and procedures shall ensure that:
	 (1) 	 The program exercises its responsibility for safeguarding and protecting the client/patient case record against loss, tampering, or unauthorized disclosure of information;
	 (2) 	 Content and format of client/patient records are kept uniform; and
	 (3) 	 Entries in the client/patient case record are signed and dated.
	  b.   	 The program shall provide adequate physical facilities for the storage, processing, and handling of client/patient case records. These facilities shall include suitably locked, secured rooms or file cabinets.
	  c.   	 Appropriate records shall be readily accessible to those staff members providing services directly to the client/patient and other individuals specifically authorized by program policy. Records should be kept in proximity to the area in which the client/patient normally receives services.
	  d.   	 The program shall have a written policy governing the disposal and maintenance of client/patient case records. Client/patient case records shall be maintained for not less than seven years from the date they are officially closed.
	  e.   	 Each file cabinet or storage area containing client/patient case records shall be locked.
	  f.   	 The governing body shall establish policies that specify the conditions under which information on applicants or client/patients may be released and the procedures to be followed for releasing such information. Even if a program is not federally funded, all such policies and procedures regarding substance abuse client/patients shall be in accordance with HIPAA and the federal confidentiality regulations, “Confidentiality of Alcohol and Drug Abuse Patient Records,” 42 CFR Part 2, effective June 9, 1987, which implement federal statutory provisions, 42 U.S.C. 290dd-3 applicable to alcohol abuse client/patient records, and 42 U.S.C. 290ee-3 applicable to drug abuse client/patient records, and state confidentiality laws and regulations. All such policies and procedures regarding problem gambling client/patients shall be in accordance with HIPAA and Iowa Code chapter 228.
	  g.   	 Confidentiality of alcohol and drug abuse client/patient records. The confidentiality of alcohol and drug abuse client/patient records maintained by a program is protected by HIPAA and the “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations, 42 CFR Part 2, effective June 9, 1987, which implement federal statutory provisions, 42 U.S.C. 290dd-3 applicable to alcohol abuse client/patient records, and 42 U.S.C. 290ee-3 applicable to drug abuse client/patient records.
	  h.   	 Confidentiality of problem gambling client/patient records. The confidentiality of problem gambling client/patient records maintained by a program is protected by HIPAA and Iowa Code chapter 228.
	  i.   	 The provision of treatment to a client/patient through any electronic means, including the Internet, telephone, or the Iowa communications network or any fiberoptic media, regardless of the location of the licensee, shall constitute the practice of treatment in the state of Iowa and shall be subject to regulation in accordance with Iowa Code chapter 125 and 2009 Iowa Code Supplement section 135.150 and these rules. A licensee who provides services via electronic media shall inform the client/patient of the limitations and risks associated with such services and shall document in the client/patient case record that such notice has been provided.
	  j.   	 Confidentiality and transfer of records. Upon receipt of a properly executed written release of information signed by the client/patient, the program shall release client/patient records in a timely manner. A program shall not refuse to transfer or release client/patient records related to continuation of care solely because payment has not been received. A program may refuse to release client/patient records which are unrelated to continuation of care if payment has not been received. A program may refuse to file the reporting form required by 641—subrule 157.3(1), “Notice Iowa Code 321J—Confidential Medical Record,” reporting screening, evaluation, and treatment completion, if payment has not been received for such services.
	 155.21(11) Placement screening, admission, assessment and evaluation.
	  a.   	 The program shall conduct an initial assessment for substance abuse client/patients which shall include evaluation of the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition, Revised, or other national or recognized criteria approved by the department upon granting a variance by the director in accordance with 641—Chapter 178 for determining the eligibility of individuals for placement and admission. The program shall utilize a recognized diagnostic test/tool to determine substance abuse or dependence as defined in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).
	  b.   	 The program shall conduct an initial assessment for problem gambling client/patients that shall utilize a recognized diagnostic test/tool to determine pathological gambling as defined in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). The client/patient is a problem gambler if the client/patient meets any of the diagnostic criteria for pathological gambling.
	  c.   	 The program shall have written policies and procedures governing a uniform assessment process that defines:
	 (1) 	 The types of information to be gathered on all individuals upon admission;
	 (2) 	 Procedures to be followed when accepting referrals from outside agencies or organizations;
	 (3) 	 The types of records to be kept on all individuals applying for services.
	  d.   	 Following admission, the comprehensive assessment (psychosocial history) shall be an analysis and synthesis of the client/patient’s status and shall address the client/patient’s strengths and needs, which may be documented in the comprehensive assessment or in the treatment plan, and areas of clinical concern. Sufficient information shall be collected so that a comprehensive treatment plan can be developed. The comprehensive treatment plan shall be developed within the period of time between admission and the first review date specified for that particular level of care within the management of care review process, or within 30 days for problem gambling client/patients.
	  e.   	 At the time of admission, documentation shall be made that the individual has been informed of:
	 (1) 	 General nature and goals of the program;
	 (2) 	 Rules governing client/patient conduct and infractions that can lead to disciplinary action or discharge from the program;
	 (3) 	 In a nonresidential program, the hours during which services are available;
	 (4) 	 Treatment costs to be borne by the client/patient, if any;
	 (5) 	 Client/patient’s rights and responsibilities;
	 (6) 	 Confidentiality laws, rules and regulations;
	 (7) 	 HIV/AIDS information; and
	 (8) 	 Safety and emergency procedures for residential, halfway house, inpatient and treatment services with housing.
	  f.   	 The results of the screening and admission process shall be clearly explained to the client/patient and to the client/patient’s family when appropriate. This shall be documented in the client/patient record.
	 155.21(12) Treatment plans. Based upon the initial assessment, an individualized written treatment plan shall be developed and recorded in the client/patient case record. The program shall have written policies and procedures governing a uniform process for treatment planning.
	  a.   	 A treatment plan shall be developed as soon after the client/patient’s admission as is clinically feasible and within the period of time between admission and the next review date specified for that particular level of care within the management of care review process.
	  b.   	 The individualized treatment plan shall minimally contain:
	 (1) 	 A clear and concise statement of the client/patient’s current strengths and needs, which may be documented in the treatment plan or in the comprehensive assessment;
	 (2) 	 Clear and concise statements of the short- and long-term goals the client/patient will be attempting to achieve;
	 (3) 	 Type and frequency of therapeutic activities in which the client/patient will be participating;
	 (4) 	 The staff person(s) to be responsible for the client/patient’s treatment; and
	 (5) 	 Treatment plans shall be culturally and environmentally specific so as to meet the needs of the client/patient. Treatment plans shall be written in a manner readily understandable to the client/patient, with assistance if necessary.
	  c.   	 Treatment plans shall be developed in partnership with the client/patient and shall be reviewed by the primary counselor and the client/patient as often as necessary and in accordance with the time frames specified within the management of care review process.
	  d.   	 The reviews shall consist of: a reassessment of the client/patient’s current status in conjunction with the continued stay review criteria, accomplishments and needs, and a redefining of treatment goals when appropriate. The date of the review, as well as any changes, shall be recorded in the record.
	  e.   	 The use of abstract terms, technical jargon, or slang should be avoided in the treatment plan. The program should provide the client/patient with copies of all treatment plans upon request.
	 155.21(13) Progress notes. A client/patient’s progress and current status in meeting the goals set in the treatment plan shall be recorded in the client/patient case record. Information will be noted following each individual counseling session and a summary of group counseling services shall be documented at least weekly.
	  a.   	 Entries shall be filed in chronological order and shall include the date services were provided or observations made, the date the entry was made, and the signature or initials and staff title of the individual rendering the services. All progress notes shall be legibly entered into the client/patient case record in permanent pen, by typewriter, or by computer. In those instances where records are maintained electronically, a staff identification code number authorizing access shall be accepted in lieu of a signature.
	  b.   	 All entries that involve subjective interpretations of a client/patient’s progress should be supplemented with a description of the actual behavioral observations which were the basis for the interpretation.
	  c.   	 The use of abstract terms, technical jargon, or slang should be avoided in progress notes.
	  d.   	 The program shall develop a uniform progress note format to be used by all clinical staff.
	 155.21(14) Client/patient case record contents. There shall be a case record for each client/patient that contains:
	  a.   	 Results of all examinations, tests, and screening and admissions information;
	  b.   	 Reports from referring sources;
	  c.   	 Treatment plans;
	  d.   	 Continued stay and discharge reviews;
	  e.   	 Medication records, which shall allow for the monitoring of all medications administered and self-administered and the detection of adverse drug reactions. All medication orders in the client/patient case records shall define at least the name of the medication, dose, route of administration, frequency of administration, the name of the physician who prescribed the medication, and the name of the person administering or dispensing the medication;
	  f.   	 Reports from outside resources shall be dated and include the name of the resource;
	  g.   	 Multidisciplinary case conference and consultation notes, including the date of the conference or consultation, recommendations made, actions taken, and individuals involved;
	  h.   	 Correspondence related to the client/patient, including all letters and dated notations of telephone conversations relevant to the client/patient’s treatment;
	  i.   	 Treatment consent forms, if applicable;
	  j.   	 Information release forms;
	  k.   	 Progress notes;
	  l.   	 Records of services provided;
	  m.   	 Discharge summaries of services provided shall be completed within 30 days of discharge and shall be sufficiently detailed to identify the types of services the client/patient has received and action taken to address specific problems identified. General terms such as “counseling” or “activities” shall be avoided in describing services;
	  n.   	 Management information system or other appropriate data forms; and
	  o.   	 Incident reports.
	  p.   	 Records of financial counseling services for problem gambling client/patients. The treatment program shall offer financial counseling services to problem gambling client/patients. Financial counseling services shall be provided in-house or through consultation. If the treatment program determines that the problem gambling client/patient has financial problems, then financial counseling services shall include assisting the client/patient in preparing a budget and discussing financial debt options, including restitution and bankruptcy.
	 155.21(15) Drug screening. All programs serving client/patients who are receiving treatment for use or abuse of a controlled substance shall establish policies and procedures, if applicable, for the collection of urine specimens and utilization of urinalysis results.
	  a.   	 Urine specimens obtained from client/patients shall be collected under direct supervision and analyzed as indicated by the program, or the program shall have a policy in place to reduce the client/patient’s ability to skew the test.
	  b.   	 Any laboratory used by the program for urine testing and analysis shall comply, if applicable, with all federal and state proficiency testing programs.
	  c.   	 Any program conducting on-site urine testing shall comply with the Clinical Laboratory Improvement Act regulations.
	  d.   	 Client/patient records shall reflect the manner in which urine test results are utilized in treatment.
	  e.   	 For programs with a urinalysis service, policies shall be developed concerning measures to be employed when urine specimens of client/patients are found to contain substances.
	 155.21(16) Medical services. The treatment program shall have policies and procedures developed in conjunction with a physician to examine and evaluate client/patients/concerned persons seeking or undergoing treatment or rehabilitation.
	  a.   	 Individuals who enter an inpatient, residential, halfway house, chemotherapy or emergency care facility (ASAM Levels III.1, III.3, III.5, III.7 and IV) shall undergo a medical history and physical examination. Laboratory examinations may be performed as deemed necessary by the physician. The medical history, physical examination, and necessary laboratory examinations shall be performed as soon as possible, however minimally, as follows:
	 (1) 	 Inpatient medically managed and medically monitored residential treatment services (ASAM Levels IV and III.7) within 24 hours of admission;
	 (2) 	 Primary residential and extended residential treatment (Levels III.5 and III.3) within 7 calendar days of admission; and
	 (3) 	 Halfway house services (Level III.1) within 21 calendar days of admission.
	  b.   	 For individuals who enter a Level I or Level II service, a medical history shall be obtained upon admission.
	  c.   	 A program may accept medical history and physical examination results from referral sources if the medical history and examination were completed no more than 90 days prior to admission.
	  d.   	 All client/patients admitted to residential, inpatient or halfway house services and high-risk outpatient client/patients shall have a tuberculosis skin test administered and read within 5 days of admission. If the client/patient has documentation of a negative tuberculosis skin test within the previous 90 days, the tuberculosis test may be accepted if the client/patient does not show any symptoms. If the client/patient has unexplained symptoms or a history of positive tuberculosis skin tests, the physician shall determine what tests are needed.
	 155.21(17) Emergency medical services. The program shall ensure, by affiliation agreement, or contract, that emergency medical services at a general hospital are available on a 24-hour basis.
	  a.   	 The program will maintain emergency medical service coverage on a 24-hour, seven days a week, basis.
	  b.   	 The program shall ensure that all community service providers, medical facilities, law enforcement agencies, and other appropriate personnel are informed of the 24-hour emergency services and treatment available.
	 155.21(18) Medication control. Policies and procedures shall be developed to ensure that prescription and over-the-counter drugs are administered or self-administered safely and properly in accordance with federal, state and local laws and regulations. The written policies and procedures shall include, but not be limited to, the following:
	  a.   	 Authorized personnel who administer medications shall be qualified, and an updated list of such personnel shall be maintained. Only the following are designated by 657—8.32(124,155A) as qualified individuals to whom a physician can delegate the administration of controlled substances:
	 (1) 	 Persons who have successfully completed a medication administration course reviewed by the board of pharmacy examiners.
	 (2) 	 Advanced emergency medical technicians and paramedics.
	 (3) 	 Licensed physician assistants.
	 (4) 	 Licensed pharmacists.
	 (5) 	 Nurse, intern or other qualified individual delegated the responsibility to administer a prescription drug by a practitioner, licensed by the appropriate state board, to administer drugs to patients, in accordance with Iowa Code section 155A.4(2)“c.”
	  b.   	 Medications shall be administered only in accordance with the instructions of the attending physician. The type and amount of the medication, the time and date, and the staff member administering the medication shall be documented in the client/patient’s record.
	  c.   	 Self-administration of prescription medication shall be observed by a staff member who has been oriented to the program’s policies and procedures on self-administration. Self-administration of prescription medications shall be permitted only when the client/patient’s medication is clearly labeled. There shall be written policies and procedures relative to self-administration of prescription medications by client/patients and only when:
	 (1) 	 Medications are prescribed by a physician.
	 (2) 	 The physician agrees that the client/patient can self-administer the drug.
	 (3) 	 What is taken, how, and when, are documented in the record of the client/patient.
	  d.   	 Drugs/medications shall be prescribed by a physician or other practitioner authorized to prescribe under Iowa law.
	  e.   	 Prescription drugs shall not be administered or self-administered to a client/patient without a written order signed by a physician or other practitioner authorized to prescribe under Iowa law. All prescribed medications shall be clearly labeled indicating the client/patient’s full name, physician’s name, prescription number, name and strength of the medication, dosage, directions for use, date of issue; and name, address and telephone number of the pharmacy or physician issuing the medication. Medications shall be packaged and labeled according to state and federal guidelines.
	  f.   	 If the medications the client/patient brings to the program are not to be used, they shall be packaged, sealed and stored. The sealed packages of medications shall be returned to the client/patient, family or significant others at the time of discharge.
	  g.   	 Accountability and control of medications.
	 (1) 	 There shall be a specific routine for medication administration, indicating dose schedules and standardization of abbreviations.
	 (2) 	 There shall be specific methods for control and accountability of medication products throughout the program.
	 (3) 	 The staff member in charge of medications shall provide for monthly inspection of all storage units.
	 (4) 	 Medication containers having soiled, damaged, illegible, or makeshift labels shall be returned to the issuing pharmacist, pharmacy, or physician for relabeling or disposal.
	 (5) 	 Unused prescription drugs prescribed for residents who have left the facility without their medication shall be destroyed by the person in charge with a witness and notation made on the resident’s record. When a resident is discharged or leaves the facility, medications currently being administered shall be sent, in the original container, with the resident or with a responsible agent, and with the approval of the physician.
	  h.   	 Medication storage shall be maintained in accordance with the security requirements of federal, state and local laws.
	 (1) 	 All medication shall be maintained in locked storage. Controlled substances shall be maintained in a locked box within the locked cabinet.
	 (2) 	 Medications requiring refrigeration shall be kept in a refrigerator and separated from food and other items.
	 (3) 	 Disinfectants and medication for external use shall be stored separately from internal and injectable medications.
	 (4) 	 The medication for each client/patient shall be stored in the original containers.
	 (5) 	 All potent poisonous or caustic medication shall be plainly labeled, stored separately from other medication in a specific well-illuminated cabinet, closet, or storeroom, and made accessible only to authorized persons.
	  i.   	 Dispensed from a licensed pharmacy. Medication provided to a client/patient shall be dispensed only from a licensed pharmacy in the state of Iowa in accordance with the pharmacy laws in the Code of Iowa, or from a licensed pharmacy in another state according to the laws of that state, or by a licensed physician.
	  j.   	 Use of medications. Prescription medications prescribed for one resident may not be administered to or allowed in the possession of another resident.
	  k.   	 Patient reaction. Any unusual client/patient reaction to a medication shall be documented in the client/patient record and reported to the attending physician immediately.
	  l.   	 Dilution or reconstitution of medication. Dilution or reconstitution and labeling of medication shall be done only by a licensed pharmacist.
	 155.21(19) Management of care. The program shall ensure appropriate level of care utilization by implementing and maintaining the written placement screening, continuing service, and discharge criteria process developed by the department.
	  a.   	 The program shall also address underutilization, overutilization, and the effective use of levels of care available.
	  b.   	 The time frames for management of care activities minimally shall be implemented within 30 days for Levels I and III.1; within 7 days for Levels II.1, II.5, III.3 and III.5; and daily for Levels III.7 and IV.
	  c.   	 The discharge planning process shall begin at admission and shall include a determination of the client/patient’s continued need for treatment services and development of a plan to address ongoing client/patient needs posttreatment. Discharge planning may or may not include a document identified as a discharge plan.
	 155.21(20) Quality improvement. The program shall have an ongoing quality improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of client/patient care, pursue opportunities to improve client/patient care, and resolve identified problems. Quality improvement efforts shall be facilitywide in scope and include review of clinical and professional services.
	  a.   	 There shall be a written plan for a quality improvement program that describes the objectives, organization, scope, and mechanisms for overseeing the effectiveness of monitoring, evaluation, and problem-solving activities.
	  b.   	 The program shall establish written policies and procedures to both describe and document the quality improvement of the program’s monitoring and evaluation activities. The policies and procedures shall ensure that:
	 (1) 	 Information is collected or screened by a designated individual, individuals, or committee. Quality improvement activities may be contracted through all outside resources;
	 (2) 	 Objective criteria shall be utilized in the development and application of criteria relating to the care or service it provides; and
	 (3) 	 Objective criteria shall be utilized in the evaluation of the information collected in order to identify important problems in, or opportunities to improve, client/patient care and clinical performance.
	  c.   	 The program shall document that the quality of client/patient care is improved and identified problems are resolved through actions taken as appropriate by the program’s administrative and supervisory staffs and through professional staff functions.
	  d.   	 Necessary information shall be communicated among program components, modalities, or services when problems or opportunities to improve client/patient care involve more than one program component or service.
	  e.   	 The program shall ensure that the status of identified problems is tracked to ensure improvement or resolution.
	  f.   	 Information from program components or services and the findings of discrete quality improvement activities are used to detect trends, patterns of performance, or potential problems that affect more than one program component or service.
	  g.   	 The objectives, scope, organization, and effectiveness of the quality improvement program are evaluated at least annually and revised as necessary.
	 155.21(21) Building construction and safety. All buildings in which client/patients receive screenings, evaluations, assessments or treatment shall be designed, constructed, equipped, and maintained in a manner that provides for the physical safety of client/patients, personnel, and visitors.
	  a.   	 If required by local jurisdiction, all programs shall maintain a certification of occupancy.
	  b.   	 During all phases of construction or alterations of buildings, the level of life safety shall not be diminished in any occupied area. The construction shall be in compliance with all applicable federal, state, and local codes.
	  c.   	 New construction shall comply with Iowa Code chapter 104A and all applicable federal and local codes and provide for safe and convenient use by disabled individuals.
	  d.   	 All programs shall have written policies and procedures to provide a safe environment for client/patients, personnel, and visitors and to monitor that environment. The program shall document implementation of the procedures. The written policies and procedures shall include, but not be limited to, the following:
	 (1) 	 The process for the identification, development, implementation, and review of safety policies and procedures for all departments or services.
	 (2) 	 The promotion and maintenance of an ongoing, facilitywide hazard surveillance program to detect and report all safety hazards related to client/patients, visitors, and personnel.
	 (3) 	 The process by which the staff is to dispose of biohazardous waste within the clinical service areas.
	 (4) 	 All program areas.
	  1. 	 Stairways, halls, and aisles shall be of substantial nonslippery material, shall be maintained in a good state of repair, shall be adequately lighted and shall be kept free from obstructions at all times. All stairways shall have handrails.
	  2. 	 Radiators, registers, and steam and hot water pipes shall have protective covering or insulation. Electrical outlets and switches shall have wall plates.
	  3. 	 For juvenile facilities, fuse boxes shall be under lock and key or six feet above the floor.
	  4. 	 Facilities shall have written procedures for the handling and storage of hazardous materials.
	  5. 	 Facilities shall have policies and procedures for weapons removal.
	  6. 	 Swimming pools shall conform to state and local health and safety regulations. Adult supervision shall be provided at all times when children are using the pool.
	  7. 	 Facilities shall have policies regarding fishing ponds, lakes, or any bodies of water located on or near the program and accessible to the client/patient.
	 155.21(22) Outpatient facility. The outpatient facility shall be safe, clean, well ventilated, properly heated, free from vermin and rodents and in good repair.
	  a.   	 The facility shall be appropriate for providing services available from the program and for protecting confidentiality.
	  b.   	 Furniture shall be in good repair.
	  c.   	 There shall be a written plan outlining procedures to be followed in the event of fire or tornado. These plans shall be conspicuously displayed at the facility.
	 155.21(23) Therapeutic environment. All programs shall establish an environment that enhances the positive self-image of client/patients and preserves their human dignity. The grounds of the program shall have adequate space for the program to carry out its stated goals. When client/patient needs or program goals involve outdoor activities, these activities and programs shall be appropriate to the ages and clinical needs of the client/patient.
	  a.   	 All services shall be accessible to people with disabilities or the program shall have written policies and procedures that describe how people with disabilities can attain access to the facility for necessary services. All programs shall comply with the Americans with Disabilities Act.
	  b.   	 The waiting or reception areas shall be of adequate size, have appropriate furniture and be located so as to ensure confidentiality of client/patients in session or receiving services.
	  c.   	 Program staff shall be available in waiting or reception areas so as to address the needs of the client/patients and visitors.
	  d.   	 The program shall have written policies and procedures regarding chemical substances in the facility.
	  e.   	 Smoking shall be prohibited within any facilities or any portion of a facility used for outpatient drug and alcohol treatment services and programs. Smoking shall be prohibited, except in designated areas within facilities or portions of facilities used for inpatient and residential drug and alcohol treatment services.
	  f.   	 A program or person shall not sell, give, or otherwise supply any tobacco, tobacco products, or cigarettes to any person under 18 years of age, and a person under 18 years of age shall not smoke, use, purchase, or attempt to purchase, any tobacco, tobacco products, or cigarettes.
	  g.   	 There shall be written policies and procedures to address the following:
	 (1) 	 There shall be a policy to inform client/patients of their legal and human rights at the time of admission;
	 (2) 	 Client/patient communication, opinions, or grievances, with a mechanism for redress;
	 (3) 	 Prohibition of sexual harassment; and
	 (4) 	 Client/patient rights to privacy.
[ARC 8792B, IAB 6/2/10, effective 7/1/10; ARC 9774B, IAB 10/5/11, effective 11/9/11]