441—82.2(249A) Licensing and certification. In order to participate in the program, a facility shall be licensed as an intermediate care facility for persons with an intellectual disability by the department of inspections and appeals under the department of inspections and appeals rules found in 481—Chapter 64. The facility shall meet the following conditions of participation:
	82.2(1) Governing body and management.
	a. 	Governing body. The facility shall identify an individual or individuals to constitute the governing body of the facility. The governing body shall:
	(1)	Exercise general policy, budget, and operating direction over the facility.
	(2)	Set the qualifications (in addition to those already set by state law) for the administrator of the facility.
	(3)	Appoint the administrator of the facility.
	b. 	Compliance with federal, state, and local laws. The facility shall be in compliance with all applicable provisions of federal, state and local laws, regulations and codes pertaining to health, safety, and sanitation.
	c. 	Client records.
	(1)	The facility shall develop and maintain a record-keeping system that includes a separate record for each client and that documents the clients’ health care, active treatment, social information, and protection of the client’s rights.
	(2)	The facility shall keep confidential all information contained in the clients’ records, regardless of the form or storage method of the records.
	(3)	The facility shall develop and implement policies and procedures governing the release of any client information, including consents necessary from the client or parents (if the client is a minor) or legal guardian.
	(4)	Any individual who makes an entry in a client’s record shall make it legibly, date it, and sign it.
	(5)	The facility shall provide a legend to explain any symbol or abbreviation used in a client’s record.
	(6)	The facility shall provide each identified residential living unit with appropriate aspects of each client’s record.
	d. 	Services provided under agreements with outside sources.
	(1)	If a service required under this rule is not provided directly, the facility shall have a written agreement with an outside program, resource, or service to furnish the necessary service, including emergency and other health care.
	(2)	The agreement shall:
	1.	Contain the responsibilities, functions, objectives, and other terms agreed to by both parties.
	2.	Provide that the facility is responsible for ensuring that the outside services meet the standards for quality of services contained in this rule.
	(3)	The facility shall ensure that outside services meet the needs of each client.
	(4)	If living quarters are not provided in a facility owned by the ICF/ID, the ICF/ID remains directly responsible for the standards relating to physical environment that are specified in subrule 82.2(7), paragraphs “a” to “g,” “j,” and “k.”
	e. 	Disclosure of ownership. The facility shall supply to the licensing agency full and complete information, and promptly report any changes which would affect the current accuracy of the information, as to identify:
	(1)	Each person having a direct or indirect ownership interest of 5 percent or more in the facility and the owner in whole or in part of any property or assets (stock, mortgage, deed of trust, note or other obligation) secured in whole or in part by the facility.
	(2)	Each officer and director of the corporation, if the facility is organized as a corporation.
	(3)	Each partner, if the facility is organized as a partnership.
	82.2(2) Client protections.
	a. 	Protection of clients’ rights. The facility shall ensure the rights of all clients. Therefore, the facility shall:
	(1)	Inform each client, parent (if the client is a minor), or legal guardian of the client’s rights and the rules of the facility.
	(2)	Inform each client, parent (if the child is a minor), or legal guardian, of the client’s medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment.
	(3)	Allow and encourage individual clients to exercise their rights as clients of the facility, and as citizens of the United States, including the right to file complaints and the right to due process.
	(4)	Allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities.
	(5)	Ensure that clients are not subjected to physical, verbal, sexual, or psychological abuse or punishment.
	(6)	Ensure that clients are free from unnecessary drugs and physical restraints and are provided active treatment to reduce dependency on drugs and physical restraints.
	(7)	Provide each client with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs.
	(8)	Ensure that clients are not compelled to perform services for the facility and ensure that clients who do work for the facility are compensated for their efforts at prevailing wages and commensurate with their abilities.
	(9)	Ensure clients the opportunity to communicate, associate and meet privately with individuals of their choice, and to send and receive unopened mail.
	(10)	Ensure that clients have access to telephones with privacy for incoming and outgoing local and long distance calls except as contraindicated by factors identified within their individual program plans.
	(11)	Ensure clients the opportunity to participate in social, religious, and community group activities.
	(12)	Ensure that clients have the right to retain and use appropriate personal possessions and clothing, and ensure that each client is dressed in the client’s own clothing each day.
	(13)	Permit a husband and wife who both reside in the facility to share a room.
	b. 	Client finances.
	(1)	The facility shall establish and maintain a system that ensures a full and complete accounting of clients’ personal funds entrusted to the facility on behalf of clients and precludes any commingling of client funds with facility funds or with the funds of any person other than another client.
	(2)	The client’s financial record shall be available on request to the client, parents (if the client is a minor), or legal guardian.
	c. 	Communication with clients, parents, and guardians. The facility shall:
	(1)	Promote participation of parents (if the client is a minor) and legal guardians in the process of providing active treatment to a client unless their participation is unobtainable or inappropriate.
	(2)	Answer communications from clients’ families and friends promptly and appropriately.
	(3)	Promote visits by individuals with a relationship to the client (such as family, close friends, legal guardians and advocates) at any reasonable hour, without prior notice, consistent with the right of that client’s and other clients’ privacy, unless the interdisciplinary team determines that the visit would not be appropriate.
	(4)	Promote visits by parents or guardians to any area of the facility that provides direct client care services to the client, consistent with the right of that client’s and other clients’ privacy.
	(5)	Promote frequent and informal leaves from the facility for visits, trips, or vacations.
	(6)	Notify promptly the client’s parents or guardian of any significant incidents or changes in the client’s condition including, but not limited to, serious illness, accident, death, abuse, or unauthorized absence.
	d. 	Staff treatment of clients.
	(1)	The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.
	1.	Staff of the facility shall not use physical, verbal, sexual or psychological abuse or punishment.
	2.	Staff shall not punish a client by withholding food or hydration that contributes to a nutritionally adequate diet.
	3.	The facility shall prohibit the employment of individuals with a conviction or prior employment history of child or client abuse, neglect or mistreatment.
	(2)	The facility shall ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials 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 shall be reported to the administrator or designated representative or to other officials in accordance with state law within five working days of the incident, and, if the alleged violation is verified, appropriate corrective action shall be taken.
	82.2(3) Facility staffing.
	a. 	Qualified intellectual disability professional. Each client’s active treatment program shall be integrated, coordinated and monitored by a qualified intellectual disability professional who has at least one year of experience working directly with persons with an intellectual disability or other developmental disabilities and is one of the following:
	(1)	A doctor of medicine or osteopathy.
	(2)	A registered nurse.
	(3)	An individual who holds at least a bachelor’s degree in a professional category specified in 82.2(3)“b”(5).
	b. 	Professional program services.
	(1)	Each client shall receive the professional program services needed to implement the active treatment program defined by each client’s individual program plan. Professional program staff shall work directly with clients and with paraprofessional, nonprofessional and other professional program staff who work with clients.
	(2)	The facility shall have available enough qualified professional staff to carry out and monitor the various professional interventions in accordance with the stated goals and objectives of every individual program plan.
	(3)	Professional program staff shall participate as members of the interdisciplinary team in relevant aspects of the active treatment process.
	(4)	Professional program staff shall participate in ongoing staff development and training in both formal and informal settings with other professional, paraprofessional, and nonprofessional staff members.
	(5)	Professional program staff shall be licensed, certified, or registered, as applicable, to provide professional services by the state in which the staff practices. Those professional program staff who do not fall under the jurisdiction of state licensure, certification, or registration requirements shall meet the following qualifications:
	1.	To be designated as an occupational therapist, an individual shall be eligible for certification as an occupational therapist by the American Occupational Therapy Association or another comparable body.
	2.	To be designated as an occupational therapy assistant, an individual shall be eligible for certification as an occupational therapy assistant by the American Occupational Therapy Association or another comparable body.
	3.	To be designated as a physical therapist, an individual shall be eligible for certification as a physical therapist by the American Physical Therapy Association or another comparable body.
	4.	To be designated as a physical therapy assistant, an individual shall be eligible for registration as a physical therapy assistant by the American Physical Therapy Association or be a graduate of a two-year college-level program approved by the American Physical Therapy Association or another comparable body.
	5.	To be designated as a psychologist, an individual shall have at least a master’s degree in psychology from an accredited school.
	6.	To be designated as a social worker, an individual shall hold a graduate degree from a school of social work accredited or approved by the Council on Social Work Education or another comparable body or hold a bachelor of social work degree from a college or university accredited or approved by the Council on Social Work Education or another comparable body.
	7.	To be designated as a speech-language pathologist or audiologist, an individual shall be eligible for a Certificate of Clinical Competence in Speech-Language Pathology or Audiology granted by the American Speech-Language Hearing Association or another comparable body or meet the educational requirements for certification and be in the process of accumulating the supervised experience required for certification.
	8.	To be designated as a professional recreation staff member, an individual shall have a bachelor’s degree in recreation or in a specialty area such as art, dance, music or physical education.
	9.	To be designated as a professional dietitian, an individual shall be eligible for registration by the Academy of Nutrition and Dietetics.
	10.	To be designated as a human services professional, an individual shall have at least a bachelor’s degree in a human services field (including, but not limited to, sociology, special education, rehabilitation counseling or psychology).
	(6)	If the client’s individual program plan is being successfully implemented by facility staff, professional program staff meeting the qualifications of 82.2(3)“b”(5) are not required except for qualified intellectual disability professionals who must meet the requirements set forth in 82.2(3)“a.”
	c. 	Facility staffing.
	(1)	The facility shall not depend upon clients or volunteers to perform direct care services for the facility.
	(2)	There shall be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: clients for whom a physician has ordered a medical care plan; clients who are aggressive, assaultive or security risks; more than 16 clients; or fewer than 16 clients within a multi-unit building.
	(3)	There shall be a responsible direct care staff person on duty on a 24-hour basis, when clients are present, to respond to injuries and symptoms of illness, and to handle emergencies, in each defined residential living unit housing: clients for whom a physician has not ordered a medical care plan; clients who are not aggressive, assaultive or security risks; and 16 or fewer clients.
	(4)	The facility shall provide sufficient support staff so that direct care staff are not required to perform support services to the extent that these duties interfere with the exercise of their primary direct client care duties.
	d. 	Direct care (residential living unit) staff.
	(1)	The facility shall provide sufficient direct care staff to manage and supervise clients in accordance with their individual program plans.
	(2)	Direct care staff are defined as the present on-duty staff calculated over all shifts in a 24-hour period for each defined residential living unit.
	(3)	Direct care staff shall be provided by the facility in the following minimum ratios of direct care staff to clients:
	1.	For each defined residential living unit serving children under the age of 12, severely and profoundly intellectually disabled clients, clients with severe physical disabilities, or clients who are aggressive, assaultive, or security risks, or who manifest severely hyperactive or psychotic-like behavior, the staff-to-client ratio is 1 to 3.2.
	2.	For each defined residential living unit serving moderately intellectually disabled clients, the staff-to-client ratio is 1 to 4.
	3.	For each defined residential living unit serving clients who function within the range of mild intellectual disability, the staff-to-client ratio is 1 to 6.4.
	4.	When there are no clients present in the living unit, a responsible staff member must be available by telephone.
	e. 	Staff training program.
	(1)	The facility shall provide each employee with initial and continuing training that enables the employee to perform the employee’s duties effectively, efficiently, and competently.
	(2)	For employees who work with clients, training shall focus on skills and competencies directed toward clients’ developmental, behavioral, and health needs.
	(3)	Staff shall be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
	(4)	Staff shall be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client for whom they are responsible.
	82.2(4) Active treatment services.
	a. 	Active treatment.
	(1)	Each client shall receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this paragraph, that is directed toward: the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status.
	(2)	Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.
	b. 	Admissions, transfers, and discharge.
	(1)	Clients who are admitted by the facility shall be in need of and receiving active treatment services.
	(2)	Admission decisions shall be based on a preliminary evaluation of the client that is conducted or updated by the facility or by outside sources.
	(3)	A preliminary evaluation shall contain background information as well as currently valid assessments of functional developmental, behavioral, social, health and nutritional status to determine if the facility can provide for the client’s needs and if the client is likely to benefit from placement in the facility.
	(4)	If a client is to be either transferred or discharged, the facility shall have documentation in the client’s record that the client was transferred or discharged for good cause and shall provide a reasonable time to prepare the client and the client’s parents or guardian for the transfer or discharge (except in emergencies).
	(5)	At the time of the discharge, the facility shall develop a final summary of the client’s developmental, behavioral, social, health and nutritional status and, with the consent of the client, parents (if the client is a minor) or legal guardian, provide a copy to authorized persons and agencies, and shall provide a post-discharge plan of care that will assist the client to adjust to the new living environment.
	c. 	Individual program plan.
	(1)	Each client shall have an individual program plan developed by an interdisciplinary team that represents the professions, disciplines or service areas that are relevant to identifying the client’s needs, as described by the comprehensive functional assessments required in 82.2(4)“c”(3), and designing programs that meet the client’s needs.
	(2)	Appropriate facility staff shall participate in interdisciplinary team meetings. Participation by other agencies serving the client is encouraged. For those clients enrolled with a managed care organization, the client’s case manager shall participate as appropriate and as allowed by the client. Participation by the client, the client’s parents (if the client is a minor), or the client’s legal guardian is required unless that participation is unobtainable or inappropriate.
	(3)	Within 30 days after admission, the interdisciplinary team shall perform accurate assessments or reassessments as needed to supplement the preliminary evaluation conducted prior to admission. The comprehensive functional assessment shall take into consideration the client’s age (for example, child, young adult, elderly person) and the implications for active treatment at each stage, as applicable, and shall:
	1.	Identify the presenting problems and disabilities and, where possible, their causes.
	2.	Identify the client’s specific developmental strengths.
	3.	Identify the client’s specific developmental and behavioral management needs.
	4.	Identify the client’s need for services without regard to the actual availability of the services needed.
	5.	Include physical development and health, nutritional status, sensorimotor development, affective development, speech and language development, auditory functioning, cognitive development, social development, adaptive behaviors or independent living skills necessary for the client to be able to function in the community, and vocational skills as applicable.
	(4)	Within 30 days after admission, the interdisciplinary team shall prepare for each client an individual program plan that states the specific objectives necessary to meet the client’s needs, as identified by the comprehensive assessment required by 82.2(4)“c”(3), and the planned sequence for dealing with those objectives. These objectives shall:
	1.	Be stated separately, in terms of a single behavioral outcome.
	2.	Be assigned projected completion dates.
	3.	Be expressed in behavioral terms that provide measurable indices of performance.
	4.	Be organized to reflect a developmental progression appropriate to the individual.
	5.	Be assigned priorities.
	(5)	Each written training program designed to implement the objectives in the individual program plan shall specify:
	1.	The methods to be used.
	2.	The schedule for use of the method.
	3.	The person responsible for the program.
	4.	The type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
	5.	The inappropriate client behaviors, if applicable.
	6.	Provision for the appropriate expression of behavior and the replacement of inappropriate behavior, if applicable, with behavior that is adaptive or appropriate.
	(6)	The individual program plan shall also:
	1.	Describe relevant interventions to support the individual toward independence.
	2.	Identify the location where program strategy information (which shall be accessible to any person responsible for implementation) can be found.
	3.	Include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
	4.	Identify mechanical supports, if needed, to achieve proper body position, balance, or alignment. The plan shall specify the reason for each support, the situations in which each is to be applied, and a schedule for the use of each support.
	5.	Provide that clients who have multiple disabling conditions spend a major portion of each waking day out of bed and outside the bedroom area, moving about by various methods and devices whenever possible.
	6.	Include opportunities for client choice and self-management.
	(7)	A copy of each client’s individual program plan shall be made available to all relevant staff, including staff of other agencies who work with the client, and to the client, parents (if the client is a minor) or legal guardian.
	d. 	Program implementation.
	(1)	As soon as the interdisciplinary team has formulated a client’s individual program plan, each client shall receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.
	(2)	The facility shall develop an active treatment schedule that outlines the current active treatment program and that is readily available for review by relevant staff.
	(3)	Except for those facets of the individual program plan that must be implemented only by licensed personnel, each client’s individual program plan shall be implemented by all staff who work with the client, including professional, paraprofessional and nonprofessional staff.
	e. 	Program documentation.
	(1)	Data relative to accomplishment of the criteria specified in client individual program plan objectives shall be documented in measurable terms.
	(2)	The facility shall document significant events that are related to the client’s individual program plan and assessments and that contribute to an overall understanding of the client’s ongoing level and quality of functioning.
	f. 	Program monitoring and change.
	(1)	The individual program plan shall be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to, situations in which the client:
	1.	Has successfully completed an objective or objectives identified in the individual program plan.
	2.	Is regressing or losing skills already gained.
	3.	Is failing to progress toward identified objectives after reasonable efforts have been made.
	4.	Is being considered for training toward new objectives.
	(2)	At least annually, the comprehensive functional assessment of each client shall be reviewed by the interdisciplinary team for relevancy and updated as needed, and the individual program plan shall be revised, as appropriate, repeating the process set forth in 82.2(4)“c.”
	(3)	The facility shall designate and use a specially constituted committee or committees consisting of members of facility staff, parents, legal guardians, clients (as appropriate), qualified persons who have either experience or training in contemporary practices to change inappropriate client behavior, and persons with no ownership or controlling interest in the facility to:
	1.	Review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.
	2.	Ensure that these programs are conducted only with the written informed consent of the client, parent (if the client is a minor), or legal guardian.
	3.	Review, monitor and make suggestions to the facility about its practices and programs as they relate to drug usage, physical restraints, time-out rooms, application of painful or noxious stimuli, control of inappropriate behavior, protection of client rights and funds, and any other area that the committee believes needs to be addressed.
	(4)	The provisions of 82.2(4)“f”(3) may be modified only if, in the judgment of the department of inspections and appeals, court decrees, state law or regulations provide for equivalent client protection and consultation.
	82.2(5) Client behavior and facility practices.
	a. 	Facility practices—conduct toward clients.
	(1)	The facility shall develop and implement written policies and procedures for the management of conduct between staff and clients. These policies and procedures shall:
	1.	Promote the growth, development, and independence of the client.
	2.	Address the extent to which client choice will be accommodated in daily decision making, emphasizing self-determination and self-management, to the extent possible.
	3.	Specify client conduct to be allowed or not allowed.
	4.	Be available to all staff, clients, parents of minor children, and legal guardians.
	(2)	To the extent possible, clients shall participate in the formulation of these policies and procedures.
	(3)	Clients shall not discipline other clients, except as part of an organized system of self-government, as set forth in facility policy.
	b. 	Management of inappropriate client behavior.
	(1)	The facility shall develop and implement written policies and procedures that govern the management of inappropriate client behavior. These policies and procedures shall be consistent with the provisions of 82.2(5)“a.” These procedures shall:
	1.	Specify all facility-approved interventions to manage inappropriate client behavior.
	2.	Designate these interventions on a hierarchy to be implemented ranging from most positive or least intrusive to least positive or most intrusive.
	3.	Ensure, prior to the use of more restrictive techniques, that the client’s record documents that programs incorporating the use of less intrusive or more positive techniques have been tried systematically and have been demonstrated to be ineffective.
	4.	Address the use of time-out rooms, the use of physical restraints, the use of drugs to manage inappropriate behavior, the application of painful or noxious stimuli, the staff members who may authorize the use of specified interventions, and a mechanism for monitoring and controlling the use of these interventions.
	(2)	Interventions to manage inappropriate client behavior shall be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.
	(3)	Techniques to manage inappropriate client behavior shall never be used for disciplinary purposes, for the convenience of staff or as a substitute for an active treatment program.
	(4)	The use of systematic interventions to manage inappropriate client behavior shall be incorporated into the client’s individual program plan, in accordance with 82.2(4)“c”(4) and (5).
	(5)	Standing or as-needed programs to control inappropriate behavior are not permitted.
	c. 	Time-out rooms.
	(1)	A client may be placed in a room from which egress is prevented only if the following conditions are met:
	1.	The placement is a part of an approved systematic time-out program as required by 82.2(5)“b.”
	2.	The client is under the direct constant visual supervision of designated staff.
	3.	The door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member to keep the mechanism engaged.
	(2)	Placement of a client in a time-out room shall not exceed one hour.
	(3)	Clients placed in time-out rooms shall be protected from hazardous conditions including, but not limited to, presence of sharp corners and objects, uncovered light fixtures, unprotected electrical outlets.
	(4)	A record of time-out activities shall be kept.
	d. 	Physical restraints.
	(1)	The facility may employ physical restraint only:
	1.	As an integral part of an individual program plan that is intended to lead to less restrictive means of managing and eliminating the behavior for which the restraint is applied.
	2.	As an emergency measure, but only if absolutely necessary to protect the client or others from injury.
	3.	As a health-related protection prescribed by a physician, but only if absolutely necessary during the conduct of a specific medical or surgical procedure, or only if absolutely necessary for client protection during the time that a medical condition exists.
	(2)	Authorizations to use or extend restraints as an emergency shall be in effect no longer than 12 consecutive hours and shall be obtained as soon as the client is restrained or stable.
	(3)	The facility shall not issue orders for restraint on a standing or as-needed basis.
	(4)	A client placed in restraint shall be checked at least every 30 minutes by staff trained in the use of restraints, shall be released from the restraint as quickly as possible, and a record of these checks and usage shall be kept.
	(5)	Restraints shall be designated and used so as not to cause physical injury to the client and so as to cause the least possible discomfort.
	(6)	Opportunity for motion and exercise shall be provided for a period of not less than ten minutes during each two-hour period in which restraint is employed, and a record of the activity shall be kept.
	(7)	Barred enclosures shall not be more than three feet in height and shall not have tops.
	e. 	Drug usage.
	(1)	The facility shall not use drugs in doses that interfere with the individual client’s daily living activities.
	(2)	Drugs used for control of inappropriate behavior shall be approved by the interdisciplinary team and be used only as an integral part of the client’s individual program plan that is directed specifically toward the reduction and eventual elimination of the behaviors for which the drugs are employed.
	(3)	Drugs used for control of inappropriate behavior shall not be used until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the drugs.
	(4)	Drugs used for control of inappropriate behavior shall be monitored closely, in conjunction with the physician and the drug regimen review requirement at 82.2(6)“j,” for desired responses and adverse consequences by facility staff, and shall be gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated.
	82.2(6) Health care services.
	a. 	Physician services.
	(1)	The facility shall ensure the availability of physician services 24 hours a day.
	(2)	The physician shall develop, in coordination with licensed nursing personnel, a medical care plan of treatment for a client if the physician determines that an individual client requires 24-hour licensed nursing care. This plan shall be integrated in the individual program plan.
	(3)	The facility shall provide or obtain preventive and general medical care as well as annual physical examinations of each client that at a minimum include the following:
	1.	Evaluation of vision and hearing.
	2.	Immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.
	3.	Routine screening laboratory examinations as determined necessary by the physician, and special studies when needed.
	4.	Tuberculosis control, appropriate to the facility’s population, and in accordance with the recommendations of the American College of Chest Physicians or the section of diseases of the chest of the American Academy of Pediatrics, or both.
	(4)	To the extent permitted by state law, the facility may utilize physician assistants and nurse practitioners to provide physician services as described in this subrule.
	b. 	Physician participation in the individual program plan. A physician shall participate in:
	(1)	The establishment of each newly admitted client’s initial individual program plan.
	(2)	If appropriate, physicians shall participate in the review and update of an individual program plan as part of the interdisciplinary team process either in person or through written report to the interdisciplinary team.
	c. 	Nursing services. The facility shall provide clients with nursing services in accordance with their needs. These services shall include:
	(1)	Participation as appropriate in the development, review, and update of an individual program plan as part of the interdisciplinary team process.
	(2)	The development, with a physician, of a medical care plan of treatment for a client when the physician has determined that an individual client requires such a plan.
	(3)	For those clients certified as not needing a medical care plan, a review of their health status which shall:
	1.	Be by a direct physical examination.
	2.	Be by a licensed nurse.
	3.	Be on a quarterly or more frequent basis depending on client need.
	4.	Be recorded in the client’s record.
	5.	Result in any necessary action including referral to a physician to address client health problems.
	(4)	Other nursing care as prescribed by the physician or as identified by client needs.
	(5)	Implementing, with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to:
	1.	Training clients and staff as needed in appropriate health and hygiene methods.
	2.	Control of communicable diseases and infections, including the instruction of other personnel in methods of infection control.
	3.	Training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients.
	d. 	Nursing staff.
	(1)	Nurses providing services in the facility shall have a current license to practice in the state.
	(2)	The facility shall employ or arrange for licensed nursing services sufficient to care for clients’ health needs including those clients with medical care plans.
	(3)	The facility shall utilize registered nurses as appropriate and required by state law to perform the health services specified in this subrule.
	(4)	If the facility utilizes only licensed practical or vocational nurses to provide health services, it shall have a formal arrangement with a registered nurse to be available for verbal or on-site consultation with the licensed practical or vocational nurse.
	(5)	Nonlicensed nursing personnel who work with clients under a medical care plan shall do so under the supervision of licensed persons.
	e. 	Dental services.
	(1)	The facility shall provide or make arrangements for comprehensive diagnostic and treatment services for each client from qualified personnel, including licensed dentists and dental hygienists, either through organized dental services in-house or through arrangement.
	(2)	If appropriate, dental professionals shall participate in the development, review and update of an individual program plan as part of the interdisciplinary process either in person or through written report to the interdisciplinary team.
	(3)	The facility shall provide education and training in the maintenance of oral health.
	f. 	Comprehensive dental diagnostic services. Comprehensive dental diagnostic services include:
	(1)	A complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client’s oral condition, not later than one month after admission to the facility unless the examination was completed within 12 months prior to admission.
	(2)	Periodic examination and diagnosis performed at least annually, including radiographs when indicated and detection of manifestations of systemic disease.
	(3)	A review of the results of examination and entry of the results in the client’s dental record.
	g. 	Comprehensive dental treatment. The facility shall ensure comprehensive dental treatment services that include:
	(1)	The availability for emergency dental treatment on a 24-hour-a-day basis by a licensed dentist.
	(2)	Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
	h. 	Documentation of dental services.
	(1)	If the facility maintains an in-house dental service, the facility shall keep a permanent dental record for each client, with a dental summary maintained in the client’s living unit.
	(2)	If the facility does not maintain an in-house dental service, the facility shall obtain a dental summary of the results of dental visits and maintain the summary in the client’s living unit.
	i. 	Pharmacy services. The facility shall provide or make arrangements for the provision of routine and emergency drugs and biologicals to its clients. Drugs and biologicals may be obtained from community or contract pharmacists or the facility may maintain a licensed pharmacy.
	j. 	Drug regimen review.
	(1)	A pharmacist with input from the interdisciplinary team shall review the drug regimen of each client at least quarterly.
	(2)	The pharmacist shall report any irregularities in clients’ drug regimens to the prescribing physician and interdisciplinary team.
	(3)	The pharmacist shall prepare a record of each client’s drug regimen reviews and the facility shall maintain that record.
	(4)	An individual medication administration record shall be maintained for each client.
	(5)	As appropriate, the pharmacist shall participate in the development, implementation, and review of each client’s individual program plan either in person or through written report to the interdisciplinary team.
	k. 	Drug administration. The facility shall have an organized system for drug administration that identifies each drug up to the point of administration. The system shall ensure that:
	(1)	All drugs are administered in compliance with the physician’s orders.
	(2)	All drugs, including those that are self-administered, are administered without error.
	(3)	Unlicensed personnel are allowed to administer drugs only if state law permits.
	(4)	Clients are taught how to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective, and if the physician does not specify otherwise.
	(5)	The client’s physician is informed of the interdisciplinary team’s decision that self-administration of medications is an objective for the client.
	(6)	No client self-administers medications until the client demonstrates the competency to do so.
	(7)	Drugs used by clients while not under the direct care of the facility are packaged and labeled in accordance with state law.
	(8)	Drug administration errors and adverse drug reactions are recorded and reported immediately to a physician.
	l. 	Drug storage and record keeping.
	(1)	The facility shall store drugs under proper conditions of sanitation, temperature, light, humidity, and security.
	(2)	The facility shall keep all drugs and biologicals locked except when being prepared for administration. Only authorized persons may have access to the keys to the drug storage area. Clients who have been trained to self-administer drugs in accordance with 82.2(6)“k”(4) may have access to keys to their individual drug supply.
	(3)	The facility shall maintain records of the receipt and disposition of all controlled drugs.
	(4)	The facility shall, on a sample basis, periodically reconcile the receipt and disposition of all controlled drugs in Schedules II through IV (drugs subject to the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C. 801 et seq.).
	(5)	If the facility maintains a licensed pharmacy, the facility shall comply with the regulations for controlled drugs.
	m. 	Drug labeling.
	(1)	Labeling of drugs and biologicals shall be based on currently accepted professional principles and practices, and shall include the appropriate accessory and cautionary instructions, as well as the expiration date, if applicable.
	(2)	The facility shall remove from use outdated drugs and drug containers with worn, illegible, or missing labels.
	(3)	Drugs and biologicals packaged in containers designated for a particular client shall be immediately removed from the client’s current medication supply if discontinued by the physician.
	n. 	Laboratory services.
	(1)	For purposes of this subrule, “laboratory” means an entity for the microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or assessment of a medical condition.
	(2)	If a facility chooses to provide laboratory services, the laboratory shall meet the management requirements specified in 42 CFR 493.1407 as amended to March 29, 2022, and provide personnel to direct and conduct the laboratory services.
The laboratory director shall be technically qualified to supervise the laboratory personnel and test performance and shall meet licensing or other qualification standards established by the state with respect to directors of clinical laboratories.
The laboratory director shall provide adequate technical supervision of the laboratory services and ensure that tests, examinations and procedures are properly performed, recorded and reported.
The laboratory director shall ensure that the staff has appropriate education, experience, and training to perform and report laboratory tests promptly and proficiently; is sufficient in number for the scope and complexity of the services provided; and receives in-service training appropriate to the type of complexity of the laboratory services offered.
The laboratory technologists shall be technically competent to perform test procedures and report test results promptly and proficiently.
	(3)	The laboratory shall meet the proficiency testing requirements specified in 42 CFR 493.801 as amended to March 29, 2022.
	(4)	If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory shall be an approved Medicare laboratory.
	82.2(7) Physical environment.
	a. 	Client living environment.
	(1)	The facility shall not house clients of grossly different ages, developmental levels, and social needs in close physical or social proximity unless the housing is planned to promote the growth and development of all those housed together.
	(2)	The facility shall not segregate clients solely on the basis of their physical disabilities. It shall integrate clients who have ambulation deficits or who are deaf, hard of hearing, blind, or have seizure disorders with others of comparable social and intellectual development.
	b. 	Client bedrooms.
	(1)	Bedrooms shall:
	1.	Be rooms that have at least one outside wall.
	2.	Be equipped with or located near toilet and bathing facilities.
	3.	Accommodate no more than four clients unless granted a variance under 82.2(7)“b”(3).
	4.	Measure at least 60 square feet per client in multiple-client bedrooms and at least 80 square feet in single-client bedrooms.
	5.	In all facilities initially certified or in buildings constructed or with major renovations or conversions, have walls that extend from floor to ceiling.
	(2)	If a bedroom is below grade level, it shall have a window that is usable as a second means of escape by the client occupying the rooms and shall be no more than 44 inches measured to the windowsill above the floor unless the facility is surveyed under the Health Care Occupancy Chapter of the Life Safety Code, in which case the window must be no more than 36 inches measured to the windowsill above the floor.
	(3)	The department of inspections and appeals may grant a variance from the limit of four clients per room only if a physician who is a member of the interdisciplinary team and who is a qualified intellectual disability professional certifies that each client to be placed in a bedroom housing more than four persons is so severely medically impaired as to require direct and continuous monitoring during sleeping hours and documents the reasons why housing in a room of only four or fewer persons would not be medically feasible.
	(4)	The facility shall provide each client with:
	1.	A separate bed of proper size and height for the convenience of the client.
	2.	A clean, comfortable mattress.
	3.	Bedding appropriate to the weather and climate.
	4.	Functional furniture appropriate to the client’s needs, and individual closet space in the client’s bedroom with clothes racks and shelves accessible to the client.
	c. 	Storage space in bedroom. The facility shall provide:
	(1)	Space and equipment for daily out-of-bed activity for all clients who are not yet mobile, except those who have a short-term illness or those few clients for whom out-of-bed activity is a threat to health and safety.
	(2)	Suitable storage space, accessible to clients, for personal possessions such as televisions, radios, prosthetic equipment and clothing.
	d. 	Client bathrooms. The facility shall:
	(1)	Provide toilet and bathing facilities appropriate in number, size, and design to meet the needs of the clients.
	(2)	Provide for individual privacy in toilets, bathtubs, and showers.
	(3)	In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit.
	e. 	Heating and ventilation.
	(1)	Each client bedroom in the facility shall have at least one window to the outside and direct outside ventilation by means of windows, air conditioning, or mechanical ventilation.
	(2)	The facility shall maintain the temperature and humidity within a normal comfort range by heating, air conditioning or other means and ensure that the heating apparatus does not constitute a burn or smoke hazard to clients.
	f. 	Floors. The facility shall have:
	(1)	Floors that have a resilient, nonabrasive, and slip-resistant surface.
	(2)	Nonabrasive carpeting, if the area used by clients is carpeted and serves clients who lie on the floor or ambulate with parts of their bodies, other than feet, touching the floor.
	(3)	Exposed floor surfaces and floor coverings that promote mobility in areas used by clients, and promote maintenance of sanitary conditions.
	g. 	Space and equipment. The facility shall:
	(1)	Provide sufficient space and equipment in dining, living, health services, recreation, and program areas (including adequately equipped and sound treated areas for hearing and other evaluations if they are conducted in the facility) to enable staff to provide clients with needed services as required by this rule and as identified in each client’s individual program plan.
	(2)	Furnish, maintain in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client.
	(3)	Provide adequate clean linen and dirty linen storage areas.
	h. 	Emergency plan and procedures.
	(1)	The facility shall develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients.
	(2)	The facility shall communicate, periodically review, make the plan available, and provide training to the staff.
	i. 	Evacuation drills.
	(1)	The facility shall hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to ensure that all personnel on all shifts are trained to perform assigned tasks; ensure that all personnel on all shifts are familiar with the use of the facility’s fire protection features; and evaluate the effectiveness of emergency and disaster plans and procedures.
	(2)	The facility shall actually evacuate clients during at least one drill each year on each shift; make special provisions for the evacuation of clients with physical disabilities; file a report and evaluation on each evacuation drill; and investigate all problems with evacuation drills, including accidents, and take corrective action. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code.
	(3)	Facilities shall meet the requirements of 82.2(7)“i”(1) and (2) for any live-in and relief staff they utilize.
	j. 	Fire protection.
	(1)	General.
	1.	Except as specified in 82.2(7)“i”(2), the facility shall meet the applicable provisions of either the Health Care Occupancies Chapters or the Residential Board and Care Occupancies Chapter of the Life Safety Code (LSC) of the National Fire Protection Association, 1985 edition, which is incorporated by reference.
	2.	The department of inspections and appeals may apply a single chapter of the LSC to the entire facility or may apply different chapters to different buildings or parts of buildings as permitted by the LSC.
	3.	A facility that meets the LSC definition of a residential board and care occupancy and that has 16 or fewer beds shall have its evacuation capability evaluated in accordance with the Evacuation Difficulty Index of the LSC (Appendix F).
	(2)	Exceptions.
	1.	For facilities that meet the LSC definition of a health care occupancy, the Centers for Medicare and Medicaid Services may waive, for a period it considers appropriate, specific provisions of the LSC if the waiver would not adversely affect the health and safety of the clients and rigid application of specific provisions would result in an unreasonable hardship for the facility.
The department of inspections and appeals may apply the state’s fire and safety code instead of the LSC if the Secretary of the Department of Health and Human Services finds that the state has a code imposed by state law that adequately protects a facility’s clients.
Compliance on November 28, 1982, with the 1967 edition of the LSC or compliance on April 18, 1986, with the 1981 edition of the LSC, with or without waivers, is considered to be compliance with this standard as long as the facility continues to remain in compliance with that edition of the code.
	2.	For facilities that meet the LSC definition of a residential board and care occupancy and that have more than 16 beds, the department of inspections and appeals may apply the state’s fire and safety code as specified above.
	k. 	Paint. The facility shall:
	(1)	Use lead-free paint inside the facility.
	(2)	Remove or cover interior paint or plaster containing lead so that it is not accessible to clients.
	l. 	Infection control.
	(1)	The facility shall provide a sanitary environment to avoid sources and transmission of infections. There shall be an active program for the prevention, control, and investigation of infection and communicable diseases.
	(2)	The facility shall implement successful corrective action in affected problem areas.
	(3)	The facility shall maintain a record of incidents and corrective actions related to infections.
	(4)	The facility shall prohibit employees with symptoms or signs of a communicable disease from direct contact with clients and their food.
	82.2(8) Dietetic services.
	a. 	Food and nutrition services.
	(1)	Each client shall receive a nourishing, well-balanced diet including modified and specially prescribed diets.
	(2)	A qualified dietitian shall be employed either full-time, part-time or on a consultant basis at the facility’s discretion.
	(3)	If a qualified dietitian is not employed full-time, the facility shall designate a person to serve as the director of food services.
	(4)	The client’s interdisciplinary team, including a qualified dietitian and physician, shall prescribe all modified and special diets including those used as a part of a program to manage inappropriate client behavior.
	(5)	Foods proposed for use as a primary reinforcement of adaptive behavior are evaluated in light of the client’s nutritional status and needs.
	(6)	Unless otherwise specified by medical needs, the diet shall be prepared at least in accordance with the latest edition of the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences, adjusted for age, sex, disability and activity.
	b. 	Meal services.
	(1)	Each client shall receive at least three meals daily, at regular times comparable to normal mealtimes in the community with:
	1.	Not more than 14 hours between a substantial evening meal and breakfast of the following day, except on weekends and holidays when a nourishing snack is provided at bedtime, 16 hours may elapse between a substantial evening meal and breakfast.
	2.	Not less than 10 hours between breakfast and the evening meal of the same day, except as provided under 82.2(8)“b”(1)“1.”
	(2)	Food shall be served:
	1.	In appropriate quantity.
	2.	At appropriate temperature.
	3.	In a form consistent with the developmental level of the client.
	4.	With appropriate utensils.
	(3)	Food served to clients individually and uneaten shall be discarded.
	c. 	Menus.
	(1)	Menus shall:
	1.	Be prepared in advance.
	2.	Provide a variety of foods at each meal.
	3.	Be different for the same days of each week and adjusted for seasonal change.
	4.	Include the average portion sizes for menu items.
	(2)	Menus for food actually served shall be kept on file for 30 days.
	d. 	Dining areas and service. The facility shall:
	(1)	Serve meals for all clients, including persons with ambulation deficits, in dining areas, unless otherwise specified by the interdisciplinary team or a physician.
	(2)	Provide table service for all clients who can and will eat at a table, including clients in wheelchairs.
	(3)	Equip areas with tables, chairs, eating utensils, and dishes designed to meet the developmental needs of each client.
	(4)	Supervise and staff dining rooms adequately to direct self-help dining procedure, to ensure that each client receives enough food and to ensure that each client eats in a manner consistent with the client’s developmental level.
	(5)	Ensure that each client eats in an upright position, unless otherwise specified by the interdisciplinary team or physician.
This rule is intended to implement Iowa Code section 249A.12.
[ARC 0582C, IAB 2/6/13, effective 4/1/13; ARC 2361C, IAB 1/6/16, effective 1/1/16; ARC 5808C, IAB 7/28/21, effective 9/1/21; ARC 6776C, IAB 12/28/22, effective 2/1/23]