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    CHAPTER 24ACCREDITATION OF PROVIDERS OF SERVICES TO PERSONS WITH MENTAL ILLNESS, INTELLECTUAL DISABILITIES, OR DEVELOPMENTAL DISABILITIESPreambleThe mental health and disability services commission has adopted this set of standards to be met by all providers of services to people with mental illness, intellectual disabilities, or developmental disabilities. These standards apply to providers that are not required to be licensed by the department of inspections and appeals. These providers include community mental health centers, mental health services providers, case management providers, supported community living providers, and crisis response providers in accordance with Iowa Code chapter 225C.The standards serve as the foundation of a performance-based review of those organizations for which the department holds accreditation responsibility, as set forth in Iowa Code chapters 225C and 230A. The mission of accreditation is to assure individuals using the services and the general public of organizational accountability for meeting best practices performance levels, for efficient and effective management, and for the provision of quality services that result in quality outcomes for individuals using the services.The department’s intent is to establish standards that are based on the principles of quality improvement and are designed to facilitate the provision of excellent quality services that lead to positive outcomes. The intent of these standards is to make organizations providing services responsible for effecting efficient and effective management and operational systems that enhance the involvement of individuals using the services and to establish a best practices level of performance by which to measure provider organizations.DIVISION ISERVICES FOR INDIVIDUALS WITH DISABILITIESPreambleThis set of standards in this division has been established to be met by all providers of case management, day treatment, intensive psychiatric rehabilitation, supported community living, partial hospitalization, outpatient counseling and emergency services.441—24.1(225C)  Definitions.  
    "Accreditation" means the decision made by the division that the organization has met the applicable standards.
    "Advanced registered nurse practitioner" means a nurse who has current licensure as a registered nurse in Iowa, or licensure in another state that is recognized in Iowa pursuant to Iowa Code chapter 152E, and who is also registered as certified in psychiatric mental health specialties pursuant to board of nursing rules in 655—Chapter 7.
    "Advisory board" means the board that reviews and makes recommendations to the organization on the program being accredited. The advisory board shall meet at least three times a year and shall have at least three members, at least 51 percent of whom are not providers. The advisory board shall include representatives who have disabilities or family members of persons with disabilities. The advisory board’s duties include review and recommendation of policies, development and review of the organizational plan for the program being accredited, review and recommendation of the budget for the program being accredited, and review and recommendation of the performance improvement program of the program being accredited.
    "Anticipated discharge plan" means the statement of the condition or circumstances by which the individual using the service would no longer need each of the specific services accredited under this chapter.
    "Appropriate" means the degree to which the services or supports or activities provided or undertaken by the organization are suitable and desirable for the needs, situation, or problems of the individual using the service.
    "Assessment" means the review of the current functioning of the individual using the service in regard to the individual’s situation, needs, strengths, abilities, desires and goals.
    "Benchmarks" means the processes of an organization that lead to implementation of the indicators.
    "Chronic mental illness" means the condition present in people aged 18 and over who have a persistent mental or emotional disorder that seriously impairs their functioning relative to such primary aspects of daily living as personal relations, living arrangements, or employment. People with chronic mental illness typically meet at least one of the following criteria:
    1. They have undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization or inpatient hospitalization).
    2. They have experienced at least one episode of continuous, structured, supportive residential care other than hospitalization.
    In addition, people with chronic mental illness typically meet at least two of the following criteria on a continuing or intermittent basis for at least two years:
    1. They are unemployed, employed in a sheltered setting, or have markedly limited skills and a poor work history.
    2. They require financial assistance for out-of-hospital maintenance and may be unable to procure this assistance without help.
    3. They show severe inability to establish or maintain a personal social support system.
    4. They require help in basic living skills.
    5. They exhibit inappropriate social behavior that results in demand for intervention by the mental health or judicial system.
    In atypical instances, a person who varies from these criteria could still be considered to be a person with chronic mental illness.
    "Commission" means the mental health and disability services commission (MHDS commission) as established and defined in Iowa Code section 225C.5.
    "Community" means a natural setting where people live, learn, work, and socialize.
    "Community mental health center" "CMHC" means an organization providing mental health services that is established pursuant to Iowa Code chapters 225C and 230A and accredited in accordance with Division III of this chapter.
    "Crisis intervention plan" means a personalized, individualized plan developed with the individual using the service that identifies potential personal psychiatric, environmental, and medical emergencies. This plan shall also include those life situations identified as problematic and the identified strategies and natural supports developed with the individual using the service to enable the individual to self-manage, alleviate, or end the crisis. This plan shall also include how the individual can access emergency services that may be needed.
    "Deemed status" means acceptance by the division of accreditation or licensure of a program or service by another accrediting body in lieu of accreditation based on review and evaluation by the division.
    "Department" means the Iowa department of human services.
    "Developmental disability" means a severe, chronic disability that:
    1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;
    2. Is manifested before the age of 22;
    3. Is likely to continue indefinitely;
    4. Results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency; and
    5. Reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.
    A person from birth to the age of nine, inclusive, who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described above if the person, without services and supports, has a high probability of meeting those criteria later in life.
    "Direct services" means services providing therapy, habilitation, or rehabilitation activities or support services such as transportation.
    "Division" means the division of mental health and disability services, community, of the department of human services.
    "Doctor of medicine or osteopathic medicine" means a person who is licensed in the state of Iowa under Iowa Code chapter 148 as a physician and surgeon or under Iowa Code chapter 150A as an osteopathic physician and surgeon.
    "Functional assessment" means the analysis of daily living skills. The functional assessment also takes into consideration the strengths, stated needs, and level and kind of disability of the individual using the service.
    "Goal achieving" means to gain the required skills and supports to obtain the goal of choice. For purposes of this chapter, the definition and explanation are taken from the Psychiatric Rehabilitation Practitioner Tools, as developed by the Boston Center for Psychiatric Rehabilitation.
    "Goal keeping" means assisting the individual using the service in maintaining successful and satisfying role performance to prevent the emergence of symptoms associated with role deterioration. For purposes of this chapter, the definition and explanation are taken from the Psychiatric Rehabilitation Practitioner Tools, as developed by the Boston Center for Psychiatric Rehabilitation.
    "Incident," for the purposes of this chapter, means an occurrence involving the individual using the service that:
    1. Results in a physical injury to or by the individual that requires a physician’s treatment or admission to a hospital, or
    2. Results in someone’s death, or
    3. Requires emergency mental health treatment for the individual, or
    4. Requires the intervention of law enforcement, or
    5. Results from any prescription medication error, or
    6. Is reportable to protective services.
    "Indicators" means conditions that will exist when the activity is done competently and benchmarks are achieved. Indicators also provide a means to assess the activity’s effect on outcomes of services.
    "Informed consent" refers to time-limited, voluntary consent. The individual using the service or the individual’s legal guardian may withdraw consent at any time without risk of punitive action. “Informed consent” includes a description of the treatment and specific procedures to be followed, the intended outcome or anticipated benefits, the rationale for use, the risks of use and nonuse, and the less restrictive alternatives considered. The individual using the service or the legal guardian has the opportunity to ask questions and have them satisfactorily answered.
    "Intellectual disability" means a diagnosis of intellectual disability (intellectual developmental disorder), global developmental delay, or unspecified intellectual disability (intellectual developmental disorder) under these rules which shall be made only when the onset of the person’s condition was during the developmental period and shall be based on an assessment of the person’s intellectual functioning and level of adaptive skills. A licensed psychologist or psychiatrist who is professionally trained to administer the tests required to assess intellectual functioning and to evaluate a person’s adaptive skills shall make the diagnosis. A diagnosis of intellectual disability shall be made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
    "Intensive psychiatric rehabilitation practitioner" means a person who has at least 60 contact hours of training in intensive psychiatric rehabilitation and either:
    1. Is certified as a psychiatric rehabilitation practitioner by the United States Psychiatric Rehabilitation Association; or
    2. Holds a bachelor’s degree with 30 semester hours or equivalent quarter hours in a human services field (including, but not limited to, psychology, social work, mental health counseling, marriage and family therapy, nursing, education, occupational therapy, and recreational therapy) and has at least one year of experience in the delivery of services to the population groups that the person is hired to serve.
    "Leadership" means the governing board, the chief administrative officer or executive director, managers, supervisors, and clinical leaders who participate in developing and implementing organizational policies, plans and systems.
    "Marital and family therapist" means a person who is licensed under Iowa Code chapter 154D in the application of counseling techniques in the assessment and resolution of emotional conditions. This includes the alteration and establishment of attitudes and patterns of interaction relative to marriage, family life, and interpersonal relationships.
    "Mental health counselor" means a person who is licensed under Iowa Code chapter 154D in counseling services involving assessment, referral, consultation, and the application of counseling, human development principles, learning theory, group dynamics, and the etiology of maladjustment and dysfunctional behavior to individuals, families, and groups.
    "Mental health professional" means a person who meets all of the following conditions:
    1. Holds at least a master’s degree in a mental health field including, but not limited to, psychology, counseling and guidance, psychiatric nursing and social work; or is a doctor of medicine or osteopathic medicine; and
    2. Holds a current Iowa license when required by the Iowa professional licensure laws (such as a psychiatrist, a psychologist, a marital and family therapist, a mental health counselor, an advanced registered nurse practitioner, a psychiatric nurse, or a social worker); and
    3. Has at least two years of postdegree experience supervised by a mental health professional in assessing mental health problems, mental illness, and service needs and in providing mental health services.
    "Mental health service provider" means an organization whose services are established to specifically address mental health services to individuals or the administration of facilities in which these services are provided. Organizations included are:
    1. Those contracting with a county board of supervisors to provide mental health services in lieu of that county’s affiliation with a community mental health center (Iowa Code chapter 230A).
    2. Those that may contract with a county board of supervisors for special services to the general public or special segments of the general public and that are not accredited by any other accrediting body.
    These standards do not apply to individual practitioners or partnerships of practitioners covered under Iowa’s professional licensure laws.
    "Natural supports" means those services and supports an individual using the service identifies as wanted or needed that are provided at no cost by family, friends, neighbors, and others in the community, or by organizations or entities that serve the general public.
    "New organization" means an entity that has never been accredited under 441—Chapter 24 or an accredited entity under 441—Chapter 24 that makes a significant change in its ownership, structure, management, or service delivery.
    "Organization" means:
    1. A governmental entity or an entity that meets Iowa Code requirements for a business organization as a for-profit or not-for-profit business. These entities include, but are not limited to, a business corporation under Iowa Code chapter 490 or a nonprofit corporation under Iowa Code chapter 504 that provides a service accredited pursuant to the rules in this chapter.
    2. A county, consortium of counties, or the department of human services that provides or subcontracts for the provision of case management.
    3. A division or unit of a larger entity, such as a unit within a hospital or parent organization.
    “Organization” does not include: an individual for whom a license to engage in a profession is required under Iowa Code section 147.2, any person providing a service if the person is not organized as a corporation or other business entity recognized under the Iowa Code, or an entity that provides only financial, administrative, or employment services and that does not directly provide the services accredited under this chapter.
    "Outcome" means the result of the performance or nonperformance of a function or process or activity.
    "Policies" means the principles and statements of intent of the organization.
    "Procedures" means the steps taken to implement the policies of the organization.
    "Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals for the population of a specified geographic area or for special target populations.
    "Psychiatric crisis intervention plan" means a personalized, individualized plan developed with the individual using the service that identifies potential personal psychiatric emergencies. This plan shall also include those life situations identified as problematic and the identified strategies and natural supports developed with the individual using the service to enable the individual to self-manage, alleviate, or end the crisis. This plan shall also include how the individual can access emergency services that may be needed.
    "Psychiatric nurse" means a person who meets the requirements of a certified psychiatric nurse, is eligible for certification by the American Nursing Association, and is licensed by the state of Iowa to practice nursing as defined in Iowa Code chapter 152.
    "Psychiatrist" means a doctor of medicine or osteopathic medicine who is certified by the American Board of Psychiatry and Neurology or who is eligible for certification and who is fully licensed to practice medicine in the state of Iowa.
    "Psychologist" means a person who:
    1. Is licensed to practice psychology in the state of Iowa or meets the requirements of eligibility for a license to practice psychology in the state of Iowa as defined in Iowa Code chapter 154B; or
    2. Is certified by the Iowa department of education as a school psychologist or is eligible for certification by the Iowa department of education.
    "Qualified case managers and supervisors" means people who have the following qualifications:
    1. A bachelor’s degree with 30 semester hours or equivalent quarter hours in a human services field (including, but not limited to, psychology, social work, mental health counseling, marriage and family therapy, nursing, education, occupational therapy, and recreational therapy) and at least one year of experience in the delivery of services to the population groups that the person is hired as a case manager or case management supervisor to serve; or
    2. An Iowa license to practice as a registered nurse and at least three years of experience in the delivery of services to the population group the person is hired as a case manager or case management supervisor to serve.
    People employed as case management supervisors on or before August 1, 1993, who do not meet these requirements shall be considered to meet these requirements as long as they are continuously employed by the same case management provider.
    "Readiness assessment" means a process of involving the individual using the service in clarifying motivational readiness to participate in the recovery process. For purposes of this chapter, the definition and explanation are taken from the Psychiatric Rehabilitation Practitioner Tools, as developed by the Boston Center for Psychiatric Rehabilitation.
    "Readiness development" means services designed to develop or increase an individual’s interest, motivation, and resolve to engage in the rehabilitation services process, as a means of enhancing independent functioning and quality of life. For purposes of this chapter, the definition and explanation are taken from the Psychiatric Rehabilitation Practitioner Tools, as developed by the Boston Center for Psychiatric Rehabilitation.
    "Registered nurse" means a person who is licensed to practice nursing in the state of Iowa as defined in Iowa Code chapter 152.
    "Rehabilitation services" means services designed to restore, improve, or maximize the individual’s optimal level of functioning, self-care, self-responsibility, independence and quality of life and to minimize impairments, disabilities and dysfunction caused by a serious and persistent mental or emotional disability.
    "Rights restriction" means limitations not imposed on the general public in the areas of communication, mobility, finances, medical or mental health treatment, intimacy, privacy, type of work, religion, place of residence, and people with whom the individual using the service may share a residence.
    "Serious emotional disturbance" means a diagnosable mental, behavioral, or emotional disorder that (1) is of sufficient duration to meet diagnostic criteria for the disorder specified by the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association; and (2) has resulted in a functional impairment that substantially interferes with or limits a consumer’s role or functioning in family, school, or community activities. “Serious emotional disturbance” shall not include neurodevelopmental disorders, substance-related disorders, or conditions or problems classified in the current version of the DSM as “other conditions that may be a focus of clinical attention,” unless those conditions co-occur with another diagnosable serious emotional disturbance.
    "Service plan" means an individualized goal-oriented plan of services written in language understandable by the individual using the service and developed collaboratively by the individual and the organization.
    "Staff" means people paid by the organization to perform duties and responsibilities defined in the organization’s policies and procedures.
    Related ARC(s): 1660C, 2164C, 6321C441—24.2(225C)  Standards for policy and procedures.    24.2(1)    Performance benchmark.  The organization has written policy direction for the organization and each service being accredited.  24.2(2)    Performance indicators.    a.  The organization has a policies and procedures manual with policy guidelines and administrative procedures for all organizational activities and services specific to its organization that addresses the standards in effect at the time of review.  b.  The policies and procedures cover each benchmark and indicator in this chapter.  c.  The policies and procedures manual is made available to all staff.441—24.3(225C)  Standards for organizational activities.    24.3(1)    Performance improvement system.    a.    Performance benchmark.  The organization has a systematic, organizationwide, planned approach to designing, measuring, evaluating, and improving the level of its performance.  b.    Performance indicators.  The organization:  (1)  Annually measures and assesses organizational activities and services accredited in this chapter.  (2)  Gathers information from individuals using the services, from staff, and from family members.  (3)  Implements an internal review of individual records for those services accredited under this chapter. For outpatient psychotherapy and counseling services, the organization:
    1. Reviews the individual’s involvement in and with treatment.
    2. Ensures that treatment activities are documented and are relevant to the diagnosis or presenting problem.
      (4)  Reviews the organization’s response to incidents reported under subrule 24.4(5) for necessity, appropriateness, effectiveness and prevention. This review includes analysis of incident data at least annually to identify any patterns of risk to the health and safety of consumers.  (5)  Reviews the organization’s response to any situation that poses a danger or threat to staff or to individuals using the services for necessity, appropriateness, effectiveness, and prevention.  (6)  Identifies areas in need of improvement.  (7)  Has a plan to address the areas in need of improvement. Where applicable, the organization establishes a plan to resolve the problem of patients missing appointments.  (8)  Implements the plan and documents the results.      24.3(2)    Leadership.    a.    Performance benchmark.  Organization leaders provide the framework for the planning, designing, directing, coordination, provision and improvement of services that are responsive to the individuals using the services and the community served by the organization.  b.    Performance indicators.    (1)  There are clearly articulated mission and values statements that are reflected in the long-range organizational plans and in organization policies.  (2)  The annual and long-range budgeting process involves appropriate governing and managing levels of leadership and reflects the organization’s mission and values. An independent auditor or other person as provided by law performs an annual financial audit. Designated CMHCs shall submit their annual financial audit to the department.  (3)  Individuals using the services or family members of individuals using the services are represented on the organization’s governing board or on an advisory board.  (4)  The organization’s decision-making process, including policy decisions affecting the organization, reflects involvement of the various levels of leadership and responsiveness to staff.  (5)  Organization leaders solicit input from leaders of the various community groups representing individuals served by the organization in designing responsive service delivery systems.  (6)  Organization leaders develop and implement a service system appropriate to the needs of the individuals served by the organization.  (7)  Organization leaders make educational information, resources, and service consultation available to community groups.  24.3(3)    Management information system.    a.    Performance benchmark.  Information is obtained, managed, and used in an efficient and effective method to document, enhance, and improve organizational performance and service delivery.  b.    Performance indicators.    (1)  The organization has a system in place to maintain current individual-specific information documenting the provision and outcomes of services and treatments provided.  (2)  The organization has a system in place to maintain the confidentiality and security of information that identifies specific individuals using the services, including mail, correspondence, and electronic files.  24.3(4)    Human resources.    a.    Performance benchmark.  The organization provides qualified staff to support the organization’s mission and facilitate the provision of quality services.  b.    Performance indicators.  The organization:  (1)  Has a job description in the personnel file of each staff member that clearly defines responsibilities and qualifications.  (2)  Has a process to verify qualifications of staff, including degrees, licenses, medication management training, and certification as required by the position, within 90 days of the staff person’s employment. For staff hired after July 1, 2006, personnel files contain evidence that verification of professional licenses and college degrees at the bachelor’s level or higher, as required by the position, was obtained from the primary source.  (3)  Evaluates staff annually.  (4)  Includes a plan for staff development for each staff member in the annual evaluation.  (5)  Provides training and education to all staff relevant to their positions.  (6)  Provides for approved training on child and dependent adult abuse reporter requirements to all organization staff who are mandatory abuse reporters. The organization documents in personnel records training on child and dependent adult abuse reporter requirements.  (7)  Has staff members sign a document indicating that they are aware of the organization’s policy on confidentiality and maintains these documents in the personnel files.  (8)  Provides an initial orientation to new staff and documents this orientation in the employee’s personnel file.  (9)  Has mechanisms in place that afford staff the right to express concerns about a particular care issue or to file a grievance concerning a specific employment situation.  (10)  Completes criminal and abuse record checks and evaluations as required in Iowa Code section 135C.33(5) before employment for any employee who meets with individuals using the services in the individuals’ homes.  (11)  Establishes and implements a code of ethics for all staff addressing confidentiality, individual rights, and professional and legal issues in providing services and documents in the personnel records that the code of ethics in effect at the time of review has been reviewed with each staff member.  24.3(5)    Organizational environment.    a.    Performance benchmark.  The organization provides services in an organizational environment that is safe and supportive for the individuals being served and the staff providing services.  b.    Performance indicators.    (1)  The environment enhances the self-image of the individual using the service and preserves the individual’s dignity, privacy, and self-development.  (2)  The environment is safe and accessible and meets all applicable local, state, and federal regulations.  (3)  The processes that service and maintain the environment and the effectiveness of the environment are reviewed within the organization’s monitoring and improvement system.  (4)  The organization establishes intervention procedures for behavior that presents significant risk of harm to the individual using the service or others. The interventions also ensure that the individual’s rights are protected and that due process is afforded.  (5)  The organization meets state and federal regulations in the way it implements the safe storage, provision, administration, and disposal of medication when used within the service.  (6)  All toys and other materials used by children are clean and safe.    Related ARC(s): 6321C441—24.4(225C)  Standards for services.  Providers for the services set forth in subrules 24.4(9) through 24.4(13) shall meet the standards in subrules 24.4(1) through 24.4(8) in addition to the standards for the specific service. Providers of outpatient psychotherapy and counseling services shall also meet standards in subrules 24.4(1), 24.4(2), 24.4(4), 24.4(6), 24.4(7), and 24.4(8). Providers of emergency services or evaluation services shall meet the benchmark for the services they provide.  24.4(1)    Social history.    a.    Performance benchmark.  The organization completes a social history for each individual served.  b.    Performance indicators.    (1)  The organization collects and documents relevant historical information and organizes the information in one distinct document.  (2)  The social history includes:
    1. Relevant information regarding the onset of disability.
    2. Family, physical, psychosocial, behavioral, cultural, environmental, and legal history.
    3. Developmental history for children.
    4. Any history of substance abuse, domestic violence, or physical, emotional, or sexual abuse.
      (3)  Staff review and update the social history at least annually.      24.4(2)    Assessment.    a.    Performance benchmark.  The organization develops a written assessment for each individual served. The assessment is the basis for the services provided to the individuals.  b.    Performance indicators.    (1)  The assessment includes information about the individual’s current situation, diagnosis, needs, problems, wants, abilities and desired results, gathered with the individual’s involvement.  (2)  Staff solicit collateral provider information as appropriate to the individual situation in order to compile a comprehensive and full assessment.  (3)  Staff base decisions regarding the level, type and immediacy of services to be provided, or the need for further assessment or evaluation, upon the analysis of the information gathered in the assessment.  (4)  Staff complete an annual reassessment for each individual using the service and document the reassessment.  (5)  Documentation supporting the diagnosis is contained in the individual’s record. A diagnosis of intellectual disability is supported by a psychological evaluation conducted by a qualified professional. A diagnosis of developmental disability is supported by professional documentation. A determination of chronic mental illness is supported by a psychiatric or psychological evaluation conducted by a qualified professional.  24.4(3)    Individual service plan.    a.    Performance benchmark.  Individualized, planned, and appropriate services are guided by an individual-specific service plan developed in collaboration with the individual using the service, staff, and significantly involved others as appropriate. Services are planned for and directed to where the individuals live, learn, work, and socialize.  b.    Performance indicators.    (1)  The service plan is based on the current assessment.  (2)  The service plan identifies observable or measurable individual goals and action steps to meet the goals.  (3)  The service plan includes interventions and supports needed to meet those goals with incremental action steps, as appropriate.  (4)  The service plan includes the staff, people, or organizations responsible for carrying out the interventions or supports.  (5)  Services defined in the service plan are appropriate to the severity level of problems and specific needs or disabilities.  (6)  The plan reflects desired individual outcomes.  (7)  Activities identified in the service plan encourage the ability and right of the individual using the service to make choices, to experience a sense of achievement, and to modify or continue participation in the treatment process.  (8)  Staff monitor the service plan with review occurring regularly. At least annually, staff assess and revise the service plan to determine achievement, continued need, or change in goals or intervention methods. The review includes the individual using the service, with the involvement of significant others as appropriate.  (9)  Staff develop a separate, individualized, anticipated discharge plan as part of the service plan that is specific to each service the individual receives.  (10)  The service plan includes documentation of any rights restrictions, why there is a need for the restriction, and a plan to restore those rights or a reason why a plan is not necessary or appropriate.  24.4(4)    Documentation of service provision.    a.    Performance benchmark.  Individualized and appropriate intervention services and treatments are provided in ways that support the needs, desires, and goals identified in the service plan, and that respect the rights and choices of the individual using the service.  b.    Performance indicators.    (1)  Staff document in the narrative the individual’s participation in the treatment process.  (2)  Responsible staff document the individual’s progress toward goals, the provision of staff intervention, and the individual’s response to those interventions.  (3)  Documentation of service provision is in a legible, written format in accordance with organizational policies and procedures.  24.4(5)    Incident reports.    a.    Performance benchmark.  The organization completes an incident report when organization staff first become aware that an incident has occurred.  b.    Performance indicators.    (1)  The organization documents the following information:
    1. The name of the individual served who was involved in the incident.
    2. The date and time the incident occurred.
    3. A description of the incident.
    4. The names of all organization staff and others who were present or responded at the time of the incident. (For confidentiality reasons, other individuals who receive services should be identified by initials or some other accepted means.)
    5. The action the organization staff took to handle the situation.
    6. The resolution of or follow-up to the incident.
      (2)  The staff who were directly involved at the time of the incident or who first became aware of the incident prepare and sign the incident report before forwarding it to the supervisor.  (3)  Staff file a copy of the completed incident report in a centralized location and make a notation in the individual’s file.  (4)  Staff send a copy of the incident report to the individual’s Medicaid targeted case manager or county case worker who is involved in funding the service and notify the individual’s legal guardian within 72 hours of the incident.      24.4(6)    Confidentiality and legal status.    a.    Performance benchmark.  Staff release medical and mental health information only when properly authorized.  b.    Performance indicators.    (1)  The organization obtains voluntary written authorization from the individual using the service, the individual’s legal guardian, or other people authorized by law before releasing personal identifying information, medical records, mental health records, or any other confidential information.  (2)  Staff complete voluntary written authorization forms in accordance with existing federal and state laws, rules, and regulations and maintain them in each individual file.  (3)  Documentation regarding restrictions on the individual, such as guardianship, power of attorney, conservatorship, mental health commitments, or other court orders, is placed in the individual’s record, if applicable.  24.4(7)    Service systems.    a.    Performance benchmark.  The organization develops a clear description of each of the services offered. The organization develops an admission and discharge system of services. Staff coordinate services with other settings and providers.  b.    Performance indicators.    (1)  The organization has established and documented the necessary admission information to determine each individual’s eligibility for participation in the service.  (2)  Staff include verification in each individual’s file that a service description was provided to the individual using the service and, when appropriate, to family or significant others.  (3)  Continuity of services occurs through coordination among the staff and professionals providing services. Coordination of services through linkages with other settings and providers has occurred, as appropriate.  (4)  Staff include a written discharge summary in each individual record at the time of discharge.  24.4(8)    Respect for individual rights.    a.    Performance benchmark.  Each individual using the service is recognized and respected in the provision of services, in accordance with basic human, civil, and statutory rights.  b.    Performance indicators.    (1)  Staff provide services in ways that respect and enhance the individual’s sense of autonomy, privacy, dignity, self-esteem, and involvement in the individual’s own treatment. Staff take language barriers, cultural differences, and cognitive deficits into consideration and make provisions to facilitate meaningful individual participation.  (2)  Staff inform individuals using the service and, when appropriate, family and significant others of their rights, choices, and responsibilities.  (3)  The organization has a procedure established to protect the individuals using the service during any activities, procedure or research that requires informed consent.  (4)  The organization verifies that individuals using the service and their guardians are informed of the process to express questions, concerns, complaints, or grievances about any aspect of the individual’s service, including the appeal process.  (5)  The organization provides the individuals and their guardians the right to appeal the application of policies, procedures, or any staff action that affects the individual using the service. The organization has established written appeal procedures and a method to ensure that the procedures and appeal process are available to individuals using the service.  (6)  All individuals using the service, their legal representatives, and other people authorized by law have access to the records of the individual using the service in accordance with state and federal laws and regulations.  24.4(9)    Case management services.  “Case management services” means those services established pursuant to Iowa Code section 225C.20.  a.    Performance benchmark.  Case management services link individuals using the service to service agencies and support systems responsible for providing the necessary direct service activities and coordinate and monitor those services.  b.    Performance indicators.    (1)  Staff clearly define the need for case management and document it annually.  (2)  At a minimum, the team is composed of the individual using the service, the case manager, and providers or natural supports relevant to the individual’s service needs. The team may also include family members, at the discretion of the individual using the service.  (3)  The team works with the individual using the service to establish the service plan that guides and coordinates the delivery of the services.  (4)  The case manager advocates for the individual using the service.  (5)  The case manager coordinates and monitors the services provided to the individual using the service.  (6)  Documentation of contacts includes the date, the name of the individual using the service, the name of the case manager, and the place of service.  (7)  The case manager holds individual face-to-face meetings at least quarterly with the individual using the service.  (8)  Case managers do not provide direct services. Individuals using the service are linked to appropriate resources, which provide necessary direct services and natural supports.  (9)  Individuals using the service participate in developing an individualized crisis intervention plan that includes natural supports and self-help methods.  (10)  Documentation shows that individuals using the service are informed about their choice of providers as provided in the county management plan.  (11)  Within an accredited case management program, the average caseload is no more than 45 individuals per each full-time case manager. The average caseload of children with serious emotional disturbance is no more than 15 children per full-time case manager.  (12)  The case manager communicates with the team and then documents in the individual’s file a quarterly review of the individual’s progress toward achieving the goals.  24.4(10)    Day treatment services.  “Day treatment” means an individualized service emphasizing mental health treatment and intensive psychosocial rehabilitation activities designed to increase the individual’s ability to function independently or facilitate transition from residential placement. Staff use individual and group treatment and rehabilitation services based on individual needs and identified behavioral or mental health issues.  a.    Performance benchmark.  Individuals using the service who are experiencing a significantly reduced ability to function in the community are stabilized and improved by the receipt of psychosocial rehabilitation, mental health treatment services, and in-home support services, and the need for residential or inpatient placement is alleviated.  b.    Performance indicators.    (1)  Individuals using the service participate with the organizational staff in identifying the problem areas to be addressed and the goals to be achieved that are based on the individual’s need for services.  (2)  Individuals using the service receive individualized services designed to focus on those identified mental health or behavioral issues that are causing significant impairment in their day-to-day functioning.  (3)  Individuals who receive intensive outpatient and day treatment services receive a comprehensive and integrated schedule of recognized individual and group treatment and rehabilitation services.  (4)  Individuals using the service and staff review their progress in resolving problems and achieving goals on a frequent and regular basis.  (5)  Individuals using the service receive services appropriate to defined needs and current risk factors.  (6)  Individuals using the service receive services from staff who are appropriately qualified and trained to provide the range and intensity of services required by the individual’s specific problems or disabilities. A mental health professional provides or directly supervises the provision of treatment services.  (7)  Individuals using the service participate in discharge planning that focuses on coordinating and integrating individual, family, and community and organization resources.  (8)  Family members of individuals using the service are involved in the planning and provision of services, as appropriate and as desired by the individual.  (9)  Individuals using the service participate in developing a detailed psychiatric crisis intervention plan that includes natural supports and self-help methods.  24.4(11)    Intensive psychiatric rehabilitation services.  “Intensive psychiatric rehabilitation services” means services designed to restore, improve, or maximize level of functioning, self-care, responsibility, independence, and quality of life; to minimize impairments, disabilities, and disadvantages of people who have a disabling mental illness; and to prevent or reduce the need for services in a hospital or residential setting. Services focus on improving personal capabilities while reducing the harmful effects of psychiatric disability, resulting in an individual’s recovering the ability to perform a valued role in society.  a.    Performance benchmark.  Individuals using the service who are experiencing a significantly reduced ability to function in the community due to a disability are stabilized and experience role recovery by the receipt of intensive psychiatric rehabilitation services.  b.    Performance indicators.    (1)  Individuals using the service receive services from staff who meet the definition of intensive psychiatric rehabilitation practitioner. The intensive psychiatric rehabilitation supervisor has at least a bachelor’s degree in a human services field and 60 hours of training in intensive psychiatric rehabilitation.  (2)  Individuals using the service receive four to ten hours per week of recognized psychiatric rehabilitation services. All services are provided for an identified period.  (3)  Whenever possible, intensive psychiatric rehabilitative services are provided in natural settings where individuals using the service live, learn, work, and socialize.  (4)  Significantly involved others participate in the planning and provision of services as appropriate and as desired by the individual using the service.  (5)  Individuals using the service participate in developing a detailed psychiatric crisis intervention plan that includes natural supports and self-help methods.  (6)  A readiness assessment is initially completed with staff to assist the individual in choosing a valued role and environment. The readiness assessment culminates in a score that documents the individual’s motivational readiness.  (7)  During the readiness development phase, staff document monthly in the individual’s file changes in the individual’s motivational readiness to choose valued roles and environments.  (8)  During the goal-choosing phase, staff and the individual identify personal criteria, describe alternative environments, and choose the goal. These activities are documented in the individual’s file.  (9)  During the goal-achieving phase, the functional assessment and resource assessment are completed. Skill programming or skill teaching takes place. These activities are documented in the individual’s file.  (10)  During goal keeping, individuals using the service participate in discharge planning that focuses on coordinating and integrating individual, family, community, and organization resources for successful community tenure and the anticipated end of psychiatric rehabilitation services. Staff document increases in skill acquisition and skill competency.  (11)  Staff document any positive changes in environmental status, such as moving to a more independent living arrangement, enrolling in an education program, getting a job, or joining a community group.  (12)  On an ongoing basis and at discharge, staff or the individual using the service documents the level of individual satisfaction with intensive psychiatric rehabilitation services in each individual’s file.  24.4(12)    Supported community living services.  “Supported community living services” means those services provided to individuals with a mental illness, mental retardation, or developmental disability to enable them to develop supports and learn skills that will allow them to live, learn, work and socialize in the community. Services are individualized, need- and abilities-focused, and organized according to the following components: outreach to appropriate support or treatment services; assistance and referral in meeting basic human needs; assistance in housing and living arrangements; crisis intervention and assistance; social and vocational assistance; the provision of or arrangement for personal, environmental, family, and community supports; facilitation of the individual’s identification and development of natural support systems; support, assistance, and education to the individual’s family and to the community; protection and advocacy; and service coordination.These services are to be provided by organizational staff or through linkages with other resources and are intended to be provided in the individual’s home or other natural community environment where the skills are learned or used. Supported community living is not part of an organized mental health support or treatment group, drop-in center, or clubhouse. Skill training groups may be one of the activities in the service plan and part of supported community living. Skill training groups cannot stand alone as a supported community living service.  a.    Performance benchmark.  Individuals using the service live, learn, work, and socialize in the community.  b.    Performance indicators.    (1)  Individuals receive services within their home and community setting where the skills are learned or used.  (2)  At intake, the individuals using the service participate in a functional assessment to assist in defining areas of service need and establishing a service plan. Staff summarize the findings of the functional assessment in a narrative that describes the individual’s current level of functioning in the areas of living, learning, working, and socialization. Staff review functional assessments on a regular basis to determine progress.  (3)  Individuals using the service receive skill training and support services directed to enabling them to regain or attain higher levels of functioning or to maximize functioning in the current goal areas.  (4)  Services are delivered on an individualized basis in the place where the individual using the service lives or works.  (5)  Documentation that steps have been taken to encourage the use of natural supports and develop new ones is in the individual file.  (6)  Individuals using the service participate in developing a detailed individualized crisis intervention plan that includes natural supports and self-help methods.  24.4(13)    Partial hospitalization services.  “Partial hospitalization services” means an active treatment program providing intensive group and individual clinical services within a structured therapeutic environment for individuals who are exhibiting psychiatric symptoms of sufficient severity to cause significant impairment in day-to-day functioning. Short-term outpatient crisis stabilization and rehabilitation services are provided to avert hospitalization or to transition from an acute care setting. Services are supervised and managed by a mental health professional, and psychiatric consultation is routinely available. Clinical services are provided by a mental health professional.  a.    Performance benchmark.  Individuals who are experiencing serious impairment in day-to-day functioning due to severe psychiatric distress are enabled to remain in their community living situation through the receipt of therapeutically intensive milieu services.  b.    Performance indicators.    (1)  Individuals using the service and staff mutually develop an individualized service plan that focuses on the behavioral and mental health issues and problems identified at admission. Goals are based on the individual’s need for services.  (2)  Individuals using the service receive clinical services that are provided and supervised by mental health professionals. A licensed and qualified psychiatrist provides psychiatric consultation and medication services.  (3)  Individuals using the service receive a comprehensive schedule of active, planned, and integrated psychotherapeutic and rehabilitation services provided by qualified professional staff.  (4)  Individuals using the service receive group and individual treatment services that are designed to increase their ability to function independently.  (5)  Individuals using the service are involved in the development of an anticipated discharge plan that includes linkages to family, provider, and community resources and services.  (6)  Individuals using the service have sufficient staff available to ensure their safety, to be responsive to crisis or individual need, and to provide active treatment services.  (7)  Individuals using the service receive services commensurate with current identified risk and need factors.  (8)  Support systems identified by individuals using the service are involved in the planning and provision of services and treatments as appropriate and desired by the individual using the service.  (9)  Individuals using the service participate in developing a detailed psychiatric crisis intervention plan that includes natural supports and self-help methods.  24.4(14)    Outpatient psychotherapy and counseling services.  “Outpatient psychotherapy and counseling services” means a dynamic process in which the therapist uses professional skills, knowledge and training to enable individuals using the service to realize and mobilize their strengths and abilities, take charge of their lives, and resolve their issues and problems. Psychotherapy services may be individual, group, or family, and are provided by a person meeting the criteria of a mental health professional or by a person with a master’s degree or an intern working on a master’s degree in a mental health field who is directly supervised by a mental health professional.  a.    Performance benchmark.  Individuals using the service realize and mobilize their own strengths and abilities to take control of their lives in the areas where they live, learn, work, and socialize.  b.    Performance indicators.    (1)  Individuals using the service are prepared for their role as partners in the therapeutic process at intake where they define their situations and evaluate those factors that affect their situations.  (2)  Individuals using the service establish desired problem resolution at intake during the initial assessment.  (3)  Psychiatric services other than psychopharmacological services are available from the organization as needed by the individual using the service.  (4)  Psychopharmacological services are available from the organization as needed.  (5)  Any assignment of activities to occur between sessions is documented in the following session’s documentation.  (6)  Individuals using the service who have a chronic mental illness participate in developing a detailed psychiatric crisis intervention plan that includes natural supports and self-help methods.  (7)  The record documents that the organization follows up on individuals who miss appointments.  (8)  Treatment planning is based on the assessment.  (9)  Individuals using the service participate with the organizational staff in identifying the assessed needs to be addressed.  (10)  The treatment plan identifies measurable goals, desired outcomes and time frames for achieving them.  (11)  The treatment plan includes interventions and supports to be provided.  (12)  Individuals using the service review their progress in resolving problems and achieving goals on a frequent and regular basis with organizational staff. The treatment plan is revised as appropriate to the individual’s needs and priorities.  (13)  Individuals using the service participate in transition/discharge planning that includes linkages to family, provider, and community resources and services.  (14)  Significantly involved others of individuals using the service are involved in the planning and provision of services, as appropriate and as desired by the individual.  24.4(15)    Emergency services.  “Emergency services” means crisis services that provide a focused assessment and rapid stabilization of acute symptoms of mental illness or emotional distress and are available and accessible, by telephone or face-to-face, on a 24-hour basis. The clinical assessment and psychotherapeutic services are provided by a person who has training in emergency services and who is a mental health professional or has access to a mental health professional, at least by telephone.Services may be provided by a person who holds a master’s degree in a mental health field including, but not limited to, psychology, counseling and guidance, psychiatric nursing, psychiatric rehabilitation, or social work; or a person who holds a bachelor’s degree in a human service discipline with five years’ experience providing mental health services or human services; or a psychiatric nurse who has three years of clinical experience in mental health. A comprehensive social history is not required for this treatment.  a.    Performance benchmark.  Individuals using the service receive emergency services when needed that provide a focused assessment and rapid stabilization of acute symptoms of mental illness or emotional distress.  b.    Performance indicators.    (1)  Individuals using the service can access 24-hour emergency services by telephone or in person.  (2)  Information about how to access emergency services is publicized to facilitate availability of services to individuals using the service, family members, and the public.  (3)  Individuals using the service receive assessments and services from either a mental health professional or from personnel who meet the requirements above and are supervised by a mental health professional. Psychiatric consultation is available, if needed.  (4)  Individuals using the service receive intervention commensurate with current identified risk factors.  (5)  Significantly involved others are involved as necessary and appropriate to the situation and as desired by the individual using the service.  (6)  Individuals using the service are involved in the development of postemergency service planning and resource identification and coordination.  (7)  Staff document contacts in a narrative format and maintain them in a central location that will allow timely response to the problems presented by the individual using the service.  (8)  Timely coordination of contacts with relevant professionals is made.  24.4(16)    Evaluation services.  “Evaluation services” means screening, diagnosis and assessment of individual and family functioning needs, abilities, and disabilities, and determining current status and functioning in the areas of living, learning, working, and socializing.  a.    Performance benchmark.  Individuals using the service receive comprehensive evaluation services that include screening, diagnosis, and assessment of individual or family functioning, needs and disabilities.  b.    Performance indicators.    (1)  Evaluations include screening, diagnosis, and assessment of individual or family functioning, needs, abilities, and disabilities.  (2)  Evaluations consider the emotional, behavioral, cognitive, psychosocial, and physical information as appropriate and necessary.  (3)  Evaluations includes recommendations for services and need for further evaluations.  (4)  Mental health evaluations are completed by a person who meets the criteria of a mental health professional, or a person with a master’s degree who is license-eligible and supervised by a mental health professional, or an intern of a master’s or doctorate program who is supervised by a mental health professional.    Related ARC(s): 3855C, 6321C441—24.5(225C)  Accreditation.  The division administrator shall make all decisions involving issuance, denial, or revocation of accreditation. This accreditation shall delineate all categories of service the organization is accredited to provide. Although an organization may have more than one facility or service site, the division administrator shall issue only one accreditation notice to the organization, except as provided in paragraph 24.5(5)“f.”  24.5(1)    Organizations eligible for accreditation.  The division administrator accredits the following organizations:  a.  Case management providers.  b.  Community mental health centers.  c.  Supported community living providers.  d.  Mental health service providers.  e.  Crisis response providers.  24.5(2)    Application and renewal procedures.  An applicant for accreditation shall submit Form 470-3005, Application for Accreditation, to the Division of Mental Health and Disability Services, Community, Department of Human Services, Fifth Floor, Hoover State Office Building, 1305 East Walnut, Des Moines, Iowa 50319-0114.  a.  The application shall be signed by the organization’s chief executive officer and the chairperson of the governing body and shall include the following information:  (1)  The name and address of the applicant organization.  (2)  The name and address of the chief executive officer of the applicant organization.  (3)  The type of organization and specific services for which the organization is applying for accreditation.  (4)  The targeted population groups for which services are to be provided, as applicable.  (5)  The number of individuals in each of the targeted population groups to be served, as applicable.  (6)  Other information related to the standards as requested by division staff.  b.  Organizations that have received an initial 270-day accreditation and have not provided services by the end of the 270 days shall have their accreditation lapse for that specific service. This lapse of accreditation shall not be considered a denial. New applications may be submitted that include the waiting list of individuals to be served along with specific timelines of when the services will begin.  c.  An organization in good standing may apply for an add-on service.  24.5(3)    Application review.  Upon receipt of an application, Form 470-3005, the division shall review the materials submitted to determine whether the application is complete and request any additional material as needed. Survey reviews shall commence only after the organization has submitted all application material.  a.  For a new organization, staff may initially conduct a desk audit or on-site visit to review the organization’s mission, policies, procedures, staff credentials, and program descriptions.  b.  The division shall review organizational services and activities as determined by the accreditation category. This review may include audits of case records, administrative procedures, clinical practices, personnel records, performance improvement systems and documentation, and interviews with staff, individuals, boards of directors, or others deemed appropriate, consistent with the confidentiality safeguards of state and federal laws.  c.  A team shall make an on-site visit to the organization. The division shall not be required to provide advance notice to the provider of the on-site visit for accreditation.  d.  The on-site team shall consist of designated members of the division staff. At the division’s discretion, the team may include provider staff of other providers, individuals, and others deemed appropriate.  e.  The team shall survey the organization and the services indicated on the accreditation application in order to verify information contained in the application and ensure compliance with all applicable laws, rules, and regulations. At the time of a one-year recertification visit, the team shall review the services that did not receive three-year accreditation.  f.  The team shall review case records and personnel records to see how the organization implements each of the indicators in the standards. If the documentation is not found in the records, the organization shall show, at the time the division staff is on site, documentation of how the indicator was accomplished.  g.  When an organization subcontracts with agencies to provide services, on-site reviews shall be done at each subcontracting agency to determine if each agency meets all the requirements in this chapter. The accreditation is issued to the organization.  h.  At the end of the survey, the team leader shall lend an exit review. Before the close of the on-site review, the organization must provide the team leader any documentation that demonstrates how the organization has met these standards for services.  i.  The accreditation team leader shall send a written report of the findings to the organization within 30 working days after completion of the accreditation survey.  j.  Organizations required to develop a corrective action and improvement plan pursuant to subrule 24.5(4)“a” shall submit the plan to the division within 30 working days after the receipt of a report issued as a result of the division’s survey review. The action plan shall include specific problem areas cited, corrective actions to be implemented by the organization, dates by which each corrective measure shall be completed, and quality assurance and improvement activities to measure and ensure continued compliance.  k.  Quality assurance staff shall review and approve the corrective action and improvement plan before making an accreditation recommendation to the division administrator.  l.  The division shall offer technical assistance to organizations applying for first-time accreditation. Following accreditation, any organization may request technical assistance from the division to bring into conformity those areas found in noncompliance with this chapter’s requirements. If multiple deficiencies are noted during a survey, technical assistance may be provided to an organization, as staff time permits, to assist in implementation of an organization’s corrective action plan. Renewal applicants may be provided technical assistance as needed, if staff time permits.  24.5(4)    Performance outcome determinations.  There are three major areas addressed in these standards: policies and procedures, organizational activities, and services, as set forth in rules 441—24.2(225C), 441—24.3(225C), and 441—24.4(225C). Each rule contains standards, with a performance benchmark and performance indicators for each standard. Each of the applicable standards for the three areas (policy and procedures, organizational activities, and services) shall be reviewed.  a.  Quality assurance staff shall determine a performance compliance level based on the number of indicators found to be in compliance.  (1)  For service indicators, if 25 percent or more of the files reviewed do not comply with the requirements for a performance indicator, then that indicator is considered out of compliance and corrective action is required.  (2)  Corrective action is required when any indicator under policies and procedures or organizational activities is not met.  b.  In the overall rating, the performance rating for policy and procedures shall count as 15 percent of the total, organizational activities as 15 percent of the total, and services as 70 percent of the total.  (1)  Each of the three indicators for policy and procedures has a value of 5 out of a possible score of 15.  (2)  Each of the 34 indicators for organizational activities has a value of .44 out of a possible score of 15.  (3)  Each service has a separate weighting according to the total number of indicators applicable for that service, with a possible score of 70, as follows:ServiceNumber of indicatorsValue of each indicatorCase management 50 1.4Day treatment 47 1.49Intensive psychiatric rehabilitation 50 1.4Supported community living 44 1.59Partial hospitalization 47 1.49Outpatient psychotherapy and counseling 38 1.84Emergency88.75Evaluation417.50  c.  Quality assurance staff shall determine a separate score for each service to be accredited. When an organization offers more than one service under this chapter, there shall be one accreditation award for all the services based upon the lowest score of the services surveyed.  24.5(5)    Accreditation decisions.  The division shall prepare all documents with a final recommendation regarding accreditation to the division administrator. If the division administrator approves accreditation, Form 470-3006, Notice of Action-Approval, shall be issued which states the duration of the accreditation and the services that the organization is accredited to provide. If the division administrator denies or revokes accreditation, Form 470-3008, Notice of Action-Denial, shall be issued which states the reasons for the denial.  a.    Initial 270-day accreditation.  This type of accreditation may be granted to a new organization. The division administrator shall base the accreditation decision on a report by the division that:  (1)  The organization has an approved policies and procedures manual that includes job descriptions.  (2)  Staff assigned to the positions meet the qualifications in the standards and the policies and procedures of the organization.  b.    Three-year accreditation.  An organization or service is eligible for this type of accreditation if it has achieved an 80 percent or higher performance compliance level. The organization may be required to develop and submit a plan of corrective action and improvement that may be monitored either by written report or an on-site review.  c.    One-year accreditation.  An organization is eligible for this type of accreditation when multiple and substantial deficiencies exist in specific areas causing compliance levels with performance benchmarks and indicators to fall between 70 percent and 79 percent, or when previously required corrective action plans have not been implemented or completed. The organization must submit a corrective action plan to correct and improve specific deficiencies and overall levels of functioning. Quality assurance staff shall monitor this plan through on-site reviews, written reports and the provision of technical assistance.  d.    Probational 180-day accreditation.  An organization is eligible for probational 180-day accreditation instead of denial when the overall compliance level is from 60 to 69 percent, and pervasive and serious deficiencies exist; or when corrective action plans previously required as a result of a one-year accreditation have not been implemented or completed. The division administrator may downgrade organizations with a one-year or three-year accreditation to the probational 180-day accreditation when one or more complaints are founded.All deficiencies must be corrected by the time of the follow-up on-site survey at the conclusion of the provisional period. After this survey, the organization shall meet the standards for accreditation for a one-year accreditation, or the division administrator shall deny accreditation.  e.    Add-on service accreditation.  When the on-site review of the add-on service results in a score comparable to the overall organization’s score at the time of the most recent accreditation, the organization shall have the add-on accreditation date coincide with the overall accreditation date of the organization. If the add-on service on-site review results in a lower score and lower accreditation decision, division staff shall conduct another on-site review for that add-on service when the add-on service accreditation expires.  f.    Special terms.    (1)  When an organization subcontracts with more than one agency, the length of accreditation shall be determined individually.  (2)  The accreditation period for services that have deemed status according to rule 441—24.6(225C) shall coincide with the period awarded by the national accrediting body or the certification for home- and community-based services.  (3)  New or add-on services that meet the requirements for accreditation shall receive an initial 270-day accreditation for that individual service. The term of accreditation shall be determined individually. At the time of recertification of the new add-on service, recommendation may be made to coincide with the term of accreditation for the other services of that organization that are accredited by the division administrator.  (4)  An organization must notify the division when there are changes in its ownership, structure, management, or service delivery.  g.    Extensions.  The division may grant an extension to the period of accreditation if there has been a delay in the accreditation process that is beyond the control of the organization or the division, or the organization has requested an extension to permit the organization to prepare and obtain approval of a corrective action plan. The division shall establish the length of the extension on a case-by-case basis.  h.    Denial of accreditation or revocation.    (1)  Accreditation shall be denied when there are pervasive and serious deficiencies that put individuals at immediate risk or when the overall compliance level falls to 59 percent or below. Under such circumstances no corrective action report shall be required.  (2)  When one or more complaints are received, quality assurance staff shall complete an investigation and submit a report to the division administrator. If any of the complaints are substantiated and the division administrator determines that there is a pervasive or serious deficiency, the division administrator may deny accreditation.  (3)  An organization whose accreditation has been denied or revoked shall not be approved for any service for at least six months from the notice of decision denying or revoking accreditation.  (4)  If the organization disagrees with any action or failure to act in regard to the notice of decision to deny accreditation to the organization, the organization has the right to appeal in accordance with 441—Chapter 7.  24.5(6)    Nonassignability.  Accreditation shall not be assignable to any other organization or provider. Any person or other legal entity acquiring an accredited facility for the purpose of operating a service shall make an application as provided in subrule 24.5(2) for a new certificate of accreditation. Similarly, any organization having acquired accreditation and desiring to alter the service philosophy or transfer operations to different premises must notify the division in writing 30 calendar days before taking action in order for the division to review the change.  24.5(7)    Discontinuation.    a.    Discontinued organization.  A discontinued organization is one that has terminated all of the services for which it has been accredited. Accreditation is not transferable between organizations.  (1)  An organization shall notify the division in writing of any sale, change in business status, closure, or transfer of ownership of the business at least 30 calendar days before the action.  (2)  The organization shall be responsible for the referral and placement of individuals using the services, as appropriate, and for the preservation of all records.  b.    Discontinued service.  An organization shall notify the division in writing of the discontinuation of an accredited or certified service at least 30 calendar days before the service is discontinued.  (1)  Notice of discontinuation of a service shall not be initiated during the 30 days before the start of a survey. Once a survey has begun, all services shall be considered in determining the organization’s accreditation score.  (2)  The organization shall be responsible for the referral and placement of individuals using the services, as appropriate, and for the preservation of all records.Related ARC(s): 6321C441—24.6(225C)  Deemed status (all services).  The division shall grant deemed status to organizations accredited by a recognized national, not-for-profit, accrediting body when the division determines the accreditation is for similar services. The division may also grant deemed status for supported community living services to organizations that are certified under the Medicaid home- and community-based services (HCBS) intellectual disability waiver.  24.6(1)    National accrediting bodies.    a.  The national accrediting bodies currently recognized as meeting division criteria for possible deeming are:  (1)  The Joint Commission (TJC).  (2)  The Commission on Accreditation of Rehabilitation Facilities (CARF).  (3)  The Council on Quality and Leadership (The Council).  (4)  The Council on Accreditation (COA).  b.  The accreditation credentials of these national bodies must specify the type of organization, programs, and services that these bodies accredit and include targeted population groups, if appropriate.  c.  Deemed status means that the division is accepting an outside body’s review, assessment, and accreditation of an organization’s functioning and services. Therefore, the accrediting body doing the review must be assessing categories of organizations and types of programs and services corresponding to those described under this chapter. An organization that has deemed status must adhere to and be accountable for the rules in this chapter.  d.  When an organization that is nationally accredited requests deemed status for services not covered by the national body’s standards but covered under this chapter, the division shall accredit those services. Division staff shall provide technical assistance to organizations with deemed status.  24.6(2)    Application for deemed status.    a.  To apply for deemed status, the organization shall submit Form 470-3332, Application and Letter of Agreement; copy of the latest survey report; documentation related to any corrective action required; accreditation certificate; documentation of specific programming policies and procedures for populations being served; and credentials for staff providing services to populations served.  b.  The division shall not accept an application for deemed status once the division has begun an on-site visit. The organization shall complete the accreditation process.  24.6(3)    Requirements for deemed status.  To be eligible for deemed status, the organization shall:  a.  Be currently accredited:  (1)  By a recognized national accrediting body for services as defined in subrule 24.6(1); or  (2)  For supported community living under the Medicaid HCBS intellectual disability waiver pursuant to 441—subrule 77.37(14). If individuals with mental illness are served, the organization must submit verification of the training and experience of the staff to show that its staff can meet the needs of the individuals served.  b.  Require staff for the program being deemed to have the necessary training and experience to meet the needs of the population served.  c.  Require staff to meet the incident reporting requirements in subrule 24.4(5).  24.6(4)    Granting of deemed status.  When the division grants deemed status, the accreditation period shall coincide with the period awarded by the national accrediting body or the certification for home- and community-based services. However, under no circumstances shall the division award accreditation for longer than five years.  24.6(5)    Reservations.  When deemed status is granted, the division reserves rights to the following:  a.  To have division staff conduct on-site reviews for those organizations applying for deemed status which the division has not previously accredited.  b.  To have division staff do joint site visits with the accrediting body, attend exit conferences, or conduct focused follow-behind visits as determined to be appropriate in consultation with the national accrediting organization and the provider organization.  c.  To be informed of and to investigate all complaints that fall under this chapter’s jurisdiction according to the process in rule 441—24.7(225C). The division shall report findings to the national accrediting body.  d.  To review and act upon deemed status when:  (1)  Complaints have been founded, or  (2)  The organization’s national accreditation status expires without renewal, or  (3)  The national accrediting body downgrades or withdraws the organization’s status.  24.6(6)    Continuation of deemed status.    a.  The organization shall send a copy of Form 470-3332, Application and Letter of Agreement, along with a copy of the application for renewal to the national accrediting body at the same time as application is made to a national accrediting body.  b.  HCBS staff shall furnish to the division copies of the letter notifying a provider of a forthcoming recertification for organizations deemed for supported community living under the HCBS intellectual disability waiver.  c.  Following the on-site review by a national accrediting body, the organization shall send the division a copy of the cover sheet and the national accrediting body report within 30 calendar days from the date that the organization receives the documents. If a corrective action plan is required, the organization shall send the division a copy of all correspondence and documentation related to the corrective action.  d.  HCBS staff shall furnish the division with copies of HCBS certification reports and any corrective action required by HCBS within 30 calendar days after HCBS staff complete the report or the organization completes required corrective action.Related ARC(s): 6321C441—24.7(225C)  Complaint process (all services).  The division shall receive and record complaints by individuals using the services, employees, any interested people, and the public relating to or alleging violations of applicable requirements of the Iowa Code or administrative rules.  24.7(1)    Submittal of complaint.  The complaint may be submitted in person; or by mail to the Division of Mental Health and Disability Services, Community, Department of Human Services, Hoover State Office Building, Fifth Floor, 1305 East Walnut, Des Moines, Iowa 50319-0114; electronically through the department’s website; by email to division staff; or by telephone.  a.  The division shall assist individuals in making a complaint as needed or requested.  b.  The information received should specifically state the basis of the complaint. The division shall keep the name of the complainant confidential to the extent allowed by law.  24.7(2)    Review of complaint.  Upon receipt of a complaint, the division shall make a preliminary desk review of the complaint to determine an appropriate response. That response may include notifying the person who submitted the complaint that there is no basis for a review, referring the complaint to another investigative body, or making a determination to do a full investigation. The complainant may submit a written request for a report of the findings and actions taken by the division as a result of the complaint.  24.7(3)    Investigation of complaint.  If the division concludes that the complaint is reasonable, has merit, and is based on a violation of rules in this chapter, it may make an investigation of the organization. The division may investigate complaints by an office desk audit or by an on-site investigation. The division shall give priority for on-site investigations to instances when individuals using the service are in immediate jeopardy.  a.  If a decision is made to conduct an on-site investigation, the on-site review does not require advance notice to the organization. The division shall notify the chief executive officer and board chairperson of the organization involved before or at the commencement of the on-site investigation that the division has received a complaint.  b.  The division shall give the organization an opportunity to informally present a position regarding allegations in the complaint. The organization may submit the position in writing within five working days following the on-site visit or present it in a personal conference with division staff.  c.  The division shall submit a written report by certified mail to the chief executive officer of the organization and the chairperson of the board of directors within 20 working days after completion of the investigation.  d.  The report shall indicate whether the complaint was or was not substantiated, the basis for the substantiation or nonsubstantiation decision and the specific rules violated, and a recommendation for corrective action with time lines specified in the report.  e.  If the complaint is substantiated, the division may take actions deemed appropriate, which may include requiring a corrective action plan, shortening the term of accreditation or suspending or revoking an organization’s accreditation, depending on the severity of the substantiated complaint.   f.  When the division suspends, shortens or revokes an organization’s accreditation as the result of a substantiated compliant, the organization will be notified by certified mail of the findings and actions taken by the division.   g.  The date of delivery shown by the certified mail stub shall constitute the date of official notice.  24.7(4)    Corrective action plan.  When the division acts to suspend or revoke accreditation, there will be no corrective action plan. In other instances, if the complaint is substantiated, the organization shall submit a corrective action plan to the division within 20 calendar days after receiving the division’s decision. This plan must respond to violations cited and the division’s requirements and include time lines, internal monitoring systems, and performance improvement planning.Failure of the organization to respond within 20 calendar days with an acceptable corrective action plan that addresses the organization’s plan of correction following a substantiated investigation or complaint may of itself constitute the basis for revocation or suspension of accreditation. The division shall determine the appropriate action based on the information submitted. The division shall notify the organization in writing of any action taken.Related ARC(s): 6321C441—24.8(225C)  Appeal procedure.  An appeal may be filed using the procedure identified in 441—Chapter 7. Notice of an appeal shall be sent to Appeals Section, Department of Human Services, Hoover State Office Building, Fifth Floor, 1305 East Walnut, Des Moines, Iowa 50319-0114, within 30 calendar days of the written decision from the commission.441—24.9(225C)  Exceptions to policy.  Requests for exceptions to the policies in this chapter shall follow the policies and procedures in the department’s general rule on exceptions to policy at 441—1.8(17A,217).These rules are intended to implement Iowa Code chapter 225C.441—24.10    Reserved.441—24.11    Reserved.441—24.12    Reserved.441—24.13    Reserved.441—24.14    Reserved.441—24.15    Reserved.441—24.16    Reserved.441—24.17    Reserved.441—24.18    Reserved.441—24.19    Reserved.DIVISION IICRISIS RESPONSE SERVICESPreambleThe department of human services in consultation with the mental health and disability services commission has established this set of standards to be met by all providers of crisis response services.441—24.20(225C)  Definitions.  
    "Action plan" means a written plan developed for discharge in collaboration with the individual receiving crisis response services to identify the problem, prevention strategies, and management tools for future crises.
    "Crisis assessment" means a face-to-face clinical interview to ascertain an individual’s current and previous level of functioning, potential for dangerousness, physical health, and psychiatric and medical condition. The crisis assessment becomes part of the individual’s action plan.
    "Crisis incident" means an occurrence leading to physical injury or death, or an occurrence resulting from a prescription medication error, or an occurrence triggering a report of child or dependent adult abuse.
    "Crisis response services" means short-term individualized crisis stabilization services which follow a crisis screening or assessment and which are designed to restore the individual to a prior functional level.
    "Crisis response staff" means a person trained to provide crisis response services in accordance with rule 441—24.24(225C).
    "Crisis screening" means a process to determine what crisis response service is appropriate to effectively resolve the presenting crisis.
    "Crisis stabilization community-based services" "CSCBS" means short-term services designed to de-escalate a crisis situation and stabilize an individual following a mental health crisis and provided where the individual lives, works or recreates.
    "Crisis stabilization residential services" "CSRS" means a short-term alternative living arrangement designed to de-escalate a crisis situation and stabilize an individual following a mental health crisis and is provided in organization-arranged settings of no more than 16 beds.
    "Department" means the department of human services.
    "Dispatch" means the function within crisis line operations to coordinate access to crisis care.
    "Face-to-face" means services provided in person or utilizing telehealth in conformance with the federal Health Insurance Portability and Accountability Act (HIPAA) privacy rules.
    "Family support peer specialist" means the same as defined in rule 441—25.1(331).
    "Informed consent" means the same as defined in rule 441—24.1(225C).
    "Mental health crisis" means a behavioral, emotional, or psychiatric situation which results in a high level of stress or anxiety for the individual or persons providing care for the individual and which cannot be resolved without intervention.
    "Mental health professional" means the same as defined in Iowa Code section 228.1.
    "Mobile response" means a mental health service which provides on-site, face-to-face mental health crisis services for an individual experiencing a mental health crisis. Crisis response staff providing mobile response have the capacity to intervene wherever the crisis is occurring, including but not limited to the individual’s place of residence, an emergency room, police station, outpatient mental health setting, school, recovery center or any other location where the individual lives, works, attends school, or socializes.
    "Peer support services" means a service provided by a peer support specialist, including but not limited to education and information, individual advocacy, family support groups, crisis response, and respite to assist individuals in achieving stability in the community.
    "Peer support specialist" means the same as defined in rule 441—25.1(331).
    "Physical health" means any chronic or acute health factors that need to be addressed during crisis delivery services.
    "Qualified prescriber" means a practitioner or other staff following the instruction of a practitioner as defined in Iowa Code section 155A.3 and a physician assistant or advanced registered nurse practitioner operating under the prescribing authority granted in Iowa Code section 147.107.
    "Restraint" means the application of physical force or the use of a chemical agent or mechanical device for the purpose of restraining the free movement of an individual’s body to protect the individual, or others, from immediate harm.
    "Rights restriction" means limitations not imposed on the general public in the areas of communications, mobility, finances, medical or mental health treatment, intimacy, privacy, type of work, religion, and place of residence.
    "Self-administered medication" means the process where a trained staff member observes an individual inject, inhale, ingest or, by any other means, take medication following the instructions of a qualified prescriber.
    "Stabilization plan" means a written short-term strategy used to stabilize a crisis and developed by a mental health professional, in collaboration with the crisis response staff and with the involvement and consent of the individual or the individual’s representative.
    "Staff-administered medication" means the direct application of a prescription drug, whether by injection, inhalation, ingestion, or any other means, to the body of an individual by a qualified prescriber or authorized staff following instructions of a qualified prescriber.
    "Telehealth" is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
    "Treatment summary" means a written summarization of the treatment and action plan at the point of an individual’s discharge or transition to another service.
    "Twenty-four-hour crisis line" means a crisis line providing information and referral, counseling, crisis service coordination, and linkages to crisis screening and mental health services 24 hours a day.
    "Twenty-four-hour crisis response" means services are available 24 hours a day, 365 days a year, providing access to crisis screening and assessment and linkage to mental health services.
    "Twenty-three-hour observation and holding" means a level of care provided for up to 23 hours in a secure and protected, medically staffed, psychiatrically supervised treatment environment.
    "Warm line" means a telephone line staffed by individuals with lived experience who provide nonjudgmental, nondirective support to an individual who is experiencing a personal crisis.
    Related ARC(s): 1660C441—24.21(225C)  Standards for crisis response services.  An organization may be accredited to provide any one or all of the identified crisis response services. An organization seeking crisis response service accreditation shall comply with the general standards within this division and additional standards for each specific service.Related ARC(s): 1660C441—24.22(225C)  Standards for policies and procedures.  Policies and procedures manuals contain policy guidelines and administrative procedures for all activities and services and address the standards in rule 441—24.2(225C).Related ARC(s): 1660C441—24.23(225C)  Standards for organizational activities.    24.23(1)  The organization shall meet the standards in subrules 24.3(1) through 24.3(5).  24.23(2)  The organization shall describe the staffing structure that details how staff are utilized to provide the specific crisis stabilization services in rules 441—24.32(225C) through 441—24.39(225C).Related ARC(s): 1660C, 3057C441—24.24(225C)  Standards for crisis response staff.  All crisis response staff shall meet the qualifications described in this rule. Additional staff requirements are described in each service.  24.24(1)    Performance benchmark.  Qualified crisis response staff provide crisis response services.  24.24(2)    Performance indicators.    a.  One or more of the following qualifications are met:  (1)  A mental health professional as defined in Iowa Code section 228.1.  (2)  A bachelor’s degree with 30 semester hours or equivalent in a human services field (including, but not limited to, psychology, social work, nursing, education) and a minimum of one year of experience in behavioral or mental health services.  (3)  A law enforcement officer with a minimum of two years of experience in the law enforcement officer’s field.  (4)  An emergency medical technician (EMT) with a minimum of two years of experience in the EMT’s field.  (5)  A peer support specialist with a minimum of one year of experience in behavioral or mental health services.  (6)  A family support peer specialist with a minimum of one year of experience in behavioral or mental health services.  (7)  A registered nurse with a minimum of one year of experience in behavioral or mental health services.  (8)  A bachelor’s degree in a non-human services-related field, associate’s degree, or high school diploma (or equivalency) with a minimum of two years of experience in behavioral or mental health services, and 30 hours of crisis and mental health in-service training (in addition to the required 30 hours of department-approved training).  b.  Documentation in staff records to verify satisfactory completion of department-approved training including:  (1)  A minimum of 30 hours of department-approved crisis intervention and training.  (2)  A posttraining assessment of competency is completed.Related ARC(s): 1660C, 3057C441—24.25(225C)  Standards for services.    24.25(1)    Standard for eligibility.  An eligible recipient is an individual experiencing a mental health crisis or emergency where a mental health crisis screening is needed to determine the appropriate level of care.  24.25(2)    Confidentiality and legal status.  Standards in subrule 24.4(6) are met.  24.25(3)    Service systems.  Standards in subparagraphs 24.4(7)“b”(1) to (3) are met.  24.25(4)    Respect for individual rights.  Standards in subrule 24.4(8) are met.Related ARC(s): 1660C441—24.26(225C)  Accreditation.  The administrator for the division of mental health and disability services shall determine whether to grant, deny or revoke the accreditation of the centers and services as determined in Iowa Code section 225C.6(1)“c.”  24.26(1)  The organization shall meet the standards of subrule 24.5(1), with the addition of crisis response service organizations.  24.26(2)  The organization shall meet the standards in subrules 24.5(2) and 24.5(3).  24.26(3)  Performance outcome determinations are as follows:  a.  Quality assurance staff shall determine a performance compliance level based on the number of indicators found to be in compliance.  (1)  For service indicators, if 25 percent or more of the files reviewed do not comply with the requirements for a performance indicator, that indicator is considered out of compliance and corrective action is required.  (2)  Corrective action is required when any indicator under policies and procedures or activities is not met.  b.  In the overall rating, the performance rating for policies and procedures shall count as 15 percent of the total, activities as 15 percent of the total, and services as 70 percent of the total.  (1)  Each of the three indicators for policies and procedures has a value of 5.0 out of a possible score of 15.  (2)  Each of the 34 indicators for activities has a value of .44 out of a possible score of 15.  (3)  Each service has a separate weighting according to the total number of indicators applicable for that service, with a possible score of 70, as follows:  c.  Quality assurance staff shall determine a separate score for each service to be accredited. When an organization offers more than one service under this chapter, there shall be one accreditation award for all the services based upon the lowest score of the services surveyed.ServiceNumber of IndicatorsValue of Each Indicator24-hour crisis response193.9Crisis evaluation203.524-hour crisis line233.0Warm line203.5Mobile response183.923-hour observation and holding441.6Crisis stabilization, community-based391.8Crisis stabilization, residential501.4  24.26(4)  The organization shall meet the standards in subrules 24.5(5) to 24.5(7).Related ARC(s): 1660C441—24.27(225C)  Deemed status.  The department shall grant deemed status to organizations accredited by a recognized national, not-for-profit, accrediting body when the department determines the accreditation is for similar services. The organization shall fulfill the standards described in subrules 24.6(1) to 24.6(6). The national accrediting bodies currently recognized as meeting division criteria for possible deeming are:
    1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
    2. The Commission on Accreditation of Rehabilitation Facilities (CARF).
    3. The Council on Quality and Leadership in Supports for People with Disabilities (The Council).
    4. The Council on Accreditation of Services for Families and Children (COA).
    5. The American Association of Suicidology (AAS).
    6. Contact USA.
    Related ARC(s): 1660C441—24.28(225C)  Complaint process.  The department shall receive and record complaints by individuals using services, employees, any interested people, and the public relating to or alleging violations of applicable requirements of the Iowa Code or administrative rules in accordance with the standards described in rule 441—24.7(225C).Related ARC(s): 1660C441—24.29(225C)  Appeal procedure.  The department shall receive appeals according to the process in rule 441—24.8(225C).Related ARC(s): 1660C441—24.30(225C)  Exceptions to policy.  The department shall receive exceptions to policy meeting the standards in rule 441—24.9(225C).Related ARC(s): 1660C441—24.31(225C)  Standards for individual crisis response services.  Crisis response services provided to children and youth include coordination with parents, guardians, family members, natural supports, and service providers and with other systems such as education, juvenile justice and child welfare.Crisis response services for individuals who have co-occurring or multi-occurring diagnoses focus on the integration and coordination of treatment services, and supports necessary to stabilize the individual, without regard to which condition is primary. Crisis response services are not to be denied due to the presence of a co-occurring substance abuse condition or developmental or neurodevelopmental disability.Related ARC(s): 1660C441—24.32(225C)  Crisis evaluation.  Crisis evaluation consists of two components: crisis screening and crisis assessment.  24.32(1)    Crisis screening.  The purpose of crisis screening is to determine the presenting problem and appropriate level of care.  a.    Performance benchmark.  Crisis screening includes a brief assessment of suicide lethality, substance use, alcohol use and safety needs. Crisis screening can be provided through contact with crisis response staff and through communication with the individual.  b.    Performance indicators.    (1)  Crisis response staff are trained in crisis screening.  (2)  A uniform process for crisis screening and referrals is outlined in policies and procedures.  (3)  Crisis screening records are kept in individual files.  24.32(2)    Crisis assessment.  The purpose of crisis assessment is to determine the precipitating factors of the crisis, the individual and family functioning needs, and the diagnosis if present and to initiate a stabilization plan and discharge plan. A licensed mental health professional conducts a crisis assessment within 24 hours of an individual’s admission to a crisis response service.  a.    Assessment requirements.  The crisis assessment includes:  (1)  Action plan.  (2)  Active symptoms of psychosis.  (3)  Alcohol use.  (4)  Coping ability.  (5)  History of trauma.  (6)  Impulsivity or absence of protective factors.  (7)  Intensity and duration of depression.  (8)  Lethality assessment.  (9)  Level of external support available to the individual.  (10)  Medical history.  (11)  Physical health.  (12)  Prescription medication.  (13)  Crisis details.  (14)  Stress indicators and level of stress.  (15)  Substance use.  b.    Performance benchmark.  Individuals receive comprehensive assessment by a mental health professional to determine the appropriate level of care.  c.    Performance indicators.    (1)  Written policies and procedures describe a uniform process for assessment, referrals and record documentation.  (2)  Mental health professionals as defined in Iowa Code section 228.1(6) will complete assessments.  (3)  Information collected is sufficient to determine the appropriate level of care.  (4)  Assessment results are explained to the individual and family or guardian when appropriate.  (5)  The individual’s strengths, preferences and needs are included in an action plan. The family or guardian may receive a copy of an action plan with a signed release.Related ARC(s): 1660C441—24.33(225C)  Twenty-four-hour crisis response.  The purpose of 24-hour crisis response is to provide access to crisis screening and assessment to de-escalate and stabilize the crisis. When the assessment indicates, a stabilization plan is developed to support the individual’s return to a prior level of functioning. Twenty-four-hour crisis response staff link the individual to appropriate services. Crisis response staff provide service to individuals of any age.  24.33(1)    Performance benchmark.  Individuals in crisis have the ability to access crisis response services, including, but not limited to, crisis screening, crisis assessment and stabilization in the least restrictive level of care appropriate.  24.33(2)    Performance indicators.    a.  Information on how to access 24-hour crisis response is publicized to facilitate availability of services to individuals using the service, family members and the public.  b.  Individuals accessing the service receive crisis screening and crisis response services from appropriate crisis response staff.  c.  Crisis screening is available and accessible face-to-face, using telephone or Web-based options, 24 hours a day, 365 days a year.  d.  A mental health professional is available for crisis assessment and consultation 24 hours a day, 365 days a year. The mental health professional has access to a qualified prescriber for consultation.  e.  The staffing pattern and schedule is documented.  f.  The integration and coordination of care is documented in the individual’s record.  g.  The discharge, action and follow-up plans are documented in the individual’s record, and copies of the plans are provided to the individual. The family or guardian may receive a copy with a signed release.Related ARC(s): 1660C441—24.34(225C)  Twenty-four-hour crisis line.  A 24-hour crisis line provides counseling, crisis service coordination, information and referral, linkage to services and crisis screening. Crisis line staff are qualified to provide crisis stabilization services pursuant to subrule 24.24(2).  24.34(1)    Performance benchmark.  Crisis screening, counseling, crisis service coordination and referrals are provided to individuals in crisis.  24.34(2)    Performance indicators.    a.  The crisis line service is available 24 hours a day, 365 days a year.  b.  Policies are in place regarding how the crisis line is answered live, when to utilize the hold feature, the use of queue systems and triage of calls.  c.  Policies and procedures govern the use of technology, including telephonic and Internet capability in the service delivery structure, quality assurance, data integrity and confidentiality.  d.  Procedures are in place for ensuring the quality of the crisis line, including monitoring calls and corrective action plans.  e.  The crisis line is an integrated component of the crisis response service system; the crisis line is answered in an organization setting by trained crisis response staff.  f.  Policies define collaborative efforts and triage procedure between the mobile outreach teams, law enforcement and emergency services.  g.  Policies are in place to ensure follow-up contacts are provided within 24 hours of a crisis call for all risk cases. The crisis line integrates follow-up into all crisis service contacts.  h.  The crisis line utilizes standardized call center software with the capability to track:  (1)  Date and time of answered call, topic of call, crisis screening provided, referral made, hold time, and demographics of call.  (2)  Number of contacts, including terminated and lost calls.  i.  Policies and procedures describe a uniform process of crisis screening and training for crisis line staff.  j.  Training includes crisis screening tools, lethality assessment, crisis counseling, cultural competence, crisis service coordination, and information and referral.  k.  Twenty-four-hour access to a mental health professional is required.Related ARC(s): 1660C441—24.35(225C)  Warm line.  A peer-operated warm line is a service individuals can access to talk with someone with lived experience with mental, behavioral health and trauma issues. The line provides a resource for individuals experiencing emotional distress.  24.35(1)    Performance benchmark.  A warm line provides nonjudgmental listening, nondirective assistance, information, referral, and triage when appropriate.  24.35(2)    Performance indicators.    a.  Policies are in place regarding how the warm line is answered live, placing callers on hold and when appropriate to use a queue system.  b.  Policies and procedures are in place for standard collection of demographics, the presented reason for calling and outcome of call.  c.  Policies and procedures are in place for crisis screening and when to triage a caller to a higher level of service.  d.  Data collection includes call answer times, duration of calls, and number of calls dropped, lost or terminated.  e.  Policies and procedures describe the staffing pattern and schedule.  f.  Warm-line staff can receive calls remotely through telephones or computers or within an organization.  g.  Staff qualifications and training for peer support specialists and family support peer specialists are required.  h.  Twenty-four-hour access to a mental health professional is required.Related ARC(s): 1660C441—24.36(225C)  Mobile response.  Crisis response staff provide on-site, in-person intervention for individuals experiencing a mental health crisis. The mobile response staff provide crisis response services in the individual’s home or at locations in the community. Staff work in pairs to ensure staff safety and the safety of the individual served. A single staff member may respond if another person who meets one of the criteria listed in paragraph 24.24(2)“a” will be available on site. Twenty-four-hour access to a mental health professional is required.  24.36(1)    Performance benchmark.  Mobile response services are delivered to individuals in crisis in a timely manner.  24.36(2)    Performance indicators.    a.  Mobile response staff are dispatched immediately after crisis screening has determined the appropriate level of care. If the mobile response staff already are responding to another call, staff explain to the caller that there may be a delay in receiving a mobile response and offer an alternative response.  b.  Mobile response staff have face-to-face contact with the individual in crisis within 60 minutes from dispatch. If the mobile response staff are responding to another request, there may be a delay in receiving mobile response and an alternative response should be provided.  c.  Data is collected to track and trend response time from initial dispatch, the time to respond to dispatch when a team is already in response; diversion from or admission to hospitals, correctional facilities and other crisis response services. The data for each fiscal year is reported to the department within 60 days of the close of the fiscal year.  d.  When an action plan is developed, a copy is sent within 24 hours, with the individual’s signed consent, to service providers, the individual and others as appropriate.  e.  The following information is documented in the individual’s service record:  (1)  Triage and referral information.  (2)  Reduction in the level of risk present in the crisis situation.  (3)  Coordination with other mental health resources.  (4)  Names and affiliation of all individuals participating in the mobile response.  f.  A follow-up appointment with the individual’s preferred provider will be made, and mobile response staff will follow up with the individual and document contact or attempt to contact on a periodic basis until the appointment takes place.Related ARC(s): 1660C441—24.37(225C)  Twenty-three-hour crisis observation and holding.  Twenty-three-hour crisis observation and holding services may be a stand-alone service or embedded within a crisis stabilization residential service. Twenty-three-hour crisis observation and holding services are designed for individuals who need short-term crisis intervention in a safe environment less restrictive than hospitalization. This level of service is appropriate for individuals who require protection or when an individual’s ability to cope in the community is severely compromised and it is expected the crisis can be resolved in 23 hours. Twenty-three-hour crisis observation and holding services include, but are not limited to, treatment, medication administration, meeting with extended family or significant others, and referral to appropriate services. Twenty-three-hour crisis observation and holding chairs can be utilized.  24.37(1)    Admission criteria.  The services may be provided if any of the following admission criteria are met:  a.  There are indications the symptoms can be stabilized and an alternative treatment can be initiated within a 23-hour period.  b.  The presenting crisis cannot be safely evaluated or managed in a less restrictive setting, or no such setting is available.  c.  The individual does not meet inpatient criteria, and it is determined a period of observation assists in the stabilization and prevention of symptom exacerbation.  d.  Further evaluation is necessary to determine the individual’s service needs.  e.  There is an indication of actual or potential danger to self or others as evidenced by a current threat or ideation.  f.  There is a loss of impulse control leading to life-threatening behavior and other psychiatric symptoms requiring stabilization in a structured, monitored setting.  g.  The individual is experiencing a crisis demonstrated by an abrupt or substantial change in normal life functioning brought on by a specific cause, sudden event or severe stressor.  24.37(2)    Staffing requirements.    a.  A designated medical director or administrator is responsible for the management and operation of the organization or facility.  b.  Registered nurse practitioners and physician assistants have at least two years of mental health experience.  c.  At least one mental health professional is available for consultation 24 hours a day, 365 days a year.  d.  A mental health professional as defined in Iowa Code section 228.1(6) provides mental health services appropriate to the individual’s needs.  e.  Crisis response staff are on duty 24 hours a day.  f.  A registered nurse is available on site 24 hours a day.  24.37(3)    Twenty-three-hour observation and holding safety.    a.    Performance benchmark.  An incident report is created when staff are notified an incident has occurred.  b.    Performance indicators.    (1)  The incident report documents:
    1. The name of the individual or individuals who were involved in the incident.
    2. Date and time of occurrence of the incident.
    3. A description of the incident.
    4. Names and signatures of all staff present at the time of the incident.
    5. The action taken by the staff.
    6. The resolution or follow-up to the incident.
      (2)  A copy of the incident report is kept in a centralized file and a copy is given to the individual, the mental health and disability services region, and the individual’s parent or guardian when appropriate.      24.37(4)    Service requirements.    a.    Performance benchmark.  A treatment summary is provided to the individual and the individual’s treatment team when applicable.  b.    Performance indicators.  The minimum treatment summary requirements include:  (1)  Action plan.  (2)  Crisis assessment, including challenges and strengths.  (3)  Course and progress of the individual with regard to each identified challenge.  (4)  Evaluation of the individual’s mental status to inform ongoing placement and support decisions.  (5)  Recommendations and arrangements for further service needs.  (6)  Signature of the mental health professional.  (7)  Treatment interventions.  c.    Performance benchmark.  The individual using this service is provided a safe, secure observation and holding service in a location meeting the needs of the individual and in the least restrictive setting.  d.    Performance indicators.    (1)  Individuals give informed consent.  (2)  Treatment providers, family members and other natural supports as appropriate are contacted within 23 hours of the individual’s admission.  (3)  Written policies and procedures cover medication administration, storage and documentation.  (4)  Individual records include, but are not limited to, a treatment summary and verification of individual choice.  (5)  The 23-hour crisis observation and holding facility is a welcoming and comfortable environment conducive to recovery.  (6)  The 23-hour crisis observation and holding is primarily used as a diversion from hospital level of care.  (7)  Communication attempts and contact with the individual’s team will be documented.  (8)  A follow-up appointment with the individual’s preferred provider will be made, and crisis response staff will follow up with the individual and document contact or attempt to contact on a periodic basis until the appointment takes place.  (9)  There are written policies and procedures of how to document and track discharge locations.  (10)  The actual number of individuals served within the 23-hour period is documented. Individual treatment records contain reasons why individuals stay beyond the 23-hour period.  (11)  Readmission data and length of time between admissions are tracked for data trend reports.  e.    Performance benchmark.  Policies and procedures address the additional safety standards for 23-hour crisis and observation services.  f.    Performance indicators.    (1)  Service compliance is documented regarding state fire marshal rules and fire ordinances and applicable local health, fire, occupancy code, and safety regulations.  (2)  Based on standards used for public facilities, all food and drink is clean, wholesome, free from spoilage, and stored and served in a manner safe for human consumption.  (3)  Doors must not be locked from the inside. The use of door locks is as approved by the fire marshal and professional staff.  (4)  Twenty-three-hour observation and holding services have an emergency preparedness plan to describe the process for an individual to continue receiving services during a disaster including, but not limited to, cases of severe weather or fire.  g.    Performance benchmark.  Policies and procedures address the cleanliness of the 23-hour observation and holding service.  h.    Performance indicators.    (1)  Services provide a safe, clean, well-ventilated, properly heated environment in good repair and free from vermin.  (2)  An individual’s resting or sleeping area includes:
    1. A sturdily constructed bed or comfortable chair.
    2. A sanitized mattress protected with a clean mattress pad, or sanitized chair.
    3. Curtains or blinds are on bedroom windows.
    4. Available clean linen.
    5. Doors or partitions for privacy.
    6. Right to privacy is respected.
      (3)  Bathrooms include items necessary for personal hygiene and personal privacy.
    1. A safe supply of hot and cold running water which is potable.
    2. Clean towels, electric hand dryers or paper towel dispensers, and an available supply of toilet paper and soap.
    3. Natural or mechanical ventilation capable of removing odors.
    4. Tubs or showers have slip-proof surfaces.
    5. Partitions with doors which provide privacy if a bathroom has multiple toilet stools.
    6. Toilets, wash basins, and other plumbing or sanitary facilities are maintained in good operating condition.
    7. Privacy in bathrooms for male and female individuals.
      i.    Performance benchmark.  Personal rights are acknowledged.  j.    Performance indicator.  The following are allowed:  (1)  Areas in which an individual may be alone when appropriate.  (2)  Areas for private conversations with others.  (3)  Secure space for personal belongings.  (4)  Personal clothing is allowed in accordance with organization policy.  k.    Performance benchmark.  Policies and procedures address health and safety standards.  l.    Performance indicators.    (1)  An emergency preparedness plan is designed to provide effective utilization of available resources during a disaster event including, but not limited to, cases of severe weather or fire.  (2)  Services comply with rule 441—24.39(225C).  (3)  There are written policies on safety.  (4)  Seclusion is not used.  (5)  Mechanical or chemical restraints are not used at any time.  (6)  The smokefree air Act, Iowa Code chapter 142D, is followed.    Related ARC(s): 1660C441—24.38(225C)  Crisis stabilization community-based services (CSCBS).  The goal of CSCBS is to stabilize the individual within the community. CSCBS is designed as a voluntary service for individuals in need of a safe, secure location that is less intensive and restrictive than an inpatient hospital. Individuals receive CSCBS services including, but not limited to, psychiatric services, medication, counseling, referrals, peer support and linkage to ongoing services. The duration for CSCBS is expected to be less than five days.   24.38(1)    Eligibility.  To be eligible, an individual must:  a.  Be determined appropriate for the service by mental health assessment; and  b.  Be determined not to need inpatient acute hospital psychiatric services.  24.38(2)    Staffing requirements.    a.  A designated director or administrator is responsible for the management and operation of the CSCBS.  b.  At least one licensed nurse practitioner, physician assistant, or psychiatrist is available for consultation 24 hours a day, 365 days a year.  c.  Mental health professionals with expertise appropriate to the individual’s needs provide services.  d.  Contact between the individual and a mental health professional occurs at least one time a day.  e.  Additional services are provided by crisis response staff at a minimum of one hour per day, including, but not limited to, skill building, peer support or family support peer services. The goal of CSCBS is to stabilize the individual within the community. CSCBS is designed for voluntary services for individuals in need of a safe, secure location that is less intensive and restrictive than an inpatient hospital.  f.  Crisis response staff must be awake and attentive 24 hours a day.  24.38(3)    Performance benchmark.  The individual using CSCBS is provided safe, secure and structured crisis stabilization services in the least restrictive location meeting the needs of the individual. The CSCBS can be for youth aged 18 and under or adults aged 18 and older.  24.38(4)    Performance indicators.    a.  The individual can provide consent for treatment providers, family members and other natural supports to be contacted within 24 hours of admission.  b.  Daily crisis stabilization services include, at minimum, daily contact with a mental health professional and one hour of additional crisis stabilization services from crisis response staff.  c.  The numbers of days an individual receives crisis stabilization services are documented. The documentation records specific reasons for the delivery of services beyond five days.  d.  Individual records are maintained to document the following:  (1)  Daily contact with a mental health professional.  (2)  Additional services provided including, but not limited to, skill building, peer support or family support peer services.  (3)  Medication record.  e.  Individual choice is verified including, but not limited to, treatment participation and discharge plan options.  f.  Readmission data is tracked, including an analysis of data trends looking at effectiveness, and appropriate corrective action taken. The information is documented in the performance improvement system files.  24.38(5)    Crisis stabilization incident reporting.    a.    Performance benchmark.  An incident report is filed when staff are notified an incident has occurred.  b.    Performance indicators.    (1)  The incident report documents:
    1. The name of the individual involved in the incident.
    2. Date and time the incident occurred.
    3. A description of the incident.
    4. Names and signatures of all staff present at the time of the incident.
    5. The action the staff took to handle the situation.
    6. The resolution or follow-up to the incident.
      (2)  A copy of the incident report is kept in a centralized file and a copy given to the individual, the mental health and disability services region, and the parent or guardian when appropriate.      24.38(6)    Service requirements.    a.    Stabilization plan.  The individual in crisis is involved collaboratively in all aspects of crisis stabilization services including, but not limited to, admission, treatment planning, intervention, and discharge. The involvement of family members and others is encouraged.Within 24 hours of an individual’s admission to crisis stabilization services, a written short-term stabilization plan is developed, with the involvement and consent of the individual, and is reviewed frequently to assess the need for the individual’s continued placement in CSCBS. At a minimum, this plan includes:  (1)  Criteria for discharge, including referrals and linkages to appropriate services and coordination with other systems.  (2)  Description of any physical disability and any accommodations necessary to provide the same or equal services and benefits as those afforded nondisabled individuals.  (3)  Evidence of input by the individual, including the individual’s signature.  (4)  Goal statement. Goals are consistent with the individual’s needs and projected duration of service delivery and include objectives which build on strengths and are stated in terms allowing measurement of progress.  (5)  Rights restrictions.  (6)  Names of all other persons participating in the development of the plan.  (7)  Specification of treatment responsibilities and methods.  b.    Performance benchmark.  A stabilization plan is completed within 24 hours of the individual’s admittance.  c.    Performance indicators.    (1)  Individual records include a written short-term stabilization plan developed with the involvement and consent of the individual within 24 hours of admittance and reviewed frequently to assess the need for continued placement in CSCBS.  (2)  Individual records indicate a crisis stabilization plan is completed within the 24-hour time frame.  (3)  Reasons for crisis stabilization plans not meeting the criteria are documented.  (4)  A follow-up appointment with the individual’s preferred provider will be made, and crisis response staff will follow up with the individual and document contact or attempt to contact on a periodic basis until the appointment takes place.  24.38(7)    Treatment summary.  Prior to the individual’s discharge from CSCBS, a treatment summary is completed. A copy of the summary is provided to the individual and shared with the individual’s treatment team of providers, if applicable.  a.    Contents.  At a minimum, the treatment summary includes:  (1)  Course and progress of the individual with regard to each identified problem.  (2)  Documented note of a mental health professional contact one time daily.  (3)  Evolution of the mental status to inform ongoing placement and support decisions.  (4)  Final assessment, including general observations and significant findings of the individual’s condition initially while services were being provided and at discharge.  (5)  Recommendations and arrangements for further service needs.  (6)  Signature of the mental health professional.  (7)  Stabilization plan.  (8)  Reasons for termination of service.  (9)  Treatment interventions.  b.    Performance benchmark.  A treatment summary is completed during the length of stay in CSCBS.  c.    Performance indicators.    (1)  Records include a written treatment summary developed with the involvement of the individual. A copy of the summary is provided upon discharge.  (2)  Incidents in which a treatment plan was not completed within the length of stay and any corrective action necessary to alleviate this issue are documented.  24.38(8)    Health and safety.    a.    Performance benchmark.  Emergency preparedness policies and procedures include health and safety measures.  b.    Performance indicators.    (1)  Emergency preparedness plans are designed to provide effective utilization of available resources for care to continue during a disaster event including, but not limited to, cases of severe weather or fire.  (2)  Crisis services comply with rule 441—24.39(225C).    Related ARC(s): 1660C441—24.39(225C)  Crisis stabilization residential services (CSRS).  Crisis stabilization residential services are short-term services provided in facility-based settings of no more than 16 beds. The goal of CSRS is to stabilize and reintegrate the individual back into the community. Crisis stabilization residential services are designed for voluntary individuals who are in need of a safe, secure environment less intensive and restrictive than an inpatient hospital. Crisis stabilization residential services have the capacity to serve more than two individuals at a time. Crisis stabilization residential services can be for youth aged 18 and younger or adults aged 18 and older. Youth and adults cannot be housed in the same facility setting. Facilities licensed by the department of inspections and appeals for other services would have to comply with the provisions of Iowa Administrative Code rule 481—57.50(135C) for operating another business or activity in the facility.  24.39(1)    Eligibility.  To be eligible, an individual must:  a.  Be an adult aged 18 or older or a youth aged 18 or under.  b.  Be determined appropriate for the service by a mental health assessment; and  c.  Be determined to not need inpatient acute hospital psychiatric services.  24.39(2)    Staffing requirements.    a.  A designated director or administrator is responsible for the management and operation of the CSRS of no more than 16 beds.  b.  At least one licensed mental health professional is available for consultation 24 hours a day, 365 days a year.  c.  Crisis stabilization residential services are provided by a mental health professional with expertise appropriate to the individual’s needs.  d.  Each individual has contact with a mental health professional at least one time a day.  e.  Each individual has a minimum of one hour per day of additional services provided by crisis response staff including, but not limited to, skill building, peer support or family support peer services; or other therapeutic programming.  f.  Awake and attentive staffing 24 hours a day, 365 days a year is provided.  24.39(3)    Performance benchmark.  The individual is provided safe, secure and structured crisis stabilization services in the least restrictive location meeting the individual’s needs.  24.39(4)    Performance indicators.    a.  Individual’s consent is documented, and treatment providers, family members and other natural supports are contacted within 24 hours of admission.  b.  A comprehensive mental health assessment is completed within 24 hours of admission.  c.  Daily crisis stabilization includes, at minimum, daily contact with a mental health professional and one hour of additional crisis stabilization service.  d.  The length of stay is expected to be less than five days.  e.  The number of days an individual receives crisis stabilization services is documented. The documentation records specific reasons for lengths of stay beyond five days.  f.  Records include:  (1)  Stabilization plan.  (2)  Medication record.  (3)  Treatment summary.  (4)  Daily contact with a mental health professional.  g.  Additional services provided include, but are not limited to, skill building, peer support or family support peer services.  h.  Individual choice is verified including, but not limited to, treatment participation and discharge plan options.  i.  Data of readmission is tracked including an analysis of data trends, looking at effectiveness, and appropriate corrective action. The information is documented in the performance improvement system.  j.  Documentation tracks that the youth’s education needs are met with educational services received in the CSRS, and an action plan is in place to return the youth to school upon discharge.  24.39(5)    Crisis stabilization incident reporting.    a.    Performance benchmark.  An incident report is completed when staff are notified an incident has occurred.  b.    Performance indicators.    (1)  The incident report documents:
    1. The name of the individual who was involved in the incident.
    2. Date and time of occurrence of the incident.
    3. A description of the incident.
    4. Names and signatures of all staff present at the time of the incident.
    5. The action staff took to handle the situation.
    6. The resolution or follow-up to the incident.
      (2)  A copy of the incident report is maintained in a centralized file and a copy given to the individual, the mental health and disability services region, and the parent or guardian when appropriate.      24.39(6)    Service requirements.    a.    Stabilization plan.  The individual is involved collaboratively in all aspects of crisis stabilization services including, but not limited to, admission, treatment planning, intervention, and discharge. The involvement of family members and others is encouraged.Within 24 hours of admission to CSRS, a written short-term stabilization plan is developed, with the involvement and consent of the individual, and reviewed frequently to assess the need for continued placement in CSRS. At a minimum, this plan includes:  (1)  Criteria for discharge, including referrals and linkages to appropriate services and coordination with other systems.  (2)  Description of any physical disability and accommodations necessary to provide the same or equal services and benefits as those afforded nondisabled individuals.  (3)  Evidence of input by the individual, including the individual’s signature.  (4)  Goal statement.  (5)  Goals consistent with needs and projected length of stay.  (6)  Objectives that are built on strengths and allow measurement of progress.  (7)  Rights restrictions.  (8)  Signatures of all participating in the development of the plan.  (9)  Specification of treatment responsibilities and methods.  b.    Performance benchmark.  A stabilization plan is completed within 24 hours of admittance.  c.    Performance indicators.    (1)  Records include a written short-term stabilization plan developed with the involvement and consent of the individual within 24 hours of admission and is reviewed frequently to assess the need for continued placement in CSRS.  (2)  Records indicating a stabilization plan has been completed within the 24-hour time frame are maintained.  (3)  Reasons the stabilization plan does not meet the criteria is documented.  (4)  A follow-up appointment with the individual’s preferred provider will be made, and crisis response staff will follow up with the individual and document contact or attempt to contact on a periodic basis until the appointment takes place.  24.39(7)    Treatment summary.  Prior to discharge, a treatment summary is provided and a copy shared with the individual and treatment team as appropriate.  a.    Contents.  At a minimum, this treatment summary includes:  (1)  Course and progress regarding each identified problem.  (2)  Documentation of daily contact with a mental health professional.  (3)  Impact on placement and support decisions.  (4)  Assessment.  (5)  Action plan.  (6)  Stabilization plan.  (7)  Treatment interventions.  (8)  Reasons for termination of service.  (9)  Signature of the mental health professional.  b.    Performance benchmark.  A treatment summary is completed during the individual’s length of stay in CSRS.  c.    Performance indicators.    (1)  Records include a written treatment summary developed with the involvement and consent of the individual.  (2)  An individual receives a copy of the treatment summary upon discharge.  (3)  Corrective action steps are documented when treatment plans are not completed within the length of stay.  24.39(8)    Health and safety.    a.    Performance benchmarks.    (1)  Emergency preparedness policies and procedures include health and safety measures.  (2)  Crisis stabilization services meet all applicable local, state and federal regulations.  (3)  Medication administration and documentation standards in rule 441—24.40(225C) are documented.  b.    Performance indicators.    (1)  Health and fire safety inspections.
    1. Documentation includes Iowa fire marshal rules and fire ordinances, local health, fire, occupancy code, and safety regulations.
    2. Standards for public facilities guide food and beverage safety, nutrition standards, and safe storage of all consumable products.
    3. Crisis stabilization residential services comply with rule 441—24.40(225C).
      (2)  Emergency preparedness. Emergency preparedness policies are designed to provide effective utilization of available resources for continuation during a disaster event, including, but not limited to, cases of severe weather or fire.  (3)  The facility is safe, clean, well-ventilated, and a properly heated environment in good repair and free from vermin.  (4)  Bedrooms include:
    1. A sturdily constructed bed.
    2. A sanitized mattress protected with a clean mattress pad.
    3. A designated space in proximity to the sleeping area for personal possessions including clothing.
    4. Curtains or window blinds on bedroom windows.
    5. Available clean linens.
      (5)  Sleeping areas include:
    1. Doors for privacy.
    2. Partitioning and placement of furniture to provide privacy.
    3. Rooms accommodate no more than two per room. Single room dimensions are at least 80 square feet not including closets. Dual occupancy rooms are at least 120 square feet not including closets.
    4. Personal belongings and personal touches in the rooms are defined within CSRS policy.
    5. Respect by staff for an individual’s right to privacy.
      (6)  Personal hygiene and privacy tools are provided:
    1. A safe supply of hot and cold running water which is potable.
    2. Clean towels, electric hand dryers or paper towel dispensers, and an available supply of toilet paper and soap.
    3. Natural or mechanical ventilation capable of removing odors.
    4. Tubs or showers with slip-proof surfaces.
    5. Partitions with doors which provide privacy if a bathroom has multiple toilet stools.
    6. Toilets, wash basins, and other plumbing or sanitary facilities are in good operating condition.
    7. Privacy in bathrooms for male and female individuals.
      (7)  Federal laws regarding smoking on property are recognized and followed.  (8)  The following is provided:
    1. Areas in which an individual may be alone when appropriate.
    2. Areas for private conversations with others.
    3. A secure space for personal belongings.
      c.    Housekeeping.  Maintenance of living quarters and day-to-day housekeeping activities are clearly defined in writing and a part of the orientation. Staff assistance and equipment are provided as needed.  d.    Clothing.    (1)  Personal clothing is allowed in accordance with CSRS policy.  (2)  Clothing may be washed with provided laundry mechanisms.  e.    Religion/culture.  Rights to religion and culture include:  (1)  The opportunity to participate in religious activities and services in accordance with the individual’s faith or of a minor individual’s parent(s) or guardian.  (2)  Arrange for transportation to religious activities when appropriate per CSRS policy.  f.    Smoking.  The smokefree air Act, Iowa Code chapter 142D, is included in the CSRS policy.    Related ARC(s): 1660C441—24.40(225C)  Medication—administration, storage and documentation.   This rule sets forth medication requirements for 23-hour crisis observation and holding, crisis stabilization community-based services, and crisis stabilization residential services.  24.40(1)    Performance benchmark.  Policies and procedures ensure prescription and over-the-counter drugs are administered or self-administered safely and properly in accordance with federal, state and local laws and regulations. Medication is administered by a qualified prescriber or an individual following the instructions of a qualified prescriber. Medication storage is maintained in accordance with the security requirements of federal, state and local laws. Case records include written policies and procedures regarding use of medication.  24.40(2)    Performance indicators.    a.    Administration of medication.    (1)  Medication administration dose schedules and standardization of abbreviations are documented.  (2)  Throughout the CSRS specific methods for control and accountability of medication products are established.  (3)  Prescription and over-the-counter drugs are administered or self-administered safely and properly in accordance with federal, state and local laws and regulations.  (4)  Medications are prescribed by a qualified prescriber under Iowa law.  (5)  Prescription drugs are not administered or self-administered without a written order signed by a qualified prescriber.  b.    Staff-administered medication.    (1)  Only qualified and authorized staff administers medication, and a current, accurate list of staff is maintained.  (2)  Qualified prescribers instruct how medications are administered and documented. The type and amount of medication, time and date of medication administered, and the name of staff administering the medication are transcribed in the medication record.  c.    Self-administered medication.    (1)  Policies and procedures document which staff have completed department-approved training on self-administration of prescription medication.  (2)  Self-administration of prescription and over-the-counter medications are permitted only when the medication label is clear and complete.  d.    Medication storage.  Medication storage policies under the care and control of the administration include:  (1)  All medication is maintained in locked storage, and controlled substances are maintained in a locked box within locked storage.  (2)  Medications requiring refrigeration are kept in a refrigerator separated from food and other edible items.  (3)  Disinfectants and medication for external use are stored separately from internal and injectable medications.  (4)  Each medication is stored in original containers and labeled with the name.  (5)  All potent poisonous or caustic medications are clearly labeled; stored separately from other medication, in a specific well-illuminated cabinet, closet, or storeroom; and made accessible only to authorized staff.  (6)  Medication provided is dispensed from a licensed pharmacy in the state of Iowa in accordance with the Iowa Code. It can also be provided by a qualified prescriber from a licensed pharmacy in another state according to the laws of the state.  (7)  Prescription medications prescribed for one individual are not administered or allowed in the possession of another.  e.    Medication labeling.  All prescribed medications are clearly labeled with the full name; prescriber’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 prescriber issuing the medication. Medications are packaged and labeled according to state and federal guidelines.  f.    Monthly inspection.  The staff member in charge of medication provides monthly inspection of all storage units.  g.    Damaged labels.  Medication containers having soiled, damaged, illegible, or makeshift labels are returned to the issuing pharmacist, pharmacy, or qualified prescriber for relabeling or disposal.  h.    Unused medications.  Unused prescription drugs are destroyed by staff with a witness present, when an individual leaves the crisis service without medication. A notation is documented in the record. When an individual is discharged or leaves the crisis service, medications currently being administered are sent in their original containers with the individual or with a designated person, with the approval of the qualified prescriber.  i.    Medication brought by individual.  If the prescribed and over-the-counter medication the individual brings to the CSRS is not used, the medication is packaged, sealed and stored. The sealed packages of medications are returned to the individual or family at the time of discharge.  j.    Medication documentation.    (1)  Written policies and procedures are in place for the review, approval, and implementation of ethical, safe, human and efficient behavioral intervention procedures.  (2)  Written policies and procedures are in place to inform the individual and the individual’s legal guardian, when appropriate, about prohibitions on the use of medication as a restraint.  (3)  Documentation is required in case records on adverse drug reactions when medications are administered and self-administered.  (4)  All medication orders are documented in the case records and document the name of the medication, dose, route of administration, frequency of administration, name of the qualified prescriber prescribing the medication, and name of the staff administering or dispensing the medication.  (5)  Medication records are documented by authorized staff administering the medication.  k.    Medication rights and responsibilities.    (1)  Medication is not used as a restraint. The use of psychopharmacological medication in excess of the standard plan of care is prohibited. Using medication as a restraint includes:
    1. Drugs or medications used to control behavior or restrict freedom of movement.
    2. Drugs or medications used in excessive amounts or in excessive frequency.
    3. Neuroleptics, anxiolytics, antihistamines, and atypical neuroleptics, or other medication used for calming, rather than for the medication’s indicated treatment.
      (2)  Drugs or medications used for standard treatment of the individual’s medical or psychiatric condition are not considered to be used as a restraint.    Related ARC(s): 1660C, 6321CThese rules are intended to implement Iowa Code sections331.397 and 225C.19A and chapter 230A.441—24.41    Reserved.441—24.42    Reserved.441—24.43    Reserved.441—24.44    Reserved.441—24.45    Reserved.441—24.46    Reserved.441—24.47    Reserved.441—24.48    Reserved.441—24.49    Reserved.DIVISION IIICOMMUNITY MENTAL HEALTH CENTERSPreambleThe department of human services in consultation with the mental health and disability services commission has established this set of standards to be met by all designated community mental health centers (CMHCs). CMHCs are to provide an organized set of services to adequately meet the mental health needs of individuals in their catchment area. It is the department’s responsibility to designate at least one community mental health center for addressing the mental health needs of the county or counties comprising a catchment area in accordance with Iowa Code chapter 230A.441—24.50(230A)  Definitions.  
    "Catchment area" means the same as defined in Iowa Code section 230A.102(2).
    "Community mental health center self-assessment" means the form completed and submitted to the department by a new organization as part of the initial application to be designated as a CMHC. Designated CMHCs complete the form annually and submit it to the department as part of the accreditation and CMHC monitoring process.
    "Community support services" "CSS" means services that support individuals with a mental illness and functional impairment to live and work in the community of their choice through assisting with:
    1. Monitoring of mental health symptoms and functioning/reality orientation;
    2. Transportation;
    3. Supportive relationship;
    4. Communication with other providers;
    5. Ensuring individual attends appointments/obtains medications;
    6. Crisis intervention/developing crisis plan; and
    7. Coordination and development of natural support systems for mental health support.
    "Functional impairment," for the purpose of this division, means difficulties that substantially interfere with or limit functioning in one or more major life activities, such as basic daily living (including but not limited to eating, bathing, dressing); instrumental living skills (including but not limited to maintaining a household, managing money, community involvement, taking prescribed medication); and functioning in social, family and vocational/educational contexts.
    "Psychosocial rehabilitation services" means services that promote recovery, full community integration, and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives. Psychosocial rehabilitation services are collaborative, person-directed and individualized. The service focuses on helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning, and social environments of their choice.
    "Target population" means the same as defined in Iowa Code section 230A.105.
    Related ARC(s): 6321C441—24.51(230A)  Community mental health center designation.    24.51(1)    Application.  An organization seeking designation as a community mental health center or a designated community mental health center seeking to expand its designated catchment area shall submit the following to the department:  a.  Form 470-3005, Accreditation Application, if requesting accreditation for a CMHC core service(s) other than outpatient psychotherapy and evaluation.   b.  Form 470-5691, Community Mental Health Center Designation, signed by the organization’s chief executive officer and the chairperson of the governing body.   c.  Form 470-5692, Community Mental Health Center Self-Assessment.  24.51(2)    Exceptional circumstances.  Designation for more than one CMHC in a county shall require a determination of exceptional circumstances by the department.  a.  Applicants requesting designation for a county that is part of another CMHC’s catchment area shall submit information supporting their designation request including, but not limited to, the following:  (1)  Evidence that the target population does not have access to the required core services with minimal or no service denials.  (2)  Ability to staff core services within the capacity of the catchment area’s workforce.  (3)  Mental health and disability services (MHDS) region(s) letter of support that includes the catchment area’s ability to financially support more than one CMHC.  (4)  Notification to the existing CMHC of intention to apply for designation.  (5)  Evidence of collaboration and coordination with existing CMHC.  b.  Paragraph 24.51(2)“a” and numbered paragraph “2” in rule 441—24.52(230A) do not apply to CMHCs designated as described in Iowa Code section 230A.104(2)“c.”  24.51(3)    Designation.  The department shall review information submitted by the applicant in accordance with subrule 24.51(1), subrule 24.51(2), and paragraph 24.51(3)“a” as well as input from MHDS regions, neighboring CMHCs, and mental health service providers to determine if there will be a recommendation for designation. Recommendations for designation shall be submitted by the department to the MHDS commission for approval.  a.  Applicants shall submit the following:   (1)  MHDS region(s) letter of support.  (2)  Evidence of active three-year accreditation for outpatient and evaluation services under this chapter.  (3)  Formal agreement with appropriately accredited provider if the applicant is not directly providing the service for the following:   1.  Day treatment, partial hospitalization, or psychosocial rehabilitation services, and   2.  Emergency or 24-hour crisis response.  (4)  Form 470-5692, Community Mental Health Center Self-Assessment, that demonstrates the applicant’s ability to:   1.  Provide core services in accordance with rule 441—24.54(230A).  2.  Meet service access standards according to 441—subparagraph 25.4(2)“a”(1) and 441—paragraphs 25.4(3)“a” and “c.”  3.  Serve all ages of the target population with minimal to no service denials.   4.  Make referrals for services provided outside the organization.  b.  The department shall notify the applicant in writing of the result of the review. If the department recommends designation, the applicant shall attend the MHDS commission meeting at which the department presents the request to the commission.  c.  CMHCs designated in accordance with Iowa Code chapter 230A prior to January 1, 2021, or designated as a CMHC by a county prior to October 1, 2010, will maintain their designation provided they meet the requirements set forth in rule 441—24.55(230A).  d.  Non-CMHC agencies designated as described in Iowa Code section 230A.107(2) may apply to be designated as a CMHC. The organization shall submit all required application materials in this subrule at least six months prior to the expiration of the organization’s current accreditation under this chapter.  24.51(4)    Withdrawal of designation.  Community mental health centers seeking to withdraw their designation for part or all of their catchment area shall submit to the department Form 470-5691, Community Mental Health Center Designation, signed by the organization’s chief executive officer and the chairperson of the governing body. The form shall include:  a.  Current catchment area and catchment area requesting withdrawal of designation.  b.  Reason for withdrawal request.  c.  Date withdrawal is to occur.  d.  Continuity of care plan including but not limited to communication and coordination with:  (1)  Individuals served.  (2)  Community mental health centers and mental health service providers serving neighboring and current catchment area.  (3)  MHDS region(s).  (4)  General public.  24.51(5)    Agreement.  The board of directors of a designated CMHC shall enter into an agreement with the department in accordance with Iowa Code section 230A.103(3).  24.51(6)    Appeal procedure.  An appeal to a designation determination may be filed in accordance with rule 441—24.8(225C).  24.51(7)    Exception to policy.  Requests for exceptions to policy shall be submitted in accordance with rule 441—24.9(225C).  24.51(8)    Denial of designation or revocation.  The department may deny or revoke the provider’s designation at any time for any of the following reasons:  a.  The provider has failed to provide information requested pursuant to subrule 24.51(1).  b.  The provider does not meet criteria pursuant to subrule 24.51(3).  c.  The provider refuses to allow the department to conduct a site visit pursuant to subrule 24.5(3).  d.  The provider has failed to implement the corrective actions submitted and approved by the department pursuant to subrule 24.55(2).  e.  The provider’s accreditation was discontinued or revoked pursuant to paragraph 24.5(5)“h.”Related ARC(s): 6321C441—24.52(230A)  Standards for policies and procedures.  Policies and procedures manuals shall include policy guidelines and administrative procedures for:
    1. Core services and supports,
    2. Serving the target population with minimal to no service denials,
    3. Addressing the standards in rule 441—24.2(225), and
    4. Ensuring an individual’s ability to access services regardless of ability to pay. The CMHC shall assist individuals with applying for health insurance and MHDS regional assistance when necessary to ensure access to services.
    Related ARC(s): 6321C441—24.53(230A)  Standards for organizational activities.  The organization shall meet all requirements in rule 441—24.3(225C) and the standards identified in this rule.  24.53(1)  A CMHC organized as a nonprofit corporation shall be governed by a board of directors consistent with the requirements identified in Iowa Code section 230A.110(3)“b.”  24.53(2)  A CMHC organized as a for-profit corporation shall have a policy structure that incorporates the representation identified in Iowa Code section 230A.110(3)“b.”Related ARC(s): 6321C441—24.54(230A)  Standards for core services and supports.    24.54(1)    Outpatient services.  Outpatient services include outpatient psychotherapy and counseling services and evaluation. These services are to be provided directly by the CMHC.  a.  Outpatient psychotherapy and counseling services shall be provided in accordance with subrule 24.4(14) and shall include treatment modalities and evidence-based practices for children, adults, older adults, individuals with co-occurring conditions, and individuals discharged from inpatient settings. Clinical eligibility is determined at the time of initial assessment and annually thereafter in accordance with subrule 24.4(2).  b.  Evaluation services shall be provided in accordance with subrule 24.4(16).   24.54(2)    Twenty-four-hour emergency services.  The organization shall provide or enter into a formal agreement with an accredited provider for at least one of the following:  a.  Emergency services provided in accordance with subrule 24.4(15).  b.  Twenty-four-hour crisis response provided in accordance with rule 441—24.33(225C).  24.54(3)    Day treatment, partial hospitalization, or psychosocial rehabilitation services.  The organization shall provide or enter into a formal agreement with an accredited provider for at least one of the following:  a.  Day treatment provided in accordance with subrule 24.4(10), or   b.  Partial hospitalization provided in accordance with subrule 24.4(13), or   c.  Psychosocial rehabilitation services. This shall include at least one of the following:  (1)  Assertive community treatment (ACT) provided in accordance with 441—subrule 25.6(2) and rule 441—77.38(249A).  (2)  Intensive psychiatric rehabilitation services provided in accordance with subrule 24.4(11).  24.54(4)    Admission screening for voluntary patients to a state mental health institute.    a.  Screening and evaluation shall be made available to individuals requesting admission to a state mental health institute.  b.  The organization shall have policies and procedures that define the process to assist an individual seeking voluntary admission to a state mental health institute and to refer the individual to other services if treatment at the mental health institute is not immediately available.  24.54(5)    Community support services (CSS).  The purpose of CSS is to support individuals as they live and work in the community and address mental health symptoms and functional impairments that negatively affect integration and stability in the community.  a.  Performance benchmark.  (1)  Qualified staff provide CSS.  (2)  CSS is provided to individuals in the target population with a mental illness and functional impairment.  b.  Performance indicators.  (1)  The following staff qualifications shall be met:  1.  Have knowledge and experience in working with the target population.  2.  Have the ability to create relationships with the individuals served that balance support of the mental illness and the need to allow for maximum individual independence.  3.  Have a bachelor’s degree with 30 semester hours or equivalent quarter hours in a human services field, including but not limited to psychology, social work, mental health counseling, marriage and family therapy, nursing, education, occupational therapy, and recreational therapy.  4.  Complete a minimum of 12 hours of training within the first year of employment and annually in mental health conditions, including but not limited to the following topics:
  • Mental health diagnoses, symptomology, and treatment;
  • Crisis management, intervention, and de-escalation;
  • Psychiatric medications, common medications, and potential side effects;
  • Other diagnoses or conditions present in the population served; and
  • Individual person-centered service plan, crisis plan, and behavioral support plan implementation.
    •   (2)  The following service components are provided:  1.  Monitoring of mental health symptoms and functioning/reality orientation.  2.  Transportation.  3.  Supportive relationship.  4.  Communication with other providers.  5.  Ensuring individuals attend appointments and obtain medications.  6.  Crisis intervention and developing a crisis plan.  7.  Coordination and development of natural support systems for mental health support.      24.54(6)    Consultation services.  Consultation services shall be provided in accordance with Iowa Code section 230A.106(2)“f.”  24.54(7)    Education services.  Education services shall be provided in accordance with Iowa Code section 230A.106(2)“g.”  24.54(8)    Coordination with unaffiliated agencies.  Coordination shall be provided in accordance with Iowa Code section 230A.106(3).    Related ARC(s): 6321C441—24.55(230A)  Accreditation of community mental health centers.    24.55(1)  The provider shall be accredited as a provider of outpatient psychotherapy and counseling pursuant to subrule 24.4(14) and evaluation pursuant to subrule 24.4(16) and meet the standards of rule 441—24.3(225C).  24.55(2)  The provider shall meet the standards in rules 441—24.52(230A), 441—24.53(230A), and 441—24.54(230A). Corrective action is required when any indicator under community mental health designation standards is not met.  24.55(3)  The provider shall annually submit Form 470-5692, Community Mental Health Center Self-Assessment, to the department.Related ARC(s): 6321C    Related ARC(s): 1660C, 2164C, 3057C, 3855C, 6321C