CHAPTER 70ADULT DAY SERVICES481—70.1(231D)  Definitions.  In addition to the definitions in 481—Chapter 67 and Iowa Code chapter 231D, the following definitions apply.
"Accredited" means that the program has received accreditation from an accreditation entity recognized in subrule 70.14(1).
"Adult day services" "adult day services program" or “program” means an organized program providing a variety of health-related care, social services, and other related support services for 16 hours or less in a 24-hour period to two or more persons with a functional impairment on a regularly scheduled, contractual basis.
"Applicable requirements" means Iowa Code chapter 231D, this chapter, and 481—Chapter 67 and includes any other applicable administrative rules and provisions of the Iowa Code.
"CARF" means the Commission on Accreditation of Rehabilitation Facilities.
"Change of ownership" means the purchase, transfer, assignment or lease of a certified adult day services program and includes a change in the management company responsible for the day-to-day operation of the program, if the management company is ultimately responsible for any enforcement action taken by the department.
"Cognitive disorder" means a disorder characterized by cognitive dysfunction presumed to be the result of illness that does not meet criteria for dementia, delirium, or amnestic disorder.
"Contractual agreement" means a written agreement between the program and the participant or legal representative.
"Dementia-specific adult day services program" means an adult day services program certified under this chapter that:
  1. Serves fewer than 55 participants and has 5 or more participants who have dementia between Stages 4 and 7 on the Global Deterioration Scale, or
  2. Serves 55 or more participants and 10 percent or more of the participants have dementia between Stages 4 and 7 on the Global Deterioration Scale, or
  3. Holds itself out as providing specialized care for persons with dementia, such as Alzheimer’s disease, in a dedicated setting.
"Functional impairment" means a psychological, cognitive, or physical impairment that creates an inability to perform personal and instrumental activities of daily living and associated tasks and that necessitates some form of supervision or assistance or both.
"Maximal assistance with activities of daily living" means routine total dependence on staff for the performance of a minimum of four activities of daily living for a period that exceeds 21 days.
"Medically unstable" means that a participant has a condition or conditions:
  1. Indicating physiological frailty as determined by the program’s staff in consultation with a physician or physician extender;
  2. Resulting in three or more significant hospitalizations within a consecutive three-month period for more than observation; and
  3. Requiring frequent supervision of the participant for more than 21 days by a registered nurse.
For example, a participant who has a condition such as congestive heart failure which results in three or more significant hospitalizations during a quarter and which requires that the participant receive frequent supervision may be considered medically unstable.
"Nonaccredited" means that the program has been certified under the provisions of this chapter but has not received accreditation from the accreditation entity recognized in subrule 70.14(1).
"Participant" means an individual who is the recipient of services provided by an adult day services program.
"Participant’s legal representative" means a person appointed by the court to act on behalf of a participant, or a person acting pursuant to a power of attorney.
"Unmanageable incontinence" means a condition that requires staff provision of total care for an incontinent participant who lacks the ability to assist in bladder or bowel continence care.
"Unmanageable verbal abuse" means repeated verbalizations against participants or staff that persist despite all interventions and negatively affect the program. “Unmanageable verbal abuse” includes but is not limited to threats, frequent use of profane language, or unwelcome sexually oriented remarks.
"Visiting day(s)" means up to 16 hours in a two-day period during which a person may visit a program prior to admission for the purpose of assessing eligibility for the program and personal satisfaction.
Related ARC(s): 8177B, 1927C481—70.2(231D)  Program certification.  A program may obtain certification by meeting all applicable requirements. In addition, a program may be voluntarily accredited by a recognized accreditation entity. For the purpose of these rules, certification is equivalent to licensure.  70.2(1)    Posting requirements.  A program’s current certificate shall be visibly displayed within the designated operation area of the program. In addition, the latest monitoring report, state fire marshal report, and food establishment inspections report issued pursuant to Iowa Code chapter 137F shall be made available to the public by the program upon request.  70.2(2)    Dementia-specific programs and door alarms.  If a program meets the definition of a dementia-specific adult day services program during two sequential certification monitorings, the program shall meet all requirements for a dementia-specific program, including the requirements set forth in rule 481—70.30(231D) and in subrule 70.32(2), which includes the requirements relating to door alarms.Related ARC(s): 8177B481—70.3(231D)  Certification of a nonaccredited program—application process.    70.3(1)  The applicant shall complete an application packet obtained from the department. Application materials may be obtained from the health facilities division Web site at https://dia-hfd.iowa.gov/DIA_HFD/Home.do; by mail from the Department of Inspections and Appeals, Adult Services Bureau, Lucas State Office Building, Third Floor, 321 E. 12th Street, Des Moines, Iowa 50319-0083; or by telephone at (515)281-6325.  70.3(2)  The applicant shall submit one copy of the completed application and all supporting documentation to the department at the above address at least 90 calendar days prior to the expected date of beginning operation.  70.3(3)  The appropriate fee as stated in Iowa Code section 231D.4 shall accompany each application and be payable by check or money order to the Department of Inspections and Appeals. Fees are nonrefundable.  70.3(4)  The department shall consider the application when all supporting documents and fees are received.Related ARC(s): 8177B481—70.4(231D)  Nonaccredited program—application content.  An application for certification or recertification of a nonaccredited program shall include the following:  70.4(1)  A list that includes the names, addresses, and percentage of stock, shares, partnership or other equity interest of all officers, members of the board of directors and trustees, as well as stockholders, partners or any individuals who have greater than a 10 percent equity interest in each of the following, as applicable:  a.  The real estate owner or lessor;  b.  The lessee; and  c.  The management company responsible for the day-to-day operation of the program.The program shall notify the department of any changes in the list no later than ten working days after the effective date of the change.  70.4(2)  A statement disclosing whether the individuals listed in subrule 70.4(1) have been convicted of a felony or an aggravated or serious misdemeanor or found to be in violation of the child abuse or dependent adult abuse laws of any state.  70.4(3)  A statement disclosing whether any of the individuals listed in subrule 70.4(1) have or have had an ownership interest in an adult day services program, assisted living program, elder group home, home health agency, licensed health care facility as defined in Iowa Code section 135C.1, or licensed hospital as defined in Iowa Code section 135B.1, which has been closed in any state due to removal of program, agency, or facility licensure or certification or due to involuntary termination from participation in either the Medicaid or Medicare program; or have been found to have failed to provide adequate protection or services to prevent abuse or neglect of residents, patients, tenants or participants.  70.4(4)  The policy and procedure for evaluation of each participant. A copy of the evaluation tool or tools to be used to identify the functional, cognitive and health status of each participant shall be included.  70.4(5)  The policy and procedure for service plans.  70.4(6)  The policy and procedure for addressing medication needs of participants.  70.4(7)  The policy and procedure for accidents and emergency response.  70.4(8)  The policies and procedures for food service, including those relating to staffing, nutrition, menu planning, therapeutic diets, and food preparation, service and storage.  70.4(9)  The policy and procedure for activities.  70.4(10)  The policy and procedure for transportation.  70.4(11)  The policy and procedure for staffing and training.  70.4(12)  The policy and procedure for emergencies, including natural disasters. The policy and procedure shall include an evacuation plan and procedures for notifying legal representatives in emergency situations as applicable.  70.4(13)  The policy and procedure for managing risk and upholding participant autonomy when participant decision making results in poor outcomes for the participant or others.  70.4(14)  The policy and procedure for reporting incidents including dependent adult abuse as required in rule 481—67.2(231B,231C,231D).  70.4(15)  The policy and procedure related to life safety requirements for a dementia-specific program as required by subrule 70.32(2).  70.4(16)  The participant contractual agreement and all attachments.  70.4(17)  If the program contracts for personal care or health-related care services from a certified home health agency, a mental health center or a licensed health care facility, a copy of that entity’s current license or certification.  70.4(18)  A copy of the state license for the entity that provides food service, whether the entity is the program or an outside entity or a combination of both.  70.4(19)  The fee set forth in Iowa Code section 231D.4.Related ARC(s): 8177B, 1927C481—70.5(231D)  Initial certification process for a nonaccredited program.    70.5(1)  Upon receipt of all completed documentation, including state fire marshal approval and structural and evacuation review approval, the department shall determine whether the proposed program meets applicable requirements.  70.5(2)  If, based upon the review of the complete application, including all required supporting documents, the department determines the proposed program meets the requirements for certification, a provisional certification shall be issued to the program to begin operation and accept participants.  70.5(3)  Within 180 calendar days following issuance of provisional certification, the department shall conduct a monitoring to determine the program’s compliance with applicable requirements.  70.5(4)  If a regulatory insufficiency is identified as a result of the monitoring, the process in rule 481—67.10(17A,231B,231C,231D) shall be followed.  70.5(5)  The department shall make a final certification decision based on the results of the monitoring and review of an acceptable plan of correction.  70.5(6)  The department shall notify the program of a final certification decision within 10 working days following the finalization of the monitoring report or receipt of an acceptable plan of correction, whichever is applicable.  70.5(7)  If the decision is to continue certification, the department shall issue a full two-year certification effective from the date of the original provisional certification.Related ARC(s): 8177B481—70.6(231D)  Expiration of the certification of a nonaccredited program.    70.6(1)  Unless conditionally issued, suspended or revoked, certification of a program shall expire at the end of the time period specified on the certificate.  70.6(2)  The department shall send recertification application materials to each program at least 120 calendar days prior to expiration of the program’s certification.Related ARC(s): 8177B481—70.7(231D)  Recertification process for a nonaccredited program.   To obtain recertification, a program shall:  70.7(1)  Submit one copy of the completed application, including the information required in rule 481—70.4(231D), associated documentation, and the recertification fee as listed in Iowa Code section 231D.4 to the department at the address stated in subrule 70.3(1) at least 90 calendar days prior to the expiration of the program’s certification. The program need not submit policies and procedures that have been previously submitted to the department and remain unchanged. The program shall provide a list of the policies and procedures that have been previously submitted and are not being resubmitted.  70.7(2)  Submit additional documentation that each of the following has been inspected by a qualified professional and found to be maintained in conformance with the manufacturer’s recommendations and nationally recognized standards: heating system, cooling system, water heater, electrical system, plumbing, sewage system, artificial lighting, and ventilation system; and, if located on site, garbage disposal, kitchen appliances, washing machines and dryers, and elevators.Related ARC(s): 8177B481—70.8(231D)  Notification of recertification for a nonaccredited program.    70.8(1)  The department shall review the application and associated documentation and fees. If the application is incomplete, the department shall contact the program to request the additional information. After all finalized documentation is received, including state fire marshal approval, the department shall determine the program’s compliance with applicable requirements.  70.8(2)  The department shall conduct a monitoring of the program between 60 and 90 days prior to expiration of the program’s certification.  70.8(3)  If a regulatory insufficiency is identified as a result of the monitoring, the process in rule 481—67.10(17A,231B,231C,231D) shall be followed.  70.8(4)  If no regulatory insufficiency is identified as a result of the monitoring, the department shall issue a report of the findings with the final recertification decision.  70.8(5)  If the decision is to recertify, the department shall issue the program a two-year certification effective from the date of the expiration of the previous certification.  70.8(6)  If the decision is to deny recertification, the department shall issue a notice of denial and provide the program the opportunity for a hearing pursuant to rule 481—67.13(17A,231B,231C,231D).  70.8(7)  If the department is unable to recertify a program through no fault of the program, the department shall issue to the program a time-limited extension of certification of no longer than one year.Related ARC(s): 8177B481—70.9(231D)  Certification or recertification of an accredited program—application process.    70.9(1)  An applicant for certification or recertification of a program accredited by a recognized accrediting entity shall:  a.  Submit a completed application packet obtained from the department. Application materials may be obtained from the health facilities division Web site at https://dia-hfd.iowa.gov/DIA_HFD/Home.do; by mail from the Department of Inspections and Appeals, Adult Services Bureau, Lucas State Office Building, Third Floor, 321 E. 12th Street, Des Moines, Iowa 50319-0083; or by telephone at (515)281-6325.  b.  Submit a copy of the current accreditation outcome from the recognized accrediting entity.  c.  Apply for certification or recertification within 90 calendar days following verification of compliance with the requirements of the state fire marshal division of the department of public safety pursuant to this chapter.  d.  Submit the appropriate fees as set forth in Iowa Code section 231D.4.  70.9(2)  The department shall not consider an application until it is complete and includes all supporting documentation and the appropriate fees.Related ARC(s): 8177B, 2463C481—70.10(231D)  Certification or recertification of an accredited program—application content.  An application for certification or recertification of an accredited program shall include the following:  70.10(1)  A list that includes the names, addresses and percentage of stock, shares, partnership or other equity interest of all officers, members of the board of directors, and trustees, as well as stockholders, partners or any individuals who have greater than a 10 percent equity interest in each of the following, as applicable:  a.  The real estate owner or lessor;  b.  The lessee; and  c.  The management company responsible for the day-to-day operation of the program.The program shall notify the department of any changes in the list no later than ten working days after the effective date of the change.  70.10(2)  A statement disclosing whether the individuals listed in subrule 70.10(1) have been convicted of a felony or an aggravated or serious misdemeanor or found to be in violation of the child abuse or dependent adult abuse laws of any state.  70.10(3)  A statement disclosing whether any of the individuals listed in subrule 70.10(1) have or have had an ownership interest in an adult day services program, assisted living program, elder group home, home health agency, licensed health care facility as defined under Iowa Code section 135C.1, or licensed hospital as defined under Iowa Code section 135B.1, which has been closed in any state due to removal of program, agency, or facility licensure or certification or due to involuntary termination from participation in either the Medicaid or Medicare program; or have been found to have failed to provide adequate protection or services to prevent abuse or neglect of residents, patients, tenants or participants.  70.10(4)  A copy of the current accreditation outcome from the recognized accrediting entity.Related ARC(s): 8177B, 1927C481—70.11(231D)  Initial certification process for an accredited program.    70.11(1)  Within 20 working days of receiving all finalized documentation, including state fire marshal approval, the department shall determine and notify the accredited program whether the accredited program meets applicable requirements and whether certification will be issued.  70.11(2)  If the decision is to certify, a certification shall be issued for the term of the accreditation not to exceed three years, unless the certification is conditionally issued, suspended or revoked by either the department or the recognized accrediting entity.  70.11(3)  If the decision is to deny certification, the department shall provide the applicant an opportunity for hearing in accordance with rule 481—67.13(17A,231B,231C,231D).  70.11(4)  Unless conditionally issued, suspended or revoked, certification for a program shall expire at the end of the time period specified on the certificate.Related ARC(s): 8177B481—70.12(231D)  Recertification process for an accredited program.    70.12(1)  The department shall send recertification application materials to each program at least 120 calendar days prior to expiration of the program’s certification.  70.12(2)  To obtain recertification, an accredited program shall submit one copy of the completed application, associated documentation, and the administrative fee as stated in Iowa Code section 231D.4 to the department at the address stated in subrule 70.9(1) at least 90 calendar days prior to the expiration of the program’s certification.  70.12(3)  Within 20 working days of receiving all finalized documentation, including state fire marshal approval, the department shall determine the program’s compliance with applicable requirements and make a recertification decision.  70.12(4)  The department shall notify the accredited program within 10 working days of the final recertification decision.  a.  If the decision is to recertify, a full certification shall be issued for the term of the accreditation not to exceed three years, unless the certification is conditionally issued, suspended or revoked by either the department or the recognized accrediting entity.  b.  If the decision is to deny recertification, the department shall provide the applicant an opportunity for hearing in accordance with rule 481—67.13(17A,231B,231C,231D).  70.12(5)  If the department is unable to recertify a program through no fault of the program, the department shall issue to the program a time-limited extension of certification of no longer than one year.Related ARC(s): 8177B481—70.13(231D)  Listing of all certified programs.  The department shall maintain a list of all certified programs, which is available online at https://dia-hfd.iowa.gov/DIA_HFD/Home.do, under the “Entities Book” tab.Related ARC(s): 8177B481—70.14(231D)  Recognized accrediting entity.    70.14(1)  The department designates CARF as a recognized accrediting entity for programs.  70.14(2)  To apply for designation by the department as a recognized accrediting entity for programs, an accrediting entity shall submit a letter of request, and its standards shall, at minimum, meet the applicable requirements for programs.  70.14(3)  The designation shall remain in effect for as long as the accreditation standards continue to meet, at minimum, the applicable requirements for programs.  70.14(4)  An accrediting entity shall provide annually to the department, at no cost, a current edition of the applicable standards manual and survey preparation guide, and training thereon, within 120 working days after the publications are released.Related ARC(s): 8177B481—70.15(231D)  Requirements for an accredited program.  Each accredited program that is certified by the department shall:  70.15(1)  Provide the department a copy of all survey reports including outcomes, quality improvement plans and annual conformance to quality reports generated or received, as applicable, within ten working days of receipt of the reports.  70.15(2)  Notify the department by the most expeditious means possible of all credible reports of alleged improper or inappropriate conduct or conditions within the program and any actions taken by the accrediting entity with respect thereto.  70.15(3)  Notify the department immediately of the expiration, suspension, revocation or other loss of the program’s accreditation.Related ARC(s): 8177B481—70.16(231D)  Maintenance of program accreditation.    70.16(1)  An accredited program shall continue to be recognized for certification by the department if both of the following requirements are met:  a.  The program complies with the requirements outlined in rule 481—70.15(231D).  b.  The program maintains its voluntary accreditation status for the duration of the time-limited certification period.  70.16(2)  A program that does not maintain its voluntary accreditation status must become certified by the department prior to any lapse in accreditation.  70.16(3)  A program that does not maintain its voluntary accreditation status and is not certified by the department prior to any lapse in voluntary accreditation shall cease operation as a program.Related ARC(s): 8177B481—70.17(231D)  Change of ownership—notification to the department.    70.17(1)  Certification, unless conditionally issued, suspended or revoked, may be transferable. If the program’s certification has been conditionally issued, the department must approve a change of ownership prior to the transfer of the certification.  70.17(2)  In order to transfer certification, the applicant must:   a.  Meet the requirements of the rules, regulations and standards contained in Iowa Code chapter 231D and 481—Chapter 67 and this chapter; and  b.  At least 30 days prior to the change of ownership of the program, make application on forms provided by the department.  70.17(3)  The department may conduct a monitoring within 90 days following a change in the program’s ownership to ensure that the program complies with applicable requirements. If a regulatory insufficiency is found, the department shall take any necessary enforcement action authorized by applicable requirements.Related ARC(s): 1927C481—70.18(231D)  Plan reviews of a building for a new program.    70.18(1)  Before a building is constructed or remodeled for use in a new program, the state fire marshal division of the department of public safety shall review the blueprints for compliance with requirements pursuant to this chapter. Construction or remodeling includes new construction, remodeling of any part of an existing building, addition of a new wing or floor to an existing building, or conversion of an existing building.  70.18(2)  A program applicant shall submit blueprints wet-sealed by an Iowa-licensed architect or Iowa-licensed engineer and the blueprint plan review fee as stated in Iowa Code section 231D.4 to the Department of Public Safety, State Fire Marshal Division, 215 E. 7th Street, Third Floor, Des Moines, Iowa 50319.  70.18(3)  Failure to submit the blueprint plan review fee with the blueprints shall result in delay of the blueprint plan review until the fee is received.  70.18(4)  The state fire marshal division of the department of public safety shall review the blueprints and notify the Iowa-licensed architect or Iowa-licensed engineer in writing regarding the status of compliance with requirements.  70.18(5)  The Iowa-licensed architect or Iowa-licensed engineer shall respond to the state fire marshal division of the department of public safety to state how any noncompliance will be resolved.  70.18(6)  Upon final notification by the state fire marshal division of the department of public safety that the blueprints meet structural and life safety requirements, construction or remodeling of the building may commence.  70.18(7)  The state fire marshal division of the department of public safety shall schedule an on-site visit of the building site with the contractor, or Iowa-licensed architect or Iowa-licensed engineer, during the construction or remodeling process to ensure compliance with the approved blueprints. Any noncompliance must be resolved prior to approval for certification.Related ARC(s): 8177B, 2463C481—70.19(231D)  Plan review prior to the remodeling of a building for a certified program.    70.19(1)  Before a building for a certified program is remodeled, the state fire marshal division of the department of public safety shall review the blueprints for compliance with requirements set forth in rule 481—70.35(231D). Remodeling includes modification of any part of an existing building, addition of a new wing or floor to an existing building, or conversion of an existing building.  70.19(2)  A certified program shall submit blueprints wet-sealed by an Iowa-licensed architect or Iowa-licensed engineer and the blueprint plan review fee as stated in Iowa Code section 231D.4 to the Department of Public Safety, State Fire Marshal Division, 215 E. 7th Street, Third Floor, Des Moines, Iowa 50319.  70.19(3)  Failure to submit the blueprint plan review fee with the blueprints shall result in delay of the blueprint plan review until the fee is received.  70.19(4)  The state fire marshal division of the department of public safety shall review the blueprints within 20 working days of receipt and immediately notify the Iowa-licensed architect or Iowa-licensed engineer in writing regarding the status of compliance with requirements.  70.19(5)  The Iowa-licensed architect or Iowa-licensed engineer shall respond to the state fire marshal division of the department of public safety in 20 working days to state how any noncompliance will be resolved.  70.19(6)  Upon final notification by the state fire marshal division of the department of public safety that the blueprints meet structural and life safety requirements, remodeling of the building may commence.  70.19(7)  The state fire marshal division of the department of public safety shall schedule an on-site visit of the building with the contractor, or Iowa-licensed architect or Iowa-licensed engineer, during the remodeling process to ensure compliance with the approved blueprints. Any noncompliance must be resolved prior to approval for continued certification or recertification of the program.Related ARC(s): 8177B, 2463C481—70.20(231D)  Cessation of program operation.    70.20(1)  If a certified program ceases operation, which includes seeking decertification, at any time prior to expiration of the program’s certification, the program shall submit the certificate to the department. The program shall provide, at least 90 days in advance of cessation, which includes seeking decertification, unless there is some type of emergency, written notification to the department of the date on which the program will cease operation, which includes seeking decertification.  70.20(2)  If a certified program plans to cease operation, which includes seeking decertification, at the time the program’s certification expires, the program shall provide written notice of this fact to the department at least 90 days prior to expiration of the certification.  70.20(3)  At the time a program decides to cease operation, which includes seeking decertification, the program shall submit a plan to the department and make arrangements for the safe and orderly discharge or transition of all participants within the 90-day period specified by subrule 70.20(2).  70.20(4)  The department may conduct a monitoring during the 90-day period to ensure the safety of participants during the discharge process or transition process.  70.20(5)  The department may conduct an on-site visit to verify that the program has ceased operation as a certified program in accordance with the notice provided by the program.Related ARC(s): 8177B481—70.21(231D)  Contractual agreement.    70.21(1)  The contractual agreement shall be in 12-point type or larger, shall be written in plain language using commonly understood terms and shall be easy for the participant or the participant’s legal representative to understand.  70.21(2)  In addition to the requirements of Iowa Code section 231D.17, the written contractual agreement shall include, but not be limited to, the following information in the body of the agreement or in the supporting documents and attachments:  a.  The telephone number for filing a complaint with the department.  b.  The telephone number for reporting dependent adult abuse.  c.  A copy of the program’s statement on participants’ rights.  d.  A statement that the program will notify the participant at least 90 days in advance of any planned program cessation, which includes voluntary decertification, except in cases of emergency.  e.  A copy of the program’s admission and discharge criteria.  70.21(3)  The contractual agreement shall be reviewed and updated as necessary to reflect any change in services or financial arrangements.  70.21(4)  A copy of the contractual agreement shall be provided to the participant or the participant’s legal representative, if any, and a copy shall be kept by the program.  70.21(5)  A copy of the most current contractual agreement shall be made available to the general public upon request. The basic marketing material shall include a statement that a copy of the contractual agreement is available to all persons upon request.Related ARC(s): 8177B481—70.22(231D)  Evaluation of participant.    70.22(1)    Evaluation prior to participation.  A program shall evaluate each prospective participant’s functional, cognitive and health status prior to the participant’s signing the contractual agreement and participating in the program, with the exception of visiting day(s), to determine the participant’s eligibility for the program, including whether the services needed are available. The cognitive evaluation shall be appropriate to the population served. When the cognitive evaluation indicates moderate cognitive decline and risk, the Global Deterioration Scale shall be used at all subsequent intervals, if applicable. If the participant subsequently returns to the participant’s mildly cognitively impaired state, the program may discontinue the GDS and revert to a scored cognitive screening tool. The evaluation shall be conducted by a health care professional or human service professional.  70.22(2)    Evaluation within 30 days of participation and with significant change.  A program shall evaluate each participant’s functional, cognitive and health status within 30 days of the participant’s beginning participation in the program. A program shall also evaluate each participant’s functional, cognitive and health status as needed with significant change, but not less than annually, to determine the participant’s continued eligibility for the program and to determine any changes to services needed. The evaluation shall be conducted by a health care professional or human service professional. A licensed practical nurse may complete the evaluation via nurse delegation when the participant has not exhibited a significant change.  70.22(3)    Requirements for visiting day(s).  Evaluation of the participant is not required during visiting day(s), but the program shall provide the participant or the participant’s legal representative with a written explanation of the expectations for the visiting day(s).Related ARC(s): 8177B481—70.23(231D)  Criteria for admission and retention of participants.    70.23(1)    Persons who may not be admitted or retained.  A program shall not knowingly admit or retain a participant who:  a.  Requires routine, three-person assistance with standing, transfer or evacuation; or  b.  Is dangerous to self or other participants or staff, including but not limited to a participant who:  (1)  Despite intervention chronically elopes, is sexually or physically aggressive or abusive, or displays unmanageable verbal abuse; or  (2)  Is in an acute stage of alcoholism, drug addiction, or mental illness; or  c.  Is under the age of 18.  70.23(2)    Disclosure of additional participation and discharge criteria.  A program may have additional participation or discharge criteria if the criteria are disclosed in the written contractual agreement prior to the participant’s participation in the program.  70.23(3)    Assistance with discharge from the program.  A program shall provide assistance to a participant and the participant’s legal representative, if applicable, to ensure a safe and orderly discharge from the program when the participant exceeds the program’s criteria for admission and retention.Related ARC(s): 8177B, 1547C481—70.24(231D)  Involuntary discharge from the program.    70.24(1)    Program initiation of discharge.  If a program initiates the involuntary discharge of a participant and the action is not the result of a monitoring, including a complaint investigation or program-reported incident investigation, by the department and if the participant or participant’s legal representative contests the discharge, the following procedures shall apply:  a.  The program shall notify the participant or participant’s legal representative, in accordance with the contractual agreement, of the need to discharge the participant and of the reason for the discharge.  b.  If, following the internal appeal process, the program upholds the discharge decision, the participant or participant’s legal representative may utilize other remedies authorized by law to contest the discharge.  70.24(2)    Discharge pursuant to results of monitoring or complaint or program-reported incident investigation by the department.  If one or more participants are identified as exceeding the admission and retention criteria for participants and need to be discharged as a result of a monitoring or a complaint or program-reported incident investigation conducted by the department, the following procedures shall apply:  a.    Notification of the program.  Within 20 working days of the monitoring or complaint or program-reported incident investigation, the department shall notify the program, in writing, of the identification of any participant who exceeds admission and retention criteria.  b.    Notification of others.  Each identified participant, the participant’s legal representative, if applicable, and other providers of services to the participant shall be notified of their opportunity to provide responses including: specific input, written comment, information, and documentation directly addressing any agreement or disagreement with the identification. All responses shall be provided to the department within 10 days of receipt of the notice.  c.    Program agreement with the department’s finding.  If the program agrees with the department’s finding and the program begins involuntary discharge proceedings, the program’s internal appeal process in subrule 70.24(1) shall be utilized for appeals.  d.    Program disagreement with the department’s finding.  If the program does not agree with the department’s finding that the participant exceeds admission and retention criteria, the program may collect and submit all responses to the department, including those from other interested parties. In the program’s response, the program shall identify the participant, list the known responses from others, and note the program’s agreement or disagreement with the responses from others. The program’s response shall be submitted to the department within 10 working days of the receipt of the notice. Submission of a response does not eliminate the applicable requirements, including submission of a plan of correction under 481—subrule 67.10(5). Other persons may also submit information directly to the department.  (1)  Consideration of response. Within 10 working days of receipt of the program’s response for each identified participant, the department shall consider the response and make a final finding regarding the continued retention of a participant.  (2)  Amending the regulatory insufficiency. If the department’s determination is to amend the regulatory insufficiency based on the response, the department shall modify the report of findings.  (3)  Retaining regulatory insufficiency. If the department retains the regulatory insufficiency, the department shall review the plan of correction in accordance with this chapter and 481—Chapter 67. The department shall notify the program of the opportunity to appeal the report findings as they relate to the admission and retention decision.  (4)  Effect of the filing of an appeal. If an appeal is filed, the participant who exceeds admission and retention criteria shall be allowed to continue to participate in the program until all administrative appeals have been exhausted. Appeals filed that relate to the participant’s exceeding admission and retention criteria shall be heard within 30 days of receipt, and appropriate services to meet the participant’s needs shall be provided during that period of time.  (5)  Request for waiver of criteria for retention of a participant in a program. To allow a participant to continue to participate in the program, the program may request a waiver of criteria for retention of a participant pursuant to rule 481—67.7(231B,231C,231D) from the department within 10 working days of the receipt of the report.Related ARC(s): 8177B481—70.25(231D)  Participant documents.    70.25(1)  Documentation for each participant shall be maintained by the program and shall include:  a.  A participation record including the participant’s name, birth date, and home address; identification numbers; date of beginning participation; name, address and telephone number of health professional(s); diagnosis; and names, addresses and telephone numbers of family members, friends or other designated people to contact in the event of illness or an emergency;  b.  Application forms;  c.  The initial evaluations and updates;  d.  A nutritional assessment as necessary;  e.  The initial individual service plan and updates;  f.  Signed authorizations for permission to release medical information, photographs, or other media information as necessary;  g.  A signed authorization for the participant to receive emergency medical care as necessary;  h.  A signed managed risk policy and signed managed risk consensus agreements, if any;  i.  When any personal or health-related care is delegated to the program, the medical information sheet; documentation of health professionals’ orders, such as those for treatment, therapy, and medication; and nurses’ notes written by exception;  j.  Medication lists, which shall be maintained in conformance with 481—subrule 67.5(4);  k.  Advance health care directives as applicable;  l.  A complete copy of the participant’s contractual agreement, including any updates;  m.  A written acknowledgment that the participant or the participant’s legal representative, if applicable, has been fully informed of the participant’s rights;  n.  A copy of guardianship, durable power of attorney for health care, power of attorney, or conservatorship or other documentation of a legal representative;  o.  Incident reports involving the participant, including but not limited to those related to medication errors, accidents, falls, and elopements (such reports shall be maintained by the program but need not be included in the participant’s medical record);  p.  A copy of waivers of admission or retention criteria, if any;  q.  When the participant is unable to advocate on the participant’s own behalf or the participant has multiple service providers, including hospice care providers, accurate documentation of the completion of routine personal or health-related care is required on task sheets. If tasks are doctor-ordered, the tasks shall be part of the medication administration records (MARs); and  r.  Authorizations for the release of information, if any.  70.25(2)  The program records relating to a participant shall be retained for a minimum of three years after the discharge or death of the participant.  70.25(3)  All records shall be protected from loss, damage and unauthorized use.Related ARC(s): 8177B481—70.26(231D)  Service plans.    70.26(1)  A service plan shall be developed for each participant based on the evaluations conducted in accordance with subrules 70.22(1) and 70.22(2) and shall be designed to meet the specific service needs of the individual participant. The service plan shall subsequently be updated at least annually and whenever changes are needed.  70.26(2)  Prior to the participant’s signing the contractual agreement and participating in the program, a preliminary service plan shall be developed by a health care professional or human service professional in consultation with the participant and, at the participant’s request, with other individuals identified by the participant, and, if applicable, with the participant’s legal representative. All persons who develop the plan and the participant or the participant’s legal representative shall sign the plan.  70.26(3)  When a participant needs personal care or health-related care, the service plan shall be updated within 30 days of the participant’s participation and as needed with significant change, but not less than annually.  a.  If a significant change triggers the review and update of the service plan, the updated service plan shall be signed and dated by all parties.  b.  If a significant change does not exist, the program may, after nurse review, add minor discretionary changes to the service plan without a comprehensive evaluation and without obtaining signatures on the service plan.  c.  If a significant change relates to a recurring or chronic condition, a previous evaluation and service plan of the recurring condition may be utilized without new signatures being obtained. For example, with chronic exacerbation of a urinary tract infection, nurse review is adequate to institute the previously written evaluation and service plan.  70.26(4)  The service plan shall be individualized and shall indicate, at a minimum:  a.  The participant’s identified needs and preferences for assistance;  b.  Any services and care to be provided pursuant to the contractual agreement;  c.  The service provider(s), if other than the program, including but not limited to providers of hospice care, home health care, occupational therapy, and physical therapy; and  d.  For participants who are unable to plan their own activities, including participants with dementia, planned and spontaneous activities based on the participant’s abilities and personal interests.Related ARC(s): 8177B481—70.27(231D)  Nurse review.  If a participant does not receive personal or health-related care, but an observed significant change in the participant’s condition occurs, a nurse review shall be conducted. If a participant receives personal or health-related care, the program shall provide for a registered nurse or a licensed practical nurse via nurse delegation:  70.27(1)  To monitor, at least every 90 days, or after a significant change in the participant’s condition, any participant who receives program-administered prescription medications for adverse reactions to the medications and to make appropriate interventions or referrals, and to ensure that the prescription medication orders are current and that the prescription medications are administered consistent with such orders; and  70.27(2)  To ensure that health care professionals’ orders are current for participants who receive health care professional-directed care from the program; and  70.27(3)  To assess and document the health status of each participant, to make recommendations and referrals as appropriate, and to monitor progress relating to previous recommendations at least every 90 days and whenever there are changes in the participant’s health status; and  70.27(4)  To provide the program with written documentation of the activities under the service plan, as set forth in rule 481—70.26(231D), showing the time, date and signature.Note: Refer to Table A at the end of this chapter. If the program does not provide personal or health-related care to a participant, nurse review is not required.Related ARC(s): 8177B481—70.28(231D)  Food service.    70.28(1)  The program shall provide or coordinate with other community providers to provide a hot or other appropriate meal(s) at least once a day or shall make arrangements for the availability of meals, unless otherwise noted in the contractual agreement.  70.28(2)  Meals and snacks provided by the program but not prepared on site shall be obtained from or provided by an entity that meets the standards of state and local health laws and ordinances concerning the preparation and serving of food.  70.28(3)  Menus shall be planned to provide the following percentage of the daily recommended dietary allowances as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences based on the number of meals provided by the program:  a.  A minimum of 33⅓ percent if the program provides one meal per day;  b.  A minimum of 66⅔ percent if the program provides two meals per day; and  c.  One hundred percent if the program provides three meals per day.  70.28(4)  Therapeutic diets may be provided by a program. If therapeutic diets are provided, they shall be prescribed by a physician, physician assistant, or advanced registered nurse practitioner. A current copy of the Iowa Simplified Diet Manual published by the Iowa Dietetic Association shall be available and used in the planning and serving of therapeutic diets. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and for reviewing procedures for food preparation and service for therapeutic diets.  70.28(5)  Personnel who are employed by or contract with the program and who are responsible for food preparation or service, or both food preparation and service, shall have an orientation on sanitation and safe food handling prior to handling food and shall have annual in-service training on food protection.  a.  In addition to the requirements above, a minimum of one person directly responsible for food preparation shall have successfully completed a state-approved food protection program by:  (1)  Obtaining certification as a dietary manager; or  (2)  Obtaining certification as a food protection professional; or  (3)  Successfully completing an ANSI-accredited certified food protection manager program meeting the requirements for a food protection program included in the Food Code adopted pursuant to Iowa Code chapter 137F. Another program may be substituted if the program’s curriculum includes substantially similar competencies to a program that meets the requirements of the Food Code and the provider of the program files with the department a statement indicating that the program provides substantially similar instruction as it relates to sanitation and safe food handling.  b.  If the person is in the process of completing a course or certification listed in paragraph “a,” the requirement relating to completion of a state-approved food protection program shall be considered to have been met.  70.28(6)  Programs engaged in the preparation and service of meals and snacks shall meet the standards of state and local health laws and ordinances pertaining to the preparation and service of food and shall be licensed pursuant to Iowa Code chapter 137F. The department will not require the program to be licensed as a food establishment if the program limits food activities to the following:  a.  All main meals and planned menu items must be prepared offsite and transferred to the program kitchen for service to participants.  b.  Baked goods that do not require temperature control for safety and single-service juice or milk may be stored in the program’s kitchen and provided as part of a continental breakfast.  c.  Ingredients used for food-related activities with participants may be stored in the program’s kitchen. Participant activities may include the preparation and cooking of food items in the program’s kitchen if the activity occurs on an irregular or sporadic basis and the items prepared are not part of the program’s menu.  d.  Appropriately trained staff may prepare in the program’s kitchen individual quantities of participant-requested menu-substitution food items that require limited or no preparation, such as peanut butter or cheese sandwiches or a single-service can of soup. The food items necessary to prepare the menu substitution may be stored in the program’s kitchen. These food items may not be cooked in the program’s kitchen but may be reheated in a microwave. A two- or four-slice toaster may be used for participant-requested menu-substitution items, but no bare-hand contact is permitted.  e.  Warewashing may be done in the program’s kitchen as long as the program utilizes a commercial dishwasher and documents daily testing of sanitizer chemical ppm and proper water temperatures. Verification by the department of these practices may be conducted during on-site visits.  70.28(7)  Programs may have an on-site dietitian. Programs may secure menus and a dietitian through other methods.Related ARC(s): 8177B, 1376C, 2463C481—70.29(231D)  Staffing.  In addition to the general staffing requirements in rule 481—67.9(231B,231C,231D), the following requirements apply to staffing in programs.  70.29(1)  No fewer than two staff persons who monitor participants shall be awake and on duty during all hours of operation when two or more participants are participating in the program.  70.29(2)  The owner or management corporation of the program is responsible for ensuring that all personnel employed by or contracting with the program receive training appropriate to assigned tasks and target population.  70.29(3)  A program that serves one or more participants with cognitive disorders or dementia shall follow written procedures that address how the program will respond to the emergency needs of the participants.  70.29(4)  The program shall notify the department in writing within ten business days of a change in the program’s manager.Related ARC(s): 8177B, 1927C481—70.30(231D)  Dementia-specific education for program personnel.    70.30(1)  All personnel employed by or contracting with a dementia-specific program shall receive a minimum of eight hours of dementia-specific education and training within 30 days of either employment or the beginning date of the contract, as applicable.  70.30(2)  The dementia-specific education or training shall include, at a minimum, the following:  a.  An explanation of Alzheimer’s disease and related disorders;  b.  The program’s specialized dementia care philosophy and program;  c.  Skills for communicating with persons with dementia;  d.  Skills for communicating with family and friends of persons with dementia;  e.  An explanation of family issues such as role reversal, grief and loss, guilt, relinquishing the care-giving role, and family dynamics;  f.  The importance of planned and spontaneous activities;  g.  Skills in providing assistance with instrumental activities of daily living;  h.  The importance of the service plan and social history information;  i.  Skills in working with challenging participants;  j.  Techniques for simplifying, cueing, and redirecting;  k.  Staff support and stress reduction; and  l.  Medication management and nonpharmacological interventions.  70.30(3)  All personnel employed by or contracting with a dementia-specific program shall receive a minimum of two hours of dementia-specific continuing education annually. Direct-contact personnel shall receive a minimum of eight hours of dementia-specific continuing education annually.  70.30(4)  An employee or contractor who provides documentation of completion of a dementia-specific education or training program within the past 12 months shall be exempt from the education and training requirement of subrule 70.30(1).  70.30(5)  Dementia-specific training shall include hands-on training and may include any of the following: classroom instruction, Web-based training, and case studies of participants in the program.Related ARC(s): 8177B481—70.31(231D)  Managed risk policy and managed risk consensus agreements.  The program shall have a managed risk policy. The managed risk policy shall be provided to the participant along with the contractual agreement. The managed risk policy shall include the following:  70.31(1)  An acknowledgment of the shared responsibility for identifying and meeting the needs of the participant and the process for managing risk and for upholding participant autonomy when participant decision making results in poor outcomes for the participant or others; and  70.31(2)  A consensus-based process to address specific risk situations. Program staff and the participant shall participate in the process. The result of the consensus-based process may be a managed risk consensus agreement. The managed risk consensus agreement shall include the signature of the participant and the signatures of all others who participated in the process. The managed risk consensus agreement shall be included in the participant’s file.Related ARC(s): 8177B481—70.32(231D)  Life safety—emergency policies and procedures and structural safety requirements.    70.32(1)  The program shall submit to the department and follow written emergency policies and procedures, which shall include the following:  a.  An emergency plan, which shall include procedures for natural disasters (identify where the plan is located for easy reference);  b.  Fire safety procedures;  c.  Other general or personal emergency procedures;  d.  Provisions for amending or revising the emergency plan;  e.  Provisions for periodic training of all employees;  f.  Procedures for fire drills;  g.  Regulations regarding smoking;  h.  Monitoring and testing of smoke-control systems;  i.  Participant evacuation procedures; and  j.  Procedures for reporting and documentation.  70.32(2)  An operating alarm system shall be connected to each exit door in a dementia-specific program. A program serving a person(s) with cognitive disorder or dementia, whether in a general or dementia-specific setting, shall have:  a.  Written procedures regarding alarm systems and appropriate staff response when a participant’s service plan indicates a risk of elopement or a participant exhibits wandering behavior.  b.  Written procedures regarding appropriate staff response if a participant with cognitive disorder or dementia is missing.  c.  The program shall obtain approval from the state fire marshal division before the installation of any delayed-egress specialized locking systems.  70.32(3)  The program’s structure and procedures and the facility in which a program is located shall meet the requirements adopted for adult day services programs in administrative rules promulgated by the state fire marshal. Approval of the state fire marshal indicating that the building is in compliance with these requirements is necessary for certification of a program.  70.32(4)  The program shall have the means to control the maximum temperature of water at sources accessible by a participant to prevent scalding and shall control the maximum water temperature for participants with cognitive impairment or dementia or at a participant’s request.Related ARC(s): 8177B, 2463C481—70.33(231D)  Transportation.  When transportation services are provided directly or under contract with the program:  70.33(1)  The vehicle shall be accessible and appropriate to the participants who use it, with consideration for any physical disabilities and impairments.  70.33(2)  Every participant transported shall have a seat in the vehicle, except for a participant who remains in a wheelchair during transport.  70.33(3)  Vehicles shall have adequate seat belts and securing devices for ambulatory and wheelchair-using passengers.  70.33(4)  Wheelchairs shall be secured when the vehicle is in motion.  70.33(5)  During loading and unloading of a participant, the driver shall be in the proximate area of the participants in a vehicle.  70.33(6)  The driver shall have a valid and appropriate Iowa driver’s license or commercial driver’s license as required by law for the vehicle being utilized for transport. If the driver is licensed in another state, the license shall be valid and appropriate for the vehicle being utilized for transport. The driver shall meet any state or federal requirements for licensure or certification for the vehicle operated.  70.33(7)  Each vehicle shall have a first-aid kit, fire extinguisher, safety triangles and a device for two-way communication.Related ARC(s): 8177B481—70.34(231D)  Activities.    70.34(1)  The program shall provide appropriate activities for each participant. Activities shall reflect individual differences in age, health status, sensory deficits, lifestyle, ethnic and cultural beliefs, religious beliefs, values, experiences, needs, interests, abilities and skills by providing opportunities for a variety of types and levels of involvement.  70.34(2)  Activities shall be planned to support the participant’s service plan and shall be consistent with the program statement and participation policies.  70.34(3)  A written schedule of activities shall be developed at least monthly and made available to participants and their legal representatives.  70.34(4)  Participants shall be given the opportunity to choose their levels of participation in all activities offered in the program.Related ARC(s): 8177B481—70.35(231D)  Structural requirements.    70.35(1)  The structure, equipment and physical environment of the program shall be designed and operated to meet the needs of the participants. The building, grounds and equipment shall be well-maintained, clean, safe and sanitary.  70.35(2)  There shall be at least one toilet for every ten participants and staff members.  70.35(3)  Toilets and bathing and toileting appliances shall be equipped for use by participants with multiple disabilities.  70.35(4)  There shall be a ratio of at least one hand-washing sink for every two toilets. The sink(s) shall be proximate to the toilets. Hand-washing facilities shall be readily accessible to participants and staff.  70.35(5)  Shower and tub areas, if provided, shall be equipped with grab bars and slip-resistant surfaces.  70.35(6)  Signaling emergency call devices shall be installed or placed in all bathroom areas, restroom stalls and showers, if any.  70.35(7)  A telephone shall be available to participants to make and receive calls in a private manner and for emergency purposes.  70.35(8)  A storage area(s) shall be provided for storage of program supplies and participants’ possessions, which shall be stored in such a manner that, when not in use, will prevent personal injury to participants and staff.  70.35(9)  The program shall provide a separate area to permit privacy for evaluations and to isolate participants who become ill.  70.35(10)  The program shall meet other building and public safety codes, including rules pertaining to accessibility contained in the state building code in 661—Chapter 302 and provisions of the state building code relating to persons with disabilities.  70.35(11)  The program shall meet the requirements in subrule 70.32(4).Related ARC(s): 8177B, 2463C481—70.36(231D)  Identification of veteran’s benefit eligibility.    70.36(1)  Within 30 days of a participant’s participation in an adult day services program that receives reimbursement through the medical assistance program under Iowa Code chapter 249A, the program shall ask the participant or the participant’s personal representative whether the participant is a veteran or whether the participant is the spouse, widow or dependent of a veteran and shall document the response.  70.36(2)  If the program determines that the participant may be a veteran or the spouse, widow, or dependent of a veteran, the program shall report the participant’s name along with the name of the veteran, if applicable, as well as the name of the contact person for this information, to the Iowa department of veterans affairs. When appropriate, the program may also report such information to the Iowa department of human services.  70.36(3)  If a participant is eligible for benefits through the U.S. Department of Veterans Affairs or other third-party payor, the program first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A.Related ARC(s): 8177BThese rules are intended to implement Iowa Code chapter 231D.Table A
Related ARC(s): 8177B, 1376C, 1547C, 1927C, 2463C