CHAPTER 58NURSING FACILITIES[Prior to 7/15/87, Health Department Ch 58]48158.1(135C) Definitions. For the purpose of these rules, the following terms shall have the meaning indicated in this chapter. The definitions set out in Iowa Code section 135C.1 shall be considered to be incorporated verbatim in the rules. The use of the words “shall” and “must” indicates those standards are mandatory. The use of the words “should” and “could” indicates those standards are recommended.
"Accommodation" means the provision of lodging, including sleeping, dining, and living areas.
"Administrator" means a person licensed pursuant to Iowa Code chapter 147 who administers, manages, supervises, and is in general administrative charge of a nursing facility, whether or not such individual has an ownership interest in such facility, and whether or not the functions and duties are shared with one or more individuals.
"Ambulatory" means the condition of a person who immediately and without aid of another is physically or mentally capable of traveling a normal path to safety, including the ascent and descent of stairs.
"Basement" means that part of a building where the finish floor is more than 30 inches below the finish grade.
"Board" means the regular provision of meals.
"Chairfast" means capable of maintaining a sitting position but lacking the capacity of bearing own weight, even with the aid of a mechanical device or another individual.
"Communicable disease" means a disease caused by the presence of viruses or microbial agents within a person’s body, which agents may be transmitted either directly or indirectly to other persons.
"Department" means the state department of inspections and appeals.
"Distinct part" means a clearly identifiable area or section within a health care facility, consisting of at least a residential unit, wing, floor, or building containing contiguous rooms.
"Medication" means any drug including over-the-counter substances ordered and administered under the direction of the physician.
"Nonambulatory" means the condition of a person who immediately and without aid of another is not physically or mentally capable of traveling a normal path to safety, including the ascent and descent of stairs.
"Nourishing snack" is defined as a verbal offering of items, single or in combination, from the basic food groups. Adequacy of the “nourishing snack” will be determined both by resident interviews and by evaluation of the overall nutritional status of residents in the facility.
"Person directed care environment" means the provision of care and services provided in a facility that promotes decision making and choices by the resident, enhances the primary caregiver’s capacity to respond to each resident’s needs, and promotes a homelike environment. Examples of a person directed care environment include, but are not limited to, the Green House concept, the Eden alternative, service houses and neighborhoods.
"Personal care" means assistance with the activities of daily living which the recipient can perform only with difficulty. Examples are assistance in getting in and out of bed, assistance with personal hygiene and bathing, assistance with dressing, meal assistance, and supervision over medications which can be self-administered.
"Potentially hazardous food" means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting the rapid and progressive growth of infectious or toxigenic microorganisms, the growth and toxin production of clostridium botulinum, or in raw shell eggs, the growth of salmonella enteritidis. Potentially hazardous food includes an animal food (a food of animal origin) that is raw or heat-treated; a food of plant origin that is heat-treated or consists of raw seed sprouts; cut melons; and garlic and oil mixtures that are not acidified or otherwise modified at a food processing plant in a way that results in mixtures that do not support growth of bacteria.
"Primary care provider" means any of the following who provide primary care and meet certification standards:
- A physician who is a family or general practitioner or an internist.
- An advanced registered nurse practitioner.
- A physician assistant.
"Program of care" means all services being provided for a resident in a health care facility.
"Qualified intellectual disabilities professional" means a psychologist, physician, registered nurse, educator, social worker, physical or occupational therapist, speech therapist or audiologist who meets the educational requirements for the profession, as required in the state of Iowa, and having one year’s experience working with persons with an intellectual disability.
"Qualified nurse" means a registered nurse or a licensed practical nurse, as defined in Iowa Code chapter 152.
"Rate" means that daily fee charged for all residents equally and shall include the cost of all minimum services required in these rules and regulations.
"Responsible party" means the person who signs or cosigns the admission agreement required in 481—58.13(135C) or the resident’s guardian or conservator if one has been appointed. In the event that a resident does not have a guardian, conservator or other person signing the admission agreement, the term “responsible party” shall include the resident’s sponsoring agency, e.g., the department of human services, the U.S. Department of Veterans Affairs, religious groups, fraternal organizations, or foundations that assume responsibility and advocate for their client patients and pay for their health care.
"Restraints" means any chemical, manual method or physical or mechanical device, material, or equipment attached to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.
"Substantial evening meal" is defined as an offering of three or more menu items at one time, one of which includes a high protein such as meat, fish, eggs or cheese. The meal would represent no less than 20 percent of the day’s total nutritional requirements.Related ARC(s): 0766C, 1398C, 1752C48158.2(135C) Variances. Variances from these rules may be granted by the director of the department of inspections and appeals for good and sufficient reason when the need for variance has been established; no danger to the health, safety, or welfare of any resident results; alternate means are employed or compensating circumstances exist and the variance will apply only to an individual nursing facility. Variances will be reviewed at the discretion of the director of the department of inspections and appeals. 58.2(1) To request a variance, the licensee must: a. Apply for variance in writing on a form provided by the department; b. Cite the rule or rules from which a variance is desired; c. State why compliance with the rule or rules cannot be accomplished; d. Explain alternate arrangements or compensating circumstances which justify the variance; e. Demonstrate that the requested variance will not endanger the health, safety, or welfare of any resident. 58.2(2) Upon receipt of a request for variance, the director of inspections and appeals will: a. Examine the rule from which variance is requested to determine that the request is necessary and reasonable; b. If the request meets the above criteria, evaluate the alternate arrangements or compensating circumstances against the requirement of the rules; c. Examine the effect of the requested variance on the health, safety, or welfare of the residents; d. Consult with the applicant if additional information is required. 58.2(3) Based upon these studies, approval of the variance will be either granted or denied within 120 days of receipt.48158.3(135C) Application for licensure. 58.3(1) Initial application and licensing. In order to obtain an initial nursing facility license, for a nursing facility which is currently licensed, the applicant must: a. Meet all of the rules, regulations, and standards contained in 481—Chapters 58 and 61. Applicable exceptions found in rule 481—61.2(135C) shall apply based on the construction date of the facility. b. Submit a letter of intent and a written résumé of the resident care program and other services provided for departmental review and approval; c. Make application at least 30 days prior to the change of ownership of the facility on forms provided by the department; d. Submit a floor plan of each floor of the nursing facility, drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathrooms, and designation of the use to which room will be put and window and door location; e. Submit a photograph of the front and side elevation of the nursing facility; f. Submit the statutory fee for a nursing facility license; g. Meet the requirements of a nursing facility for which licensure application is made; h. Comply with all other local statutes and ordinances in existence at the time of licensure; i. Have a certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations. 58.3(2) In order to obtain an initial nursing facility license for a facility not currently licensed as a nursing facility, the applicant must: a. Meet all of the rules, regulations, and standards contained in 481—Chapters 58 and 61. Exceptions noted in 481—subrule 61.1(2) shall not apply; b. Submit a letter of intent and a written résumé of the resident care program and other services provided for departmental review and approval; c. Make application at least 30 days prior to the change of ownership of the facility on forms provided by the department; d. Submit a floor plan of each floor of the nursing facility, drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathrooms, and designation of the use to which room will be put and window and door locations; e. Submit a photograph of the front and side elevation of the nursing facility; f. Submit the statutory fee for a nursing facility license; g. Comply with all other local statutes and ordinances in existence at the time of licensure; h. Have a certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations. 58.3(3) Renewal application. In order to obtain a renewal of the nursing facility license, the applicant must: a. Submit the completed application form 30 days prior to annual license renewal date of nursing facility license; b. Submit the statutory license fee for a nursing facility with the application for renewal; c. Have an approved current certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules and regulations; d. Submit appropriate changes in the résumé to reflect any changes in the resident care program or other services. 58.3(4) Licenses are issued to the person or governmental unit which has responsibility for the operation of the facility and authority to comply with all applicable statutes, rules or regulations.The person or governmental unit must be the owner of the facility or, if the facility is leased, the lessee.48158.4(135C) General requirements. 58.4(1) The license shall be displayed in a conspicuous place in the facility which is viewed by the public. (III) 58.4(2) The license shall be valid only in the possession of the licensee to whom it is issued. 58.4(3) The posted license shall accurately reflect the current status of the nursing facility. (III) 58.4(4) Licenses expire one year after the date of issuance or as indicated on the license. 58.4(5) No nursing facility shall be licensed for more beds than have been approved by the health facilities construction review committee. 58.4(6) Each citation or a copy of each citation issued by the department for a class I or class II violation shall be prominently posted by the facility in plain view of the residents, visitors, and persons inquiring about placement in the facility. The citation or copy of the citation shall remain posted until the violation is corrected to the satisfaction of the department. (III)48158.5(135C) Notifications required by the department. The department shall be notified: 58.5(1) Within 48 hours, by letter, of any reduction or loss of nursing or dietary staff lasting more than seven days which places the staffing ratio below that required for licensing. No additional residents shall be admitted until the minimum staffing requirements are achieved; (III) 58.5(2) Of any proposed change in the nursing facility’s functional operation or addition or deletion of required services; (III) 58.5(3) Thirty days before addition, alteration, or new construction is begun in the nursing facility or on the premises; (III) 58.5(4) Thirty days in advance of closure of the nursing facility; (III) 58.5(5) Within two weeks of any change in administrator; (III) 58.5(6) When any change in the category of license is sought; (III) 58.5(7) Prior to the purchase, transfer, assignment, or lease of a nursing facility, the licensee shall: a. Inform the department of the pending sale, transfer, assignment, or lease of the facility; (III) b. Inform the department of the name and address of the prospective purchaser, transferee, assignee, or lessee at least 30 days before the sale, transfer, assignment, or lease is completed; (III) c. Submit a written authorization to the department permitting the department to release all information of whatever kind from the department’s files concerning the licensee’s nursing facility to the named prospective purchaser, transferee, assignee, or lessee. (III) 58.5(8) Pursuant to the authorization submitted to the department by the licensee prior to the purchase, transfer, assignment, or lease of a nursing facility, the department shall upon request send or give copies of all recent licensure surveys and of any other pertinent information relating to the facility’s licensure status to the prospective purchaser, transferee, assignee, or lessee; costs for such copies shall be paid by the prospective purchaser.48158.6(135C) Witness fees. Rescinded IAB 3/30/94, effective 5/4/94. See 481—subrule 50.6(4).48158.7(135C) Licenses for distinct parts. 58.7(1) Separate licenses may be issued for distinct parts of a health care facility which are clearly identifiable, containing contiguous rooms in a separate wing or building or on a separate floor of the facility and which provide care and services of separate categories. 58.7(2) The following requirements shall be met for a separate licensing of a distinct part: a. The distinct part shall serve only residents who require the category of care and services immediately available to them within that part; (III) b. The distinct part shall meet all the standards, rules, and regulations pertaining to the category for which a license is being sought; c. A distinct part must be operationally and financially feasible; d. A separate staff with qualifications appropriate to the care and services being rendered must be regularly assigned and working in the distinct part under responsible management; (III) e. Separately licensed distinct parts may have certain services such as management, building maintenance, laundry, and dietary in common with each other.48158.8(135C) Administrator. 58.8(1) Each nursing facility shall have one person in charge, duly licensed as a nursing home administrator or acting in a provisional capacity. (III) 58.8(2) A licensed administrator may act as an administrator for not more than two nursing facilities. a. The distance between the two facilities shall be no greater than 50 miles. (II) b. The administrator shall spend the equivalent of three full eight-hour days per week in each facility. (II) c. The administrator may be responsible for no more than 150 beds in total if the administrator is an administrator of more than one facility. (II) 58.8(3) The licensee may be the licensed nursing home administrator providing the licensee meets the requirements as set forth in these regulations and devotes the required time to administrative duties. Residency in the facility does not in itself meet the requirement. (III) 58.8(4) A provisional administrator may be appointed on a temporary basis by the nursing facility licensee to assume the administrative duties when the facility, through no fault of its own, has lost its administrator and has been unable to replace the administrator. a. No facility licensed under Iowa Code chapter 135C shall be permitted to have a provisional administrator for more than 12 consecutive months. b. The facility shall notify the department in writing within ten business days of the administrator’s appointment. The written notice shall include the estimated time frame for the appointment of the provisional administrator and the reason for the appointment of a provisional administrator. (III) c. The provisional administrator’s appointment must be approved by the board of examiners for nursing home administrators. The approval shall be confirmed in writing to the department. (III) 58.8(5) In the absence of the administrator, a responsible person shall be designated in writing to the department to be in charge of the facility. The administrator shall not be absent from the facility for more than 3 months without approval of the department. (III) The person designated shall: a. Be knowledgeable of the operation of the facility; (III) b. Have access to records concerned with the operation of the facility; (III) c. Be capable of carrying out administrative duties and of assuming administrative responsibilities; (III) d. Be at least 21 years of age; (III) e. Be empowered to act on behalf of the licensee during the administrator’s absence concerning the health, safety, and welfare of the residents; (III) f. Have had training to carry out assignments and take care of emergencies and sudden illness of residents. (III) 58.8(6) A licensed administrator in charge of two facilities shall employ an individual designated as a full-time assistant administrator for each facility. (III) 58.8(7) An administrator of only one facility shall be considered as a full-time employee. Full-time employment is defined as 40 hours per week. (III)Related ARC(s): 1398C, 2020C48158.9(135C) Administration. 58.9(1) The licensee shall: a. Assume the responsibility for the overall operation of the nursing facility; (III) b. Be responsible for compliance with all applicable laws and with the rules of the department; (III) c. Establish written policies, which shall be available for review, for the operation of the nursing facility. (III) 58.9(2) The administrator shall: a. Be responsible for the selection and direction of competent personnel to provide services for the resident care program; (III) b. Be responsible for the arrangement for all department heads to annually attend a minimum of ten contact hours of educational programs to increase skills and knowledge needed for the position; (III) c. Be responsible for a monthly in-service educational program for all employees and to maintain records of programs and participants; (III) d. Make available the nursing facility payroll records for departmental review as needed; (III) e. Be required to maintain a staffing pattern of all departments. These records must be maintained for six months and are to be made available for departmental review. (III)48158.10(135C) General policies. 58.10(1) There shall be written personnel policies in facilities of more than 15 beds to include hours of work, and attendance at educational programs. (III) 58.10(2) There shall be a written job description developed for each category of worker. The job description shall include title of job, job summary, qualifications (formal education and experience), skills needed, physical requirements, and responsibilities. (III) 58.10(3) There shall be written personnel policies for each facility. Personnel policies shall include the following requirements: a. Employees shall have a physical examination before employment. (I, II, III) b. Employees shall have a physical examination at least every four years. (I, II, III) c. Screening and testing for tuberculosis shall be conducted pursuant to 481—Chapter 59. (I, II, III) 58.10(4) Health certificates for all employees shall be available for review. (III) 58.10(5) Rescinded IAB 10/19/88, effective 11/23/88. 58.10(6) There shall be written policies for emergency medical care for employees and residents in case of sudden illness or accident which includes the individual to be contacted in case of emergency. (III) 58.10(7) The facility shall have a written agreement with a hospital for the timely admission of a resident who, in the opinion of the attending physician, requires hospitalization. (III) 58.10(8) Infection control program. Each facility shall have a written and implemented infection control and exposure control program with policies and procedures based on the guidelines issued by the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. (I, II, III) CDC guidelines are available at www.cdc.gov/ncidod/dhqp/index.html. 58.10(9) Infection control committee. Each facility shall establish an infection control committee of representative professional staff responsible for overall infection control in the facility. (III) a. The committee shall annually review and revise the infection control policies and procedures to monitor effectiveness and suggest improvement. (III) b. The committee shall meet at least quarterly, submit reports to the administrator, and maintain minutes in sufficient detail to document its proceedings and actions. (III) c. The committee shall monitor the health aspect and the environment of the facility. (III) 58.10(10) There shall be written policies for resident care programs and services as outlined in these rules. (III) 58.10(11) Prior to the removal of a deceased resident/patient from a facility, the funeral director or person responsible for transporting the body shall be notified by the facility staff of any special precautions that were followed by the facility having to do with the mode of transmission of a known or suspected communicable disease. (III)Related ARC(s): 0663C48158.11(135C) Personnel. 58.11(1) General qualifications. a. No person with a current record of habitual alcohol intoxication or addiction to the use of drugs shall serve in a managerial role of a nursing facility. (II) b. No person under the influence of alcohol or intoxicating drugs shall be permitted to provide services in a nursing facility. (II) c. No person shall be allowed to provide services in a facility if the person has a disease: (1) Which is transmissible through required workplace contact, (I, II, III) (2) Which presents a significant risk of infecting others, (I, II, III) (3) Which presents a substantial possibility of harming others, and (I, II, III) (4) For which no reasonable accommodation can eliminate the risk. (I, II, III)Refer to Guidelines for Infection Control in Hospital Personnel, Centers for Disease Control, U.S. Department of Health and Human Services, PB85-923402 to determine (1), (2), (3) and (4). d. Reserved. e. Individuals with either physical or mental disabilities may be employed for specific duties, but only if that disability is unrelated to that individual’s ability to perform the duties of the job. (III) f. Persons employed in all departments, except the nursing department of a nursing facility shall be qualified through formal training or through prior experience to perform the type of work for which they have been employed. Prior experience means at least 240 hours of full-time employment in a field related to their duties. Persons may be hired in laundry, housekeeping, activities and dietary without experience or training if the facility institutes a formal in-service training program to fit the job description in question and documents such as having taken place within 30 days after the initial hiring of such untrained employees. (III) g. Rescinded, effective 7/14/82. h. The health services supervisor shall be a qualified nurse as defined in these regulations. (II) i. Those persons employed as nurse’s aides, orderlies, or attendants in a nursing facility who have not completed the state-approved 75-hour nurse’s aide program shall be required to participate in a structured on-the-job training program of 20 hours’ duration to be conducted prior to any resident contact, except that contact required by the training program. This educational program shall be in addition to facility orientation. Each individual shall demonstrate competencies covered by the curriculum. This shall be observed and documented by an R.N. and maintained in the personnel file. No aide shall work independently until this is accomplished, nor shall the aide’s hours count toward meeting the minimum hours of nursing care required by the department. The curriculum shall be approved by the department. An aide who has completed the state-approved 75-hour course may model skills to be learned.Further, such personnel shall be enrolled in a state-approved 75-hour nurse’s aide program to be completed no later than six months from the date of employment. If the state-approved 75-hour program has been completed prior to employment, the on-the-job training program requirement is waived. The 20-hour course is in addition to the 75-hour course and is not a substitute in whole or in part. The 75-hour program, approved by the department, may be provided by the facility or academic institution.Newly hired aides who have completed the state-approved 75-hour course shall demonstrate competencies taught in the 20-hour course upon hire. This shall be observed and documented by an R.N. and maintained in the personnel file.All personnel administering medications must have completed the state-approved training program in medication administration. (II) j. There shall be an organized ongoing in-service educational and training program planned in advance for all personnel in all departments. (II, III) k. Nurse aides, orderlies or attendants in a nursing facility who have received training other than the Iowa state-approved program, must pass a challenge examination approved by the department of inspections and appeals. Evidence of prior formal training in a nursing aide, orderly, attendant, or other comparable program must be presented to the facility or institution conducting the challenge examination before the examination is given. The approved facility or institution, following department of inspections and appeals guidelines, shall make the determination of who is qualified to take the examination. Documentation of the challenge examinations administered shall be maintained. 58.11(2) Nursing supervision and staffing. a. Rescinded IAB 8/7/91, effective 7/19/91. b. Where only part-time nurses are employed, one nurse shall be designated health service supervisor. (III) c. A qualified nurse shall be employed to relieve the supervising nurses, including charge nurses, on holidays, vacation, sick leave, days off, absences or emergencies. Pertinent information for contacting such relief person shall be posted at the nurse’s station. (III) d. When the health service supervisor serves as the administrator of a facility 50 beds and over, a qualified nurse must be employed to relieve the health service supervisor of nursing responsibilities. (III) e. The department may establish on an individual facility basis the numbers and qualifications of the staff required in the facility using as its criteria the services being offered and the needs of the residents. (III) f. Additional staffing, above the minimum ratio, may be required by the department commensurate with the needs of the individual residents. (III) g. The minimum hours of resident care personnel required for residents needing intermediate nursing care shall be 2.0 hours per resident day computed on a seven-day week. A minimum of 20 percent of this time shall be provided by qualified nurses. If the maximum medical assistance rate is reduced below the 74th percentile, the requirement will return to 1.7 hours per resident per day computed on a seven-day week. A minimum of 20 percent of this time shall be provided by qualified nurses. (II, III) h. The health service supervisor’s hours worked per week shall be included in computing the 20 percent requirement. i. A nursing facility of 75 beds or more shall have a qualified nurse on duty 24 hours per day, seven days a week. (II, III) j. In facilities under 75 beds, if the health service supervisor is a licensed practical nurse, the facility shall employ a registered nurse, for at least four hours each week for consultation, who must be on duty at the same time as the health service supervisor. (II, III) (1) This shall be an on-site consultation and documentation shall be made of the visit. (III) (2) The registered nurse-consultant shall have responsibilities clearly outlined in a written agreement with the facility. (III) (3) Consultation shall include but not be limited to the following: counseling the health service supervisor in the management of the health services; (III) reviewing and evaluating the health services in determining that the needs of the residents are met; (II, III) conducting a review of medications at least monthly if the facility does not employ a registered nurse part-time. (II, III) k. Facilities with 75 or more beds must employ a health service supervisor who is a registered nurse. (II) l. There shall be at least two people who shall be capable of rendering nursing service, awake, dressed, and on duty at all times. (II) m. Physician’s orders shall be implemented by qualified personnel. (II, III) 58.11(3) Employee criminal record checks, child abuse checks and dependent adult abuse checks and employment of individuals who have committed a crime or have a founded abuse. The facility shall comply with the requirements found in Iowa Code section 135C.33 and rule 481—50.9(135C) related to completion of criminal record checks, child abuse checks, and dependent adult abuse checks and to employment of individuals who have committed a crime or have a founded abuse. (I, II, III)Related ARC(s): 0903C, 5421C48158.12(135C) Admission, transfer, and discharge. 58.12(1) General admission policies. a. No resident shall be admitted or retained in a nursing facility who is in need of greater services than the facility can provide. (II, III) b. No nursing facility shall admit more residents than the number of beds for which it is licensed, except guest rooms for visitors. (II, III) c. There shall be no more beds erected than is stipulated on the license. (II, III) d. There shall be no more beds erected in a room than its size and other characteristics will permit. (II, III) e. The admission of a resident to a nursing facility shall not give the facility or any employee of the facility the right to manage, use, or dispose of any property of the resident except with the written authorization of the resident or the resident’s legal representative. (III) f. The admission of a resident shall not grant the nursing facility the authority or responsibility to manage the personal affairs of the resident except as may be necessary for the safety of the resident and safe and orderly management of the facility as required by these rules. (III) g. A nursing facility shall provide for the safekeeping of personal effects, funds, and other property of its residents. The facility may require that items of exceptional value or which would convey unreasonable responsibilities to the licensee be removed from the premises of the facility for safekeeping. (III) h. Rescinded, effective 7/14/82. i. Funds or properties received by the nursing facility belonging to or due a resident, expendable for the resident’s account, shall be trust funds. (III) j. Infants and children under the age of 16 shall not be admitted to health care facilities for adults unless given prior written approval by the department. A distinct part of a health care facility, segregated from the adult section, may be established based on a program of care submitted by the licensee or applicant which is commensurate with the needs of the residents of the health care facility and has received the department’s review and approval. (III) k. No health care facility, and no owner, administrator, employee or representative thereof shall act as guardian, trustee, or conservator for any resident’s property, unless such resident is related to the person acting as guardian within the third degree of consanguinity. l. Within 30 days of a resident’s admission to a health care facility receiving reimbursement through the medical assistance program under Iowa Code chapter 249A, the facility shall ask the resident or the resident’s personal representative whether the resident is a veteran and shall document the response. If the facility determines that the resident is a potential veteran, the facility shall report the resident’s name along with the names of the resident’s spouse and any dependent children, as well as the name of the contact person for this information, to the Iowa department of veterans affairs. Where appropriate, the facility may also report such information to the Iowa department of human services.If a resident is eligible for benefits through the United States Department of Veterans Affairs or other third-party payor, the facility first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A.The provisions of this paragraph shall not apply to the admission of an individual as a resident to a state mental health institute for acute psychiatric care or to the admission of an individual to the Iowa Veterans Home. (II, III) 58.12(2) Discharge or transfer. a. Prior notification shall be made to the resident, as well as the resident’s next of kin, legal representative, attending physician, and sponsoring agency, if any, prior to transfer or discharge of any resident. (III) b. Proper arrangements shall be made by the nursing facility for the welfare of the resident prior to transfer or discharge in the event of an emergency or inability to reach the next of kin or legal representative. (III) c. The licensee shall not refuse to discharge or transfer a resident when the physician, family, resident, or legal representative requests such a discharge or transfer. (II, III) d. Advance notification will be made to the receiving facility prior to the transfer of any resident. (III) e. When a resident is transferred or discharged, the appropriate record as set forth in 58.15(2)“k” of these rules will accompany the resident. (II, III) f. Prior to the transfer or discharge of a resident to another health care facility, arrangements to provide for continuity of care shall be made with the facility to which the resident is being sent. (II, III)48158.13(135C) Contracts. Each contract shall: 58.13(1) State the base rate or scale per day or per month, the services included, and the method of payment; (III) 58.13(2) Contain a complete schedule of all offered services for which a fee may be charged in addition to the base rate. Furthermore, the contract shall: (III) a. Stipulate that no further additional fees shall be charged for items not contained in complete schedule of services as set forth in 58.13(3); (III) b. State the method of payment of additional charges; (III) c. Contain an explanation of the method of assessment of such additional charges and an explanation of the method of periodic reassessment, if any, resulting in changing such additional charges; (III) d. State that additional fees may be charged to the resident for nonprescription drugs, other personal supplies, and services by a barber, beautician, etc.; (III) 58.13(3) Contain an itemized list of those services, with the specific fee the resident will be charged and method of payment, as related to the resident’s current condition, based on the nursing assessment at the time of admission, which is determined in consultation with the administrator; (III) 58.13(4) Include the total fee to be charged initially to the specific resident; (III) 58.13(5) State the conditions whereby the facility may make adjustments to the facility’s overall fees for resident care as a result of changing costs. (III) Furthermore, the contract shall provide that the facility shall give: a. Written notification to the resident, or responsible party when appropriate, of changes in the overall rates of both base and additional charges at least 30 days prior to effective date of such changes; (III) b. Notification to the resident, or responsible party when appropriate, of changes in additional charges, based on a change in the resident’s condition. Notification must occur prior to the date such revised additional charges begin. If notification is given orally, subsequent written notification must also be given within a reasonable time, not to exceed one week, listing specifically the adjustments made; (III) 58.13(6) State the terms of agreement in regard to refund of all advance payments in the event of transfer, death, voluntary or involuntary discharge; (III) 58.13(7) State the terms of agreement concerning the holding and charging for a bed when a resident is hospitalized or leaves the facility temporarily for recreational or therapeutic reasons. The terms shall contain a provision that the bed will be held at the request of the resident or the resident’s responsible party. a. The facility shall ask the resident or responsible party if the resident wants the bed held. This request shall be made before the resident leaves or within 48 hours after the resident leaves. The inquiry and the response shall be documented. (II) b. The facility shall reserve the bed when requested for as long as payments are made in accordance with the contract. (II) 58.13(8) State the conditions under which the involuntary discharge or transfer of a resident would be effected; (III) 58.13(9) State the conditions of voluntary discharge or transfer; (III) 58.13(10) Set forth any other matters deemed appropriate by the parties to the contract. No contract or any provision thereof shall be drawn or construed so as to relieve any health care facility of any requirement or obligation imposed upon it by this chapter or any standards or rules in force pursuant to this chapter; (III) 58.13(11) Each party shall receive a copy of the signed contract. (III)48158.14(135C) Medical services. 58.14(1) Each resident in a nursing facility shall designate a licensed physician who may be called when needed. Professional management of a resident’s care shall be the responsibility of the hospice program when: a. The resident is terminally ill, and b. The resident has elected to receive hospice services under the federal Medicare program from a Medicare-certified hospice program, and c. The facility and the hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of hospice care. 58.14(2) Each resident admitted to a nursing facility shall have had a physical examination prior to admission. If the resident is admitted directly from a hospital, a copy of the hospital admission physical and discharge summary may be made part of the record in lieu of an additional physical examination. A record of the examination, signed by the physician, shall be a part of the resident’s record. (III) 58.14(3) Arrangements shall be made to have a physician available to furnish medical care in case of emergency. (II, III) 58.14(4) Rescinded, effective 7/14/82. 58.14(5) The person in charge shall immediately notify the physician of any accident, injury, or adverse change in the resident’s condition. (I, II, III) 58.14(6) A schedule listing the names and telephone numbers of the physicians shall be posted in each nursing station. (III) 58.14(7) Residents shall be admitted to a nursing facility only on a written order signed by a physician certifying that the individual being admitted requires no greater degree of nursing care than the facility is licensed to provide. (III) 58.14(8) Physician delegation of tasks. Each resident, including private pay residents, shall be visited by or shall visit the resident’s physician at least twice a year. The year period shall be measured from the date of admission and is not to include preadmission physicals. a. For a skilled nursing patient, the resident must be seen by a physician for the initial comprehensive visit. Additional visits are required at least once every 30 days for 90 days after admission and at least once every 60 days thereafter. After the initial comprehensive visit, alternate required visits may be performed by an advanced registered nurse practitioner, clinical nurse specialist or physician assistant who is working in collaboration with a physician, as outlined in Table 1. (III) b. Notwithstanding the provisions of 42 CFR 483.40, any required physician task or visit in a nursing facility may also be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant who is working in collaboration with a physician, as outlined in Table 1. (III) c. In dually certified skilled nursing/nursing facilities, the advanced registered nurse practitioner, clinical nurse specialist, and physician assistant must follow the skilled nursing facility requirements for services for skilled nursing facility stays. For nursing facility stays in skilled nursing/nursing facilities, any required physician task or visit may be performed by an advanced registered nurse practitioner, clinical nurse specialist, or physician assistant working in collaboration with the physician. (III) d. Nurse practitioners, clinical nurse specialists, and physician assistants may perform other tasks that are not reserved to the physician such as visits outside the normal schedule needed to address new symptoms or other changes in medical status. (III)Table 1:Authority for non-physician practitioners to perform visits, sign orders, and sign certifications/recertifications when permitted by state law*Initial Comprehensive Visit/OrdersOther Required Visits1Other Medically Necessary Visits and Orders2Certification/RecertificationSkilled Nursing FacilitiesPhysician assistant, nurse practitioner and clinical nurse specialist employed by the facilityMay not perform/May not signMay perform alternate visitsMay perform and signMay not signPhysician assistant, nurse practitioner and clinical nurse specialist not a facility employeeMay not perform/May not signMay perform alternate visitsMay perform and signMay sign subject to state requirementsNursing FacilitiesNurse practitioner, clinical nurse specialist, and physician assistant employed by the facilityMay not perform/May not signMay not performMay perform and signNot applicable+Nurse practitioner, clinical nurse specialist, and physician assistant not a facility employeeMay perform/May signMay performMay perform and signNot applicable+*As permitted by state law governing the scope and practice of nurse practitioners, clinical nurse specialists, and physician assistants.1 Other required visits include the skilled nursing resident monthly visits that may be alternated between physician and advanced registered nurse practitioners, clinical nurse specialists, or physician assistants after the initial comprehensive visit is completed.2 Medically necessary visits may be performed prior to the initial comprehensive visit.+ This requirement relates specifically to coverage of Part A Medicare stays, which can take place only in a Medicare-certified skilled nursing facility.Related ARC(s): 1048C, 1398C48158.15(135C) Records. 58.15(1) Resident admission record. The licensee shall keep a permanent record on all residents admitted to a nursing facility with all entries current, dated, and signed. This shall be a part of the resident clinical record. (III) The admission record form shall include: a. Name and previous address of resident; (III) b. Birth date, sex, and marital status of resident; (III) c. Church affiliation; (III) d. Physician’s name, telephone number, and address; (III) e. Dentist’s name, telephone number, and address; (III) f. Name, address, and telephone number of next of kin or legal representative; (III) g. Name, address, and telephone number of person to be notified in case of emergency; (III) h. Mortician’s name, telephone number, and address; (III) i. Pharmacist’s name, telephone number, and address. (III) 58.15(2) Resident clinical record. There shall be a separate clinical record for each resident admitted to a nursing facility with all entries current, dated, and signed. (III) The resident clinical record shall include: a. Admission record; (III) b. Admission diagnosis; (III) c. Physical examination: The record of the admission physical examination and medical history shall portray the current medical status of the resident and shall include the resident’s name, sex, age, medical history, tuberculosis status, physical examination, diagnosis, statement of chief complaints, estimation of restoration potential and results of any diagnostic procedures. The report of the physical examination shall be signed by the physician. (III) d. Physician’s certification that the resident requires no greater degree of nursing care than the facility is licensed to provide; (III) e. Physician’s orders for medication, treatment, and diet in writing and signed by the physician quarterly; (III) f. Progress notes. (1) Physician shall enter a progress note at the time of each visit; (III) (2) Other professionals, i.e., dentists, social workers, physical therapists, pharmacists, and others shall enter a progress note at the time of each visit; (III) g. All laboratory, X-ray, and other diagnostic reports; (III) h. Nurse’s record including: (1) Admitting notes including time and mode of transportation; room assignment; disposition of valuables; symptoms and complaints; general condition; vital signs; and weight; (II, III) (2) Routine notes including physician’s visits; telephone calls to and from the physician; unusual incidents and accidents; change of condition; social interaction; and P.R.N. medications administered including time and reason administered, and resident’s reaction; (II, III) (3) Discharge or transfer notes including time and mode of transportation; resident’s general condition; instructions given to resident or legal representative; list of medications and disposition; and completion of transfer form for continuity of care; (II, III) (4) Death notes including notification of physician and family to include time, disposition of body, resident’s personal possessions and medications; and complete and accurate notes of resident’s vital signs and symptoms preceding death; (III) i. Medication record. (1) An accurate record of all medications administered shall be maintained for each resident. (II, III) (2) Schedule II drug records shall be kept in accordance with state and federal laws; (II, III) j. Death record. In the event of a resident’s death, notations in the resident’s record shall include the date and time of the resident’s death, the circumstances of the resident’s death, the disposition of the resident’s body, and the date and time that the resident’s family and physician were notified of the resident’s death; (III) k. Transfer form. (1) The transfer form shall include identification data from the admission record, name of transferring institution, name of receiving institution, and date of transfer; (III) (2) The nurse’s report shall include resident attitudes, behavior, interests, functional abilities (activities of daily living), unusual treatments, nursing care, problems, likes and dislikes, nutrition, current medications (when last given), and condition on transfer; (III) (3) The physician’s report shall include reason for transfer, medications, treatment, diet, activities, significant laboratory and X-ray findings, and diagnosis and prognosis; (III) l. Consultation reports shall indicate services rendered by allied health professionals in the facility or in health-centered agencies such as dentists, physical therapists, podiatrists, oculists, and others. (III) 58.15(3) Resident personal record. Personal records may be kept as a separate file by the facility. a. Personal records may include factual information regarding personal statistics, family and responsible relative resources, financial status, and other confidential information. b. Personal records shall be accessible to professional staff involved in planning for services to meet the needs of the resident. (III) c. When the resident’s records are closed, the information shall become a part of the final record. (III) d. Personal records shall include a duplicate copy of the contract(s). (III) 58.15(4) Incident record. a. Each nursing facility shall maintain an incident record report and shall have available incident report forms. (III) b. Report of incidents shall be in detail on a printed incident report form. (III) c. The person in charge at the time of the incident shall prepare and sign the report. (III) d. The report shall cover all accidents where there is apparent injury or where hidden injury may have occurred. (III) e. The report shall cover all accidents or unusual occurrences within the facility or on the premises affecting residents, visitors, or employees. (III) f. A copy of the incident report shall be kept on file in the facility. (III) 58.15(5) Retention of records. a. Records shall be retained in the facility for five years following termination of services. (III) b. Records shall be retained within the facility upon change of ownership. (III) c. Rescinded, effective 7/14/82. d. When the facility ceases to operate, the resident’s record shall be released to the facility to which the resident is transferred. If no transfer occurs, the record shall be released to the individual’s physician. (III) 58.15(6) Reports to the department. The licensee shall furnish statistical information concerning the operation of the facility to the department on request. (III) 58.15(7) Personnel record. a. An employment record shall be kept for each employee, consisting of the following information: name and address of employee, social security number of employee, date of birth of employee, date of employment, experience and education, references, position in the home, criminal history and dependent adult abuse background checks, and date and reason for discharge or resignation. (III) b. The personnel records shall be made available for review upon request by the department. (III)48158.16(135C) Resident care and personal services. 58.16(1) Beds shall be made daily and adjusted as necessary. A complete change of linen shall be made at least once a week and more often if necessary. (III) 58.16(2) Residents shall receive sufficient supervision so that their personal cleanliness is maintained. (II, III) 58.16(3) Residents shall have clean clothing as needed to present a neat appearance, to be free of odors, and to be comfortable. Clothing shall be based on resident choice and shall be appropriate to residents’ activities and to the weather. (III) 58.16(4) Rescinded, effective 7/14/82. 58.16(5) Residents shall be encouraged to leave their rooms and make use of the recreational room or living room of the facility. (III) 58.16(6) Residents shall not be required to pass through another’s bedroom to reach a bathroom, living room, dining room, corridor, or other common areas of the facility. (III) 58.16(7) Rescinded, effective 7/14/82. 58.16(8) Uncontrollable residents shall be transferred or discharged from the facility in accordance with contract arrangements and requirements of Iowa Code chapter 135C. (II, III) 58.16(9) Except for those who request differently, residents who are not bedfast shall be fully dressed each day to maintain self-esteem and promote the residents’ normal lifestyles. (III) 58.16(10) Residents shall receive a bath of their choice, based on the facility’s accommodations, as needed to maintain proper hygiene. (II, III)48158.17 Rescinded, effective 7/14/82.48158.18(135C) Nursing care. 58.18(1) Individual health care plans shall be based on resident treatment decisions, the nature of the illness or disability, treatment, and care prescribed. Goals shall be developed by each discipline providing service, treatment, and care. These plans shall be in writing, revised as necessary, and kept current. They shall be made available to all those rendering the services and for review by the department. (III) 58.18(2) Rescinded IAB 4/2/14, effective 5/7/14. 58.18(3) The facility shall provide resident and family education as an integral part of restorative and supportive care. (III) 58.18(4) The facility shall provide prompt response from qualified staff for the resident’s use of the nurse call system. (II, III) (Prompt response being considered as no longer than 15 minutes.)Related ARC(s): 1398C48158.19(135C) Required nursing services for residents. The resident shall receive and the facility shall provide, as appropriate, the following required nursing services under the 24-hour direction of qualified nurses with ancillary coverage as set forth in these rules: 58.19(1) Activities of daily living. a. Bathing; (II, III) b. Daily oral hygiene (denture care); (II, III) c. Routine shampoo; (II, III) d. Nail care; (III) e. Shaving; (III) f. Daily care and application of prostheses (glasses, hearing aids, glass eyes, limb prosthetics, braces, or other assistive devices); (II, III) g. Ambulation with equipment if applicable, or transferring, or positioning; (I, II, III) h. Daily routine range of motion; (II, III) i. Mobility (assistance with wheelchair, mechanical lift, or other means of locomotion); (I, II, III) j. Elimination. (1) Assistance to and from the bathroom and perineal care; (II, III) (2) Bedpan assistance; (II, III) (3) Care for incontinent residents; (II, III) (4) Bowel and bladder training programs including in-dwelling catheter care (i.e., insertion and irrigation), enema and suppository administration, and monitoring and recording of intake and output, including solid waste; (I, II, III) k. Colostomy care (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II, III) l. Ileostomy care (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II, III) m. All linens necessary; (III) n. Nutrition and meal service. (1) Regular, therapeutic, modified diets, and snacks; (I, II, III) (2) Mealtime preparation of resident; (II, III) (3) Assistance to and from meals; (II, III) (4) In-room meal service or tray service; (II, III) (5) Assistance with food preparation and meal assistance including total assistance if needed; (II, III) (6) Assistance with adaptive devices; (II, III) (7) Enteral nutrition (to be performed by a registered nurse or licensed practical nurse only); (I, II, III) (8) Sufficient fluid intake to maintain proper hydration and health; (I, II, III) o. Promote initiation of self-care for elements of resident care; (II, III) p. Oral suctioning (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse). (I, II) 58.19(2) Medication and treatment. a. Administration of all medications as ordered by the physician including oral, instillations, topical, injectable (to be injected by a registered nurse or licensed practical nurse only); (I, II) b. Provision of the appropriate care and treatment of wounds, including pressure sores, to promote healing, prevent infection, and prevent new sores from developing; (I, II) c. Blood glucose monitoring; (I, II) d. Vital signs, blood pressure, and weights; (I, II) e. Ambulation and transfer; (II, III) f. Provision of restraints; (I, II) g. Administration of oxygen (to be performed only by a registered nurse or licensed practical nurse or by a qualified aide under the direction of a registered nurse or licensed practical nurse); (I, II) h. Provision of all treatments; (I, II, III) i. Provision of emergency medical care, including arranging for transportation, in accordance with written policies and procedures of the facility; (I, II, III) j. Provision of accurate assessment and timely intervention for all residents who have an onset of adverse symptoms which represent a change in mental, emotional, or physical condition. (I, II, III)Related ARC(s): 1398C, 2560C48158.20(135C) Duties of health service supervisor. Every nursing facility shall have a health service supervisor who shall: 58.20(1) Direct the implementation of the physician’s orders; (I, II) 58.20(2) Plan for and direct the nursing care, services, treatments, procedures, and other services in order that each resident’s needs and choices, where practicable, are met; (II, III) 58.20(3) Review the health care needs and choices, where practicable, of each resident admitted to the facility and assist the attending physician in planning for the resident’s care; (II, III) 58.20(4) Develop and implement a written health care plan in cooperation with, to the extent practicable, the resident, the resident’s family or the resident’s legal representative, and others in accordance with instructions of the attending physician as follows: a. The written health care plan, based on the assessment and reassessment of the resident’s health needs and choices, where practicable, is personalized for the individual resident and indicates care to be given, goals to be accomplished, and methods, approaches, and modifications necessary to achieve best results; (III) b. The health service supervisor is responsible for preparing, reviewing, supervising the implementation, and revising the written health care plan; (III) c. The health care plan is readily available for use by all personnel caring for the resident; (III) 58.20(5) Initiate preventative and restorative nursing procedures for each resident so as to achieve and maintain the highest possible degree of function, self-care, and independence based on resident choice, where practicable; (II, III) 58.20(6) Supervise health services personnel to ensure they perform the following restorative measures in their daily care of residents: a. Maintaining good bodily alignment and proper positioning; (II, III) b. Making every effort to keep the resident active except when contraindicated by physician’s orders, and encouraging residents to achieve independence in activities of daily living by teaching self-care, transfer, and ambulation activities; (III) c. Assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests as necessary; (III) d. Assisting residents to carry out prescribed therapy exercises between visits of the therapist; (III) e. Assisting residents with routine range of motion exercises; (III) 58.20(7) Plan and conduct nursing staff orientation and in-service programs and provide for training of nurse’s aides; (III) 58.20(8) Plan with the resident and the resident’s physician and family and health-related agencies for the care of the resident upon discharge; (III) 58.20(9) Designate a responsible person to be in charge during absences; (III) 58.20(10) Be responsible for all assignments and work schedules for all health services personnel to ensure that the health needs of the residents are met; (III) 58.20(11) Ensure that all nurse’s notes are descriptive of the care rendered including the resident’s response; (III) 58.20(12) Visit each resident routinely to be knowledgeable of the resident’s current condition; (III) 58.20(13) Evaluate in writing the performance of each individual on the health care staff on at least an annual basis. This evaluation shall be available for review in the facility to the department; (III) 58.20(14) Keep the administrator informed of the resident’s status; (III) 58.20(15) Teach and coordinate rehabilitative health care including activities of daily living, promotion and maintenance of optimal physical and mental functioning; (III) 58.20(16) Supervise serving of meals to ensure that individuals unable to assist themselves are promptly fed and that special eating adaptive devices are available as needed; (II, III) 58.20(17) Make available a nursing procedure manual which shall include all procedures practiced in the facility; (III) 58.20(18) Participate with the administrator in the formulation of written policies and procedures for resident services; (III) 58.20(19) The person in charge shall immediately notify the family of any accident, injury, or adverse change in the resident’s condition requiring physician’s notification. (III)48158.21(135C) Drugs, storage, and handling. 58.21(1) Drug storage for residents who are unable to take their own medications and require supervision shall meet the following requirements: a. A cabinet with a lock, convenient to nursing service, shall be provided and used for storage of all drugs, solutions, and prescriptions; (III) b. The drug storage cabinet shall be kept locked when not in use; (III) c. The medication cabinet key shall be in the possession of the person directly responsible for issuing medications; (II, III) d. Double-locked storage of Schedule II drugs shall not be required under single unit package drug distribution systems in which the quantity stored does not exceed a three-day supply and a missing dose can be readily detected. (II) 58.21(2) Drugs for external use shall be stored separately from drugs for internal use. (III) 58.21(3) Medications requiring refrigeration shall be kept in a refrigerator and separated from food and other items. A method for locking these medications shall be provided. (III) 58.21(4) All potent, poisonous, or caustic materials shall be stored separately from drugs. They shall be plainly labeled and stored in a specific, well-illuminated cabinet, closet, or storeroom and made accessible only to authorized persons. (I, II) 58.21(5) All flammable materials shall be specially stored and handled in accordance with applicable local and state fire regulations. (II) 58.21(6) A properly trained person shall be charged with the responsibility of administering nonparenteral medications. a. The individual shall have knowledge of the purpose of the drugs, their dangers, and contraindications. b. This person shall be a licensed nurse or physician or shall have successfully completed a department-approved medication aide course or passed a department-approved medication aide challenge examination administered by an area community college. c. Prior to taking a department-approved medication aide course, the individual shall: (1) Successfully complete an approved nurse aide course, nurse aide training and testing program or nurse aide competency examination. (2) Be employed in the same facility for at least six consecutive months prior to the start of the medication aide course. This requirement is not subject to waiver. (3) Have a letter of recommendation for admission to the medication aide course from the employing facility. d. A person who is a nursing student or a graduate nurse may take the challenge examination in place of taking a medication aide course. This individual shall do all of the following before taking the medication aide challenge examination: (1) Complete a clinical or nursing theory course within six months before taking the challenge examination; (2) Successfully complete a nursing program pharmacology course within one year before taking the challenge examination; (3) Provide to the community college a written statement from the nursing program’s pharmacology or clinical instructor indicating the individual is competent in medication administration. (4) Successfully complete a department-approved nurse aide competency evaluation. e. A person who has written documentation of certification as a medication aide in another state may become a medication aide in Iowa by successfully completing a department-approved nurse aide competency examination and a medication aide challenge examination.The requirements of paragraph “c” of this subrule do not apply to this individual. 58.21(7) Unless the unit dose system is used, the person assigned the responsibility of medication administration must complete the procedure by personally preparing the dose, observing the actual act of swallowing the oral medication, and charting the medication. (II) In facilities where the unit dose system is used, the person assigned the responsibility must complete the procedure by observing the actual act of swallowing the medication and charting the medication. Medications shall be prepared on the same shift of the same day that they are administered, (II) unless the unit dose system is used. 58.21(8) An accurate written record of medications administered shall be made by the individual administering the medication. (III) 58.21(9) Records shall be kept of all Schedule II drug medications received and dispensed in accordance with the controlled drug and substance Act. (III) 58.21(10) Any unusual resident reaction shall be reported to the physician at once. (II) 58.21(11) A policy shall be established by the facility in conjunction with a licensed pharmacist to govern the distribution of prescribed medications to residents who are on leave from the facility. (III) a. Medication may be issued to residents who will be on leave from a facility for less than 24 hours. Notwithstanding the prohibition against paper envelopes in 58.21(14)“a,” non-child-resistant containers may be used. Each container may hold only one medication. A label on each container shall indicate the date, the resident’s name, the facility, the medication, its strength, dose, and time of administration. b. Medication for residents on leave from a facility longer than 24 hours shall be obtained in accordance with requirements established by the Iowa board of pharmacy examiners. c. Medication distributed as above may be issued only by a nurse responsible for administering medication. (I, II, III) 58.21(12) Emergency medications. A nursing facility shall provide emergency medications pursuant to the following requirements: (III) a. Prescription drugs as well as nonprescription items must be prescribed or approved by the physician, in consultation with the pharmacist, who provides emergency service to the facility; (III) b. The emergency medications shall be stored in an accessible place; (III) c. A list of the emergency medications and quantities of each item shall be maintained by the facility; (III) d. The container holding the emergency medications shall be closed with a seal which may be broken when drugs are required in an emergency or for inspection; (III) e. Any item removed from the emergency medications shall be replaced within 48 hours; (III) f. A permanent record shall be kept of each time the emergency medications are used; (III) g. The emergency medications shall be inspected by a pharmacist at least once every three months to determine the stability of items. (III) 58.21(13) Drug handling. a. Bulk supplies of prescription drugs shall not be kept in a nursing facility unless a licensed pharmacy is established in the facility under the direct supervision and control of a pharmacist. (III) b. Inspection of drug storage condition shall be made by the health service supervisor and a registered pharmacist not less than once every three months. The inspection shall be verified by a report signed by the nurse and pharmacist and filed with the administrator. The report shall include, but not be limited to, certifying absence of the following: expired drugs, deteriorated drugs, improper labeling, drugs for which there is no current physician’s order, and drugs improperly stored. (III) c. If the facility permits licensed nurses to dilute or reconstitute drugs at the nursing station, distinctive supplementary labels shall be available for the purpose. The notation on the label shall be so made as to be indelible. (III) d. Dilution and reconstitution of drugs and their labeling shall be done by the pharmacist whenever possible. If not possible, the following shall be carried out only by the licensed nurse: (1) Specific directions for dilution or reconstitution and expiration date should accompany the drug; (III) (2) A distinctive supplementary label shall be affixed to the drug container when diluted or reconstituted by the nurse for other than immediate use. (III) The label shall bear the following: resident’s name, dosage and strength per unit/volume, nurse’s name, expiration date, and date and time of dilution. (III) 58.21(14) Drug safeguards. a. All prescribed medications shall be clearly labeled indicating the resident’s full name, physician’s name, prescription number, name and strength of drug, dosage, directions for use, date of issue, and name and address and telephone number of pharmacy or physician issuing the drug. Where unit dose is used, prescribed medications shall, as a minimum, indicate the resident’s full name, physician’s name, name and strength of drug, and directions for use. Standard containers shall be utilized for dispensing drugs. Paper envelopes shall not be considered standard containers. (III) b. Medication containers having soiled, damaged, illegible or makeshift labels, or medication samples shall be returned to the issuing pharmacist, pharmacy, or physician for relabeling or disposal. (III) c. There shall be no medications or any solution in unlabeled containers. (II, III) d. The medications of each resident shall be kept or stored in the originally received containers. (II, III) e. Labels on containers shall be clearly legible and firmly affixed. No label shall be superimposed on another label of a drug container. (II, III) f. When a resident is discharged or leaves the facility, the unused prescription shall be sent with the resident or with a legal representative only upon the written order of a physician. (III) g. Unused prescription drugs prescribed for residents who are deceased shall be returned to the supplying pharmacist. (III) h. Prescriptions shall be refilled only with the permission of the attending physician. (II, III) i. No medications prescribed for one resident may be administered to or allowed in the possession of another resident. (II) j. Instructions shall be requested of the Iowa board of pharmacy examiners concerning disposal of unused Schedule II drugs prescribed for residents who have died or for whom the Schedule II drug was discontinued. (III) k. There shall be a formal routine for the proper disposal of discontinued medications within a reasonable but specified time. These medications shall not be retained with the resident’s current medications. Discontinued drugs shall be destroyed by the responsible nurse with a witness and a notation made to that effect or returned to the pharmacist for destruction or resident credit. Drugs listed under the Schedule II drugs shall be disposed of in accordance with the provisions of the Iowa board of pharmacy examiners. (II, III) l. All medication orders which do not specifically indicate the number of doses to be administered or the length of time the drug is to be administered shall be stopped automatically after a given time period. The automatic stop order may vary for different types of drugs. The physician, in consultation with the pharmacist serving the home, shall institute policies and provide procedures for review and endorsement of stop orders on drugs. This policy shall be conveniently located for personnel administering medications. (II, III) m. No resident shall be allowed to keep possession of any medications unless the attending physician has certified in writing on the resident’s medical record that the resident is mentally and physically capable of doing so. (II) n. Residents who have been certified in writing by the physician as capable of taking their own medications may retain these medications in their bedroom, but locked storage must be provided. (II) o. No medications or prescription drugs shall be administered to a resident without a written order signed by the attending physician. (II) p. A qualified nurse shall: (1) Establish a medication schedule system which identifies the time and dosage of each medication prescribed for each resident, is based on the resident’s desired routine, and is approved by the resident’s physician. (II, III) (2) Establish a medication record containing the information specified above needed to monitor each resident’s drug regimen. (II, III) q. Telephone orders shall be taken by a qualified nurse. Orders shall be written into the resident’s record and signed by the person receiving the order. Telephone orders shall be submitted to the physician for signature within 48 hours. (III) r. A pharmacy operating in connection with a nursing facility shall comply with the provisions of the pharmacy law requiring registration of pharmacies and the regulations of the Iowa board of pharmacy examiners. (III) s. In a nursing facility with a pharmacy or drug supply, service shall be under the personal supervision of a pharmacist licensed to practice in the state of Iowa. (III) 58.21(15) Drug administration. a. Injectable medications shall be administered as permitted by Iowa law by a qualified nurse, physician, pharmacist, or physician assistant (PA). In the case of a resident who has been certified by the resident’s physician or physician assistant (PA) as capable of taking the resident’s own insulin, the resident may inject the resident’s own insulin. (II) b. An individual inventory record shall be maintained for each Schedule II drug prescribed for each resident. (II) c. The health service supervisor shall be responsible for the supervision and direction of all personnel administering medications. (II)Related ARC(s): 1050C48158.22(135C) Rehabilitative services. Rehabilitative services shall be provided to maintain function or improve the resident’s ability to carry out the activities of daily living. 58.22(1) Physical therapy services. a. Each facility shall have a written agreement with a licensed physical therapist to provide physical therapy services. (III) b. Physical therapy shall be rendered only by a physical therapist licensed to practice in the state of Iowa. All personnel assisting with the physical therapy of residents must be under the direction of a licensed physical therapist. (II, III) c. The licensed physical therapist shall: (1) Evaluate the resident and prepare a physical therapy treatment plan conforming to the medical orders and goals; (III) (2) Consult with other personnel in the facility who are providing resident care and plan with them for the integration of a physical therapy treatment program into the overall health care plan; (III) (3) Instruct the nursing personnel responsible for administering selected restorative procedures between treatments; (III) (4) Present programs in the facility’s in-service education programs. (III) d. Treatment records in the resident’s medical chart shall include: (1) The physician’s prescription for treatment; (III) (2) An initial evaluation note by the physical therapist; (III) (3) The physical therapy care plan defining clearly the long-term and short-term goals and outlining the current treatment program; (III) (4) Notes of the treatments given and changes in the resident’s condition; (III) (5) A complete discharge summary to include recommendations for nursing staff and family. (III) e. There shall be adequate facilities, space, appropriate equipment, and storage areas as are essential to the treatment or examinations of residents. (III) 58.22(2) Other rehabilitative services. a. The facility shall arrange for specialized and supportive rehabilitative services when such services are ordered by a physician. (III) These may include audiology and occupational therapy. b. Audiology services shall be under the direction of a person licensed in the state of Iowa by the board of speech pathology and audiology. (II, III) c. Occupational therapy services shall be under the direction of a qualified occupational therapist who is currently registered by the American Occupational Therapy Association. (II, III) d. The appropriate professional shall: (1) Develop the treatment plan and administer or direct treatment in accordance with the physician’s prescription and rehabilitation goals; (III) (2) Consult with other personnel within the facility who are providing resident care and plan with them for the integration of a treatment program into the overall health care plan. (III)48158.23(135C) Dental, diagnostic, and other services. 58.23(1) Dental services. a. The nursing facility personnel shall assist residents to obtain regular and emergency dental services. (III) b. Transportation arrangements shall be made when necessary for the resident to be transported to the dentist’s office. (III) c. Dental services shall be performed only on the request of the resident, responsible relative, or legal representative. The resident’s physician shall be advised of the resident’s dental problems. (III) d. All dental reports or progress notes shall be included in the clinical record. (III) e. Nursing personnel shall assist the resident in carrying out dentist’s recommendations. (III) f. Dentists shall be asked to participate in the in-service program of the facility. (III) 58.23(2) Diagnostic services. a. The nursing facility shall make provisions for promptly securing required clinical laboratory, X-ray, and other diagnostic services. (III) b. All diagnostic services shall be provided only on the written, signed order of a physician. (III) c. Agreements shall be made with the local hospital laboratory or independent laboratory to perform specific diagnostic tests when they are required. (III) d. Transportation arrangements for residents shall be made, when necessary, to and from the source of service. (III) e. Copies of all diagnostic reports shall be requested by the facility and included in the resident’s clinical record. (III) f. The physician ordering the specific diagnostic service shall be promptly notified of the results. (III) g. Simple tests such as customarily done by nursing personnel for diabetic residents may be performed in the facility. (III) 58.23(3) Other services. a. The nursing facility shall assist residents to obtain such supportive services as requested by the physician. (III) b. Transportation arrangements shall be made when necessary. (III) c. Services could include the need for prosthetic devices, glasses, hearing aids, and other necessary items. (III)48158.24(135C) Dietary. 58.24(1) Organization of dietetic services. The facility shall meet the needs of the residents and provide the services listed in this standard. If a service is contracted out, the contractor shall meet the same standard. A written agreement shall be formulated between the facility and the contractor and shall convey to the department the right to inspect the food service facilities of the contractor. (III) a. There shall be written policies and procedures for dietetic services that include staffing, nutrition, menu planning, therapeutic diets, preparation, food service, ordering, receiving, storage, sanitation, and staff hygiene. The policies and procedures shall be made available for use by dietetic services. (III) b. There shall be written job descriptions for each position in dietetic services. The job descriptions shall be made available for use by dietetic services. (III) 58.24(2) Dietary staffing. a. The facility shall employ a qualified dietary supervisor who: (1) Is a qualified dietitian as defined in 58.24(2)“e”; or (2) Is a graduate of a dietetic technician training program approved by the Academy of Nutrition and Dietetics; or (3) Is a certified dietary manager certified by the certifying board for dietary managers of the Association of Nutrition and Foodservice Professionals and maintains that credential through 45 hours of ANFP-approved continuing education; or (4) Has completed an ANFP-approved course curriculum necessary to take the certification examination required to become a certified dietary manager; or (5) Has documented evidence of at least two years’ satisfactory work experience in food service supervision and who is in an approved dietary manager association program and will successfully complete the program within 24 months of the date of enrollment; or (6) Has completed the 90-hour training course approved by the department and is a certified food protection manager who has received training from and passed a test that is part of an American National Standards Institute (ANSI)-accredited Certified Food Protection Manager Program. (II, III) b. The supervisor shall have overall supervisory responsibility for dietetic services and shall be employed for a sufficient number of hours to complete management responsibilities that include: (1) Participating in regular conferences with the consultant dietitian, the administrator and other department heads; (III) (2) Writing menus with consultation from the dietitian and seeing that current menus are posted and followed and that menu changes are recorded; (III) (3) Establishing and maintaining standards for food preparation and service; (II, III) (4) Participating in selection, orientation, and in-service training of dietary personnel; (II, III) (5) Supervising activities of dietary personnel; (II, III) (6) Maintaining up-to-date records of residents identified by name, location and diet order; (III) (7) Visiting residents to learn individual needs and communicating with other members of the health care team regarding nutritional needs of residents when necessary; (II, III) (8) Keeping records of repairs of equipment in dietetic services. (III) c. A minimum of one person with supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has received training from and passed a test that is part of an American National Standards Institute (ANSI)-accredited Certified Food Protection Manager Program. d. The facility shall employ sufficient supportive personnel to carry out the following functions: (1) Preparing and serving adequate amounts of food that are handled in a manner to be bacteriologically safe; (II, III) (2) Washing and sanitizing dishes, pots, pans and equipment at temperatures required by procedures described in the Food Code as defined in Iowa Code section 137F.2; (II, III) (3) Serving therapeutic diets as prescribed by the physician and following the planned menu. (II, III) e. The facility may assign simultaneous duties in the kitchen and laundry, housekeeping, or nursing service to appropriately trained personnel. Proper sanitary and personal hygiene procedures shall be followed as outlined under the rules pertaining to staff hygiene. (II, III) f. If the dietetic service supervisor is not a licensed dietitian, a consultant dietitian is required. The consultant dietitian shall be licensed by the state of Iowa pursuant to Iowa Code chapter 152A. g. Consultants’ visits shall be scheduled to be of sufficient duration and at a time convenient to: (1) Record, in the resident’s medical record, any observations, assessments and information pertinent to medical nutrition therapy; (I, II, III) (2) Work with residents and staff on resident care plans; (III) (3) Consult with the administrator and others on developing and implementing policies and procedures; (III) (4) Write or approve general and therapeutic menus; (III) (5) Work with the dietetic supervisor on developing procedures, recipes and other management tools; (III) (6) Present planned in-service training and staff development for food service employees and others. Documentation of consultation shall be available for review in the facility by the department. (III) h. In facilities licensed for more than 15 beds, dietetic services shall be available for a minimum of a 12-hour span extending from the time of preparation of breakfast through supper. (III) 58.24(3) Nutrition and menu planning. a. Menus shall be planned and followed to meet the nutritional needs of each resident in accordance with the physician’s orders and in consideration of the resident’s choices and preferences. (II, III) b. Menus shall be planned to provide 100 percent 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. A current copy of the Simplified Diet Manual or other suitable diet manual shall be available and used in the planning and serving of all meals. (II) c. At least three meals or their equivalent shall be served daily at regular hours. (II) (1) There shall be no more than a 14-hour span between a substantial evening meal and breakfast except as provided in subparagraph (3) below. (II, III) (2) The facility shall offer snacks at bedtime daily. (II, III) (3) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast of the following day. The current resident group must agree to this meal span and a nourishing snack must be served. (II) d. Menus shall include a variety of foods prepared in various ways. (III) e. Menus shall be written at least one week in advance. The current menu shall be located in an accessible place in the dietetic services department for easy use by persons purchasing, preparing and serving food. (III) f. Records of menus as served shall be filed and maintained for 30 days and shall be available for review by department personnel. When substitutions are necessary, they shall be of similar nutritive value and recorded. (III) g. A file of tested recipes adjusted to the number of people to be served in the facility shall be maintained. (III) h. Alternate foods shall be offered to residents who refuse the food served. (II, III) 58.24(4) Therapeutic diets and nutritional status. a. The facility shall ensure that each resident has a nutritional assessment completed by the licensed dietitian within 14 days of admission that addresses the residents’ medical condition and therapeutic dietary needs, desires and rights in regard to their nutritional plan. (I, II, III) b. Therapeutic diets shall be prescribed by the resident’s physician. A current edition of the Simplified Diet Manual or other suitable diet manual shall be readily available to physicians, nurses and dietetic services personnel. A current diet manual shall be used as a guide for writing menus for therapeutic diets. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of food. (II, III) c. Personnel responsible for planning, preparing and serving therapeutic diets shall receive instructions on those diets. (II, III) d. The facility shall ensure that each resident maintains acceptable parameters of nutritional status, such as body weight, unless the resident’s clinical condition demonstrates that this is not possible. (I, II, III) 58.24(5) Food handling, preparation and service. All food shall be handled, prepared and served in compliance with the requirements of the Food and Drug Administration Food Code adopted under provisions of Iowa Code section 137F.2. (I, II, III) In addition, the following shall apply. a. Methods used to prepare foods shall be those which conserve nutritive value and flavor and meet the taste preferences of the residents. (III) b. Foods shall be attractively served. (III) c. Foods shall be cut up, chopped, ground or blended to meet individual needs. (I, II, III) d. Self-help devices shall be provided as needed. (II, III) e. Disposables shall not be used routinely. Plasticware, china and glassware that are unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded. (II, III) f. All food that is transported through public corridors shall be covered. (III) g. Residents may be allowed in the food preparation area. (III) h. The food preparation area may be used as a dining area for residents, staff or food service personnel if the facility engages in person-directed care. (III) i. There shall be effective written procedures established for cleaning all work and serving areas. (III) j. A schedule of cleaning duties to be performed daily shall be posted. (III) k. An exhaust system and hood shall be clean, operational and maintained in good repair. (III) l. The food service area shall be located so it will not be used as a passageway by residents, guests or non-food service staff. (III) 58.24(6) Paid nutritional assistants. A paid nutritional assistant means an individual who meets the requirements of this subrule and who is an employee of the facility or an employee of a temporary employment agency employed by the facility. A facility may use an individual working in the facility as a paid nutritional assistant only if that individual has successfully completed a state-approved training program for paid nutritional assistants. (I, II, III) a. Training program requirements. (1) A state-approved training program for paid nutritional assistants must include, at a minimum, eight hours of training in the following areas:
- Feeding techniques.
- Assistance with feeding and hydration.
- Communication and interpersonal skills.
- Appropriate responses to resident behavior.
- Safety and emergency procedures, including the Heimlich maneuver.
- Infection control.
- Resident rights.
- Recognizing changes in residents that are inconsistent with their normal behavior and reporting these changes to the supervisory nurse.
- Policies and procedures for program administration.
- Qualifications of the instructors.
- Maintenance of program records, including attendance records.
- Criteria for determining competency.
- Program costs and refund policies.
- Lesson plans, including the objectives to be taught, skills demonstrations, assignments, quizzes, and classroom, laboratory and clinical hours.