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    CHAPTER 65INTERMEDIATE CARE FACILITIESFOR PERSONS WITH MENTAL ILLNESS (ICF/PMI)481—65.1(135C)  Definitions.  For the purposes 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 incorporated verbatim in the rules. The use of the words “shall” and “must” indicate these standards are mandatory.
    "Academic services" means those activities provided to assist a person to acquire general information and skills which establish the basis for subsequent acquisition and application of knowledge.
    "Activity coordinator" means a person who has completed the state-approved activity coordinator’s course.
    "Age appropriate" means those activities, settings, and personal appearance and possessions commensurate with the person’s chronological age.
    "Chronic mental illness" (see the definition of “Mental illness”).
    "Commission" means the mental health and disability services commission.
    "Community living training services" are those activities provided to assist a person to acquire or sustain the knowledge and skills essential to independent functioning to the person’s maximum potential in the physical and social environment. These services may focus on the following areas:
    1. Independent living skills which include those skills necessary to sustain oneself in the physical environment and are essential to the management of one’s personal property and business. This includes self-advocacy skills.
    2. Socialization skills which include self-awareness and self-control, social responsiveness, group participation, social amenities and interpersonal skills.
    3. Communication skills which include expressive and receptive skills in verbal and nonverbal language, including reading and writing.
    4. Leisure time and recreational skills which include the skills necessary for a person to use leisure time in a manner which is satisfying and constructive to the person.
    5. Parenting skills which include those skills necessary to meet the needs of the person’s child. This service is designed to assist the person with mental illness to acquire or sustain the skills necessary for parenting.
    "Department" means the Iowa department of inspections and appeals.
    "Dependent adult abuse" is as defined in rule 481—52.1(235E).
    "Diagnosis" means the investigation and analysis of the cause or nature of a person’s condition, situation or problem.
    "Direct care staff" means those staff persons who provide a homelike environment for the residents and assist or supervise the resident in meeting the goals in the resident’s program plan.
    "Evaluation services" means those activities designed to identify a person’s current functioning level and those factors which are barriers to maintaining the current level or achieving a higher level of functioning.
    "Exploitation" means the act or process of taking unfair advantage of a resident, or the resident’s physical or financial resources for one’s own personal or pecuniary profit by the use of undue influence, harassment, duress, deception, false representation or false pretenses.
    "Goals" means general statements of attainable expected accomplishments to be achieved in meeting identified needs.
    "Incident" means all accidental, purposeful, or other occurrences within the facility or on the premises affecting residents, visitors, or employees whether there is apparent injury or where hidden injury may have occurred.
    "Individual program plan (IPP)" means a written plan for the provision of services to the resident that is developed and implemented using an interdisciplinary process that is based on the resident’s functional status, strengths, and needs and that identifies service activities designed to enable a person to maintain or move toward independent functioning. The plan identifies a continuum of development and outlines progressive steps and anticipated outcomes of services.
    "Informed consent" means an agreement by a person, or by the person’s legally authorized representative, based upon an understanding of:
    1. A full explanation of the procedures to be followed including an identification of those that are and are not experimental;
    2. A description of the attendant discomforts, risks, and benefits to be expected; and
    3. A disclosure of appropriate alternative procedures that would be advantageous for the person.
    "Interdisciplinary process" means an approach to assessment, individual program planning, and service implementation in which planning participants function as a team. Each participant utilizing the skills, competencies, insights and perspectives provided by the participant’s training and experience focuses on identifying the service needs of the resident and the resident’s family. The purpose of the process is for participants to review and discuss, face-to-face, all information and recommendations and to reach decisions as a team. Participants share all information and recommendations, and develop as a team, a single, integrated individual program plan to meet the resident’s needs and, when appropriate, the resident’s family’s needs.
    "Interdisciplinary team" means the group of persons who develop a single, integrated individual program plan to meet a resident’s needs for services. The interdisciplinary team consists of, at a minimum, the resident, the resident’s legal guardian, if applicable, the resident’s advocate, if desired by the resident, a referral agency representative, other appropriate staff members, the resident’s attending psychiatrist and QMHP, other providers of services, and other persons relevant to the resident’s needs.
    "Least restrictive environment" means the environment in which the interventions in the lives of people with mental illness can be carried out with a minimum of limitation, intrusion, disruption, and departure from commonly accepted patterns of living.It is the environment which allows residents to participate, to the maximum extent possible, in everyday life and to have control over the decisions that affect them. It is an environment that provides needed supports which do not interfere with personal liberty and do not unduly interfere with a person’s access to the normal events of life.
    "Legal services" means those activities designed to assist the person in exercising constitutional and legislatively enacted rights.
    "Level of functioning" means a person’s current physiological and psychological status and current academic, community living, self-care and vocational skills.
    "Mechanical restraint" means a device applied to a person’s limbs, head or body which restricts a person’s movement and includes, but is not limited to, leather straps, leather cuffs, camisoles or handcuffs.
    "Mental abuse" means, but is not limited to, humiliation, harassment, and threats of punishment or deprivation.
    "Mental health counselor" means a person who is certified or eligible for certification as a mental health counselor by the National Academy of Certified Clinical Mental Health Counselors.
    "Mental health, mental retardation commission" means the commission described in Iowa Code section 225C.5.
    "Mental illness" means a substantial disorder of thought or mood which significantly impairs judgment, behavior, or the capacity to recognize reality or the ability to cope with the ordinary demands of life. Mental illnesses include the organic and functional psychoses, neuroses, personality disorders, alcoholism and drug dependence, behavioral disorders and other disorders as defined by the current edition of “American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.” Mental illness is chronic when it is of long duration or marked by frequent recurrences.
    "Normalization" means helping persons, in accordance with their needs and preferences, to achieve a lifestyle that is consistent with the norms and patterns of general society in ways which incorporate the age-appropriate and least restrictive principles.
    "Objectives" means specific, time-limited, and measurable statements showing outcomes or accomplishments necessary to progress toward the goal.
    "Physical abuse" means, but is not limited to, corporal punishment and the use of restraints as punishment.
    "Physical injury" means damage to any bodily tissue to the extent the tissue must undergo a healing process in order to be restored to a sound and healthy condition. It may also mean damage to the extent the bodily tissue cannot be restored to a sound and healthy condition, or results in the death of the resident whose bodily tissue sustained the damage.
    "Physical or physiological treatment" means those activities designed to prevent, halt, control, relieve, or reverse symptoms or conditions which interfere with the physical or physiological functioning of the human body.
    "Physical restraint" means a technique involving the use of one or more of a staff person’s arms, legs, hands or other body areas to restrict or control the movements of a resident. This does not include the use of mechanical restraint.
    "Physician" means a person who is currently licensed in Iowa to practice medicine and surgery, osteopathic medicine and surgery, or osteopathy.
    "Primary care provider" means any of the following who provide primary care and meet certification standards:
    1. A physician who is a family or general practitioner or an internist.
    2. An advanced registered nurse practitioner.
    3. A physician assistant.
    "Program" means a set of related resources and services directed to the accomplishment of a fixed set of goals and objectives for any of the following:
    1. Special target populations;
    2. The population of a specified geographic area(s);
    3. A specified purpose; and
    4. A person.
    "Psychiatric nurse" means a person who meets the requirements of certified psychiatric-mental health nurse practitioner pursuant to 655—Chapter 7, Iowa Administrative Code, or is eligible for certification.
    "Psychiatrist" means a doctor of medicine or osteopathic medicine and surgery who is certified by the American Board of Psychiatry and Neurology or who is eligible for certification.
    "Psychologist" means a person who is licensed to practice psychology in the state of Iowa, or is certified by the Iowa department of education as a school psychologist, or is eligible for certification.
    "Psychotherapeutic treatment" means those activities designed to assist a person in the identification or modification of beliefs, emotions, attitudes, or behaviors in order to maintain or improve the person’s functioning in response to the physical, emotional and social environment.
    "Qualified mental health professional (QMHP)" means a person who:
    1. Holds at least a master’s degree in a mental health field, including but not limited to: psychology, counseling and guidance, nursing and social work; or is a doctor of medicine (M.D.) or a doctor of osteopathic medicine and surgery (D.O.); and
    2. Holds a current Iowa license when required by the Iowa licensure law; and
    3. Has at least two years of postdegree experience, supervised by a mental health professional, in assessing mental problems and needs of individuals and in providing appropriate mental health services for those individuals. See rule 481—65.4(135C) for variance procedures.
    "Resident" means a person who has been admitted to the facility to receive care and services.
    "Seclusion" means the isolation of the resident in a locked room which cannot be opened by the resident.
    "Self-care training services" means those activities provided to assist a person to acquire or sustain the knowledge, habits and skills essential to the daily needs of the person. The activities focus on personal hygiene, general health maintenance, mobility skills and other activities of daily living.
    "Service" means a set of interrelated activities provided to a resident pursuant to the IPP.
    "Sexual abuse" means, but is not limited to, the exposing of pubes to a resident, the exposure of a resident’s genitals, pubes, breasts or buttocks for sexual satisfaction, fondling or touching the inner thigh, groin, buttocks, anus or breast of a resident or the clothing covering these areas, sexually suggestive comments or remarks made to a resident, a genital to genital or rectal, or oral to genital or rectal contact, or the commission of a sexual offense under Iowa Code chapter 709 or Iowa Code section 726.2.
    "Social worker" means a person who is licensed to practice social work in the state of Iowa, or who is eligible for licensure.
    "Support services" means those activities provided to or on behalf of a person in the areas of personal care and assistance and property maintenance in order to allow a person to live in the least restrictive environment.
    "Transportation services" means those activities designed to assist a person to travel from one place to another to obtain services or carry out life’s activities.
    "Verbal abuse" means, but is not limited to, the use of derogatory terms or names, undue voice volume and rude comments, orders or responses to residents.
    "Vocational training services" means those activities designed to familiarize a person with production or employment requirements and to maintain or develop the person’s ability to function in a work setting. This service includes programming which allows or promotes the development of skills, attitudes and personal attributes appropriate to the work setting.
    "Work" means any activity during which a resident provides goods or services for wages.
    "Written, in writing or recorded" means that an account or entry is made in a permanent form.
    Related ARC(s): 0766C, 1204C, 1752C481—65.2(135C)  Application for license.  In order to obtain an initial license for an ICF/PMI, the applicant must comply with the rules and standards contained in Iowa Code chapter 135C and the standards in 481—Chapter 61. Waivers from 481—Chapter 61 regulations are allowed under rule 481—61.2(135C). An application must be submitted to the department which states the type and category of license for which the facility is applying.  65.2(1)  Each application shall include:  a.  A floor plan of each floor of the facility drawn on 8½- × 11-inch paper showing room areas in proportion, room dimensions, room numbers for all rooms, including bathroom, and designation of the use to which room will be put and window and door location;  b.  A photograph of the front and side elevation of the facility;  c.  The statutory fee for an intermediate care facility license;  d.  Evidence of a certificate signed by the state fire marshal or deputy state fire marshal as to compliance with fire safety rules.  65.2(2)  A résumé of care with a narrative which includes the following information shall be submitted:  a.  The purpose of the facility;  b.  A description of the target population and limitations on resident eligibility;  c.  An identification and description of the services the facility will provide. This shall include at least specific and measurable goals and objectives for each service available in the facility and a description of the resources needed to provide each service including staff, physical facilities and funds;  d.  A description of the human service system available in the area, including, but not limited to, social, public health, visiting nurse, vocational training, employment services, sheltered living arrangements, and services of private agencies; and  e.  A description of working relationships with the human service agencies when applicable which shall include at least how the facility will coordinate with:  (1)  The department of human services to facilitate continuity of care and coordination of services to residents; and  (2)  Other agencies to identify unnecessary duplication of services and plan for development and coordination of needed services.  65.2(3)  In order to obtain a renewal or change of ownership license of the ICF/PMI the applicant must:  a.  Submit to the department the completed application form 30 days prior to annual license renewal or change of ownership date of the ICF/PMI license;  b.  Submit the statutory license fee for an ICF/PMI with the application for renewal or change of ownership;  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  d.  Submit documentation of review of résumé of care pursuant to subrule 65.2(1), paragraph “a,” and a copy of any revisions to the plan.This rule is intended to implement Iowa Code sections 135C.7 and 135C.9.Related ARC(s): 1205C, 5719C481—65.3(135C)  Licenses for distinct parts.  Separate licenses may be issued for distinct parts which are clearly identifiable parts of a health care facility, containing contiguous rooms in a separate wing or building or on a separate floor of the facility, which provide care and services of separate categories.The following requirements shall be met for a separate licensing of a distinct part:
    1. The distinct part shall serve only residents who require the category of care and services immediately available to them within that part. (III)
    2. The distinct part shall meet all the standards, rules and regulations pertaining to the category for which a license is being sought.
    3. The distinct part must be operationally and financially feasible.
    4. A separate personal care 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)
    5. Separately licensed distinct parts may have certain services such as management, building maintenance, laundry and dietary in common with each other.
    This rule is intended to implement Iowa Code section 135C.6(2).    481—65.4(135C)   Waivers.  Waivers from these rules may be granted by the director of the department when:
    1. The need for a waiver has been established consistent with the résumé of care or the resident’s individual program plan.
    2. There is no danger to the health, safety, welfare or rights of any resident.
    3. The waiver will apply only to a specific intermediate care facility for the mentally ill.
    Waivers shall be reviewed at least at the time of each licensure survey and any other time by the department to see if the need for the waiver is still acceptable.  65.4(1)  To request a waiver, the licensee must:  a.  Apply in writing on a form provided by the department;  b.  Cite the rule or rules from which a waiver is desired;  c.  State why compliance with the rule or rules cannot be accomplished;  d.  Explain how the waiver is consistent with the résumé of care or the individual program plan; and  e.  Demonstrate that the requested waiver will not endanger the health, safety, welfare or rights of any resident.  65.4(2)  Upon receipt of a request for waiver, the director will:  a.  Examine the rule from which the waiver is requested;  b.  Evaluate the requested waiver against the requirement of the rule to determine whether the request is necessary to meet the needs of the residents;  c.  Examine the effect of the requested waiver on the health, safety or welfare of the residents;  d.  Consult with the applicant to obtain additional written information if required; and  e.  Obtain approval of the Iowa mental health and disability services commission, when the request is for a waiver from the requirement for qualification of a mental health professional.  65.4(3)  Based upon this information, approval of the waiver will be either granted or denied within 120 days of receipt.    Related ARC(s): 0766C, 5719C481—65.5(135C)  General requirements.    65.5(1)  A valid license shall be posted in each facility so the public can easily see it. (III)  65.5(2)  Each license is valid only for the premises and person named on the license and is not transferable.  65.5(3)  The posted license shall accurately reflect the current status of the facility. (III)  65.5(4)  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)  65.5(5)  Licenses expire one year after the date of issuance or as indicated on the license.  65.5(6)  There shall be no more beds erected than are stipulated on the license. (II, III)This rule is intended to implement Iowa Code section 135C.8.481—65.6(135C)  Notification required by the department.  The department shall be notified within 48 hours, by letter, of any reduction or loss of personal care or dietary staff lasting more than seven days which places the staff ratio below that required for licensing. No additional residents shall be admitted until the minimum staff requirements are achieved. (II, III)  65.6(1)  Other required notification and time periods are:  a.  Within 30 days of any proposed change in the résumé of care for the ICF/PMI; (II, III)  b.  Thirty days before addition, alteration, or new construction is begun in the ICF/PMI or on the premises; (III)  c.  Thirty days before the ICF/PMI closes; (III)  d.  Within two weeks of any change of administrator; (II, III) and  e.  Within 30 days when any change in the category of license is sought. (III)  65.6(2)  Prior to the purchase, transfer, assignment, or lease of an ICF/PMI the licensee shall:  a.  Inform the department in writing of the pending sale, transfer, assignment, or lease of the facility; (III)  b.  Inform the department in writing 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) and  c.  Submit a written authorization to the department permitting the department to release information of whatever kind from the department’s files concerning the licensee’s ICF/PMI to the named prospective purchaser, transferee, assignee or lessee. (III)  65.6(3)  After the authorization has been submitted to the department, the department shall upon request send or give copies of all recent licensure surveys and any other pertinent information relating to the facility’s licensure status to the prospective purchaser, transferee, assignee or lessee. Costs for copies requested shall be paid by the prospective purchaser, transferee, assignee or lessee. No information personally identifying any resident shall be provided to the prospective purchaser, transferee, assignee or lessee. (II, III)This rule is intended to implement Iowa Code sections 135C.6(3) and 135C.16(2).481—65.7(135C)  Administrator.  Each ICF/PMI shall have one person in charge, duly approved by the department or acting in a provisional capacity in accordance with these regulations. (II, III)  65.7(1)  The administrator shall be at least 21 years of age and shall meet at least one of the following conditions:  a.  Be licensed in Iowa as a nursing home administrator, or certified as a residential care administrator. No residential care facility administrator certified under a waiver from the department shall administrate an intermediate care facility for persons with mental illness. The administrator must have at least two years’ experience in direct care or supervision of people with mental illness and at least one year of experience in an administrative capacity; (II, III) or  b.  Be a qualified mental health professional (QMHP) with at least one year of experience in an administrative capacity. (II, III)If an ICF/PMI is a distinct part of a licensed health care facility, the administrator of the facility as a whole may serve as the administrator of the ICF/PMI without meeting the requirements of subrule 65.7(1), paragraph “a” or “b.” When this occurs, the person in charge of the ICF/PMI distinct part shall meet the requirements of subrule 65.7(1), paragraph “a” or “b.” (II, III)  65.7(2)  The administrator of more than one facility shall be responsible for no more than 150 beds in total. (II, III)  a.  The distance between the two farthest facilities shall be no greater than 50 miles. (II, III)  b.  An administrator of more than one facility must designate an administrative staff person in each facility who shall be responsible for directing programs in the facility during the administrator’s absence. (II, III)  65.7(3)  The administrative staff person shall be designated in writing and immediately available to the facility on a 24-hour basis when the administrator is absent and residents are in the facility. (II, III)The person(s) designated shall:  a.  Have at least two years’ experience or training in a supervisory or direct care position in a mental health setting; (II, III)  b.  Be knowledgeable of the operation of the facility; (II, III)  c.  Have access to records concerned with the operation of the facility; (II, III)  d.  Be capable of carrying out administrative duties and of assuming administrative responsibilities; (II, III)  e.  Be at least 21 years of age; (III)  f.  Be empowered to act on behalf of the licensee during the administrator’s absence concerning the health, safety and welfare of the residents; (II, III) and  g.  Have training to carry out assignments and take care of emergencies and sudden illnesses of residents. (II, III)  65.7(4)  If an administrator serves more than one facility, a written plan shall be developed, implemented and available for review by the department designating regular and specific times the administrator will be available to meet with the staff and residents to provide direction and supervision of resident care and services. (II, III)  65.7(5)  When a facility has been unable to replace the administrator, through no fault of its own, a provisional administrator meeting the qualifications of the administrative staff person may be appointed on a temporary basis by the licensee to assume the administrative responsibilities for the facility. This person shall not serve more than three months without approval from the department. The department must be notified before the appointment of the provisional administrator. (III)  65.7(6)  A facility applying for initial licensing shall not have a provisional administrator. (III)This rule is intended to implement Iowa Code section 135C.14(2).481—65.8(135C)  Administration.    65.8(1)  The licensee shall:  a.  Be responsible for the overall operation of the ICF/PMI; (III)  b.  Be responsible for compliance with all applicable laws and with the rules of the department; (II, III)  c.  Establish written policies, which shall be available for review by the department or other agencies designated by Iowa Code section 135C.16(3), for the operation of the ICF/PMI including, but not limited to: (III)  (1)  Personnel; (III)  (2)  Admission; (III)  (3)  Evaluation services; (II, III)  (4)  Programming and individual program plan; (II, III)  (5)  Crisis intervention; (II, III)  (6)  Discharge or transfer; (III)  (7)  Medication management; (II)  (8)  Resident property; (II, III)  (9)  Financial affairs; (II, III)  (10)  Records; (III)  (11)  Health and safety; (II, III)  (12)  Nutrition; (III)  (13)  Physical facilities and maintenance; (III)  (14)  Resident rights; (II, III) and  d.  Furnish statistical information concerning the operation of the facility to the department within 30 days of request. (III)  65.8(2)  The administrator shall be responsible for the implementation of procedures to support the policies established by the licensee. (III)This rule is intended to implement Iowa Code section 135C.14.Related ARC(s): 1205C481—65.9(135C)  Personnel.    65.9(1)  The personnel policies and procedures shall include the following requirements:  a.  Written job descriptions for all employees or agreements for all consultants, which include duties and responsibilities, education, experience, or other requirements, and supervisory relationships; (III)  b.  Annual performance evaluations of all employees and consultants which are dated and signed by the employee or consultant and the supervisor; (III)  c.  Personnel records which are current, accurate, complete and confidential to the extent allowed by law. The record shall contain documentation of how the employee’s or consultant’s education and experience are relevant to the position for which they were hired; (III)  d.  Roles, responsibilities, and limitation of student interns and volunteers; (III)  e.  An orientation program for all newly hired employees and consultants which includes introduction to facility personnel policies and procedures and a discussion of the safety plan. Subparagraphs 65.9(1)“f”(3), (5) and (9) shall be included; (II, III)  f.  A plan for a continuing education program with a minimum of 12 in-service programs per year. There shall be a written, individualized staff development plan implemented for each employee. The plan shall take into consideration the duties of the employee and the needs of the facility identified in the résumé of care. The plan shall ensure that each employee has the opportunity to develop and enhance skills and to broaden and increase knowledge needed to provide effective resident care including, but not limited to:  (1)  First aid; (II, III)  (2)  Human needs and behavior; (II, III)  (3)  Problems and needs of persons with mental illness; for example, diagnosis and treatment, suicide assessment and prevention; (II, III)  (4)  Medication; (II, III)  (5)  Crisis intervention; for example, use of restraints and seclusion; (II)  (6)  Delivery of services in accordance with the principles of normalization; (III)  (7)  Infection control and wellness; (III)  (8)  Fire safety, disaster, and tornado preparation; (II, III) and  (9)  Resident rights. (II, III)  g.  Equal opportunity and affirmative action employment practices; (III)  h.  Procedures to be used when disciplining an employee; (III) and  i.  Appropriate dress and personal hygiene for staff and residents. (III)  65.9(2)  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 and at least every four years after beginning employment. (III)  b.  Screening and testing for tuberculosis shall be conducted pursuant to 481—Chapter 59. (I, II, III)  c.  No one shall 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; (I, II, III)  (4)  For which no reasonable accommodation can eliminate the risk. (I, II, III)Refer to Guideline for Infection Control in Hospital Personnel, 1998, Centers for Disease Control, U.S. Department of Health and Human Services, to determine (1), (2), (3) and (4).  d.  There shall be written policies for emergency medical care for employees in case of sudden illness or accident. These policies shall include the administrative individuals to be contacted. (III)  e.  Health certificates for all employees shall be available for review by the department. (III)  65.9(3)  Staffing. The facility shall establish, subject to approval of the department, the numbers and qualifications of the staff required in an ICF/PMI using as its criteria the services being offered as indicated on the résumé of care and as required for implementation of individual program plans. (II, III)  a.  Direct care staff. Direct care staff shall be present in the facility unless all residents are involved in activities away from the facility. The policies and procedures shall provide for an on-call staff person to be available when residents and staff are absent from the facility. (II, III)  (1)  The on-call staff person shall be designated in writing. (II, III)  (2)  Residents or another responsible person shall be informed of how to contact the on-call person. (II, III)The staffing plan shall ensure that at least one qualified direct care staff person is on duty to carry out and implement the individual program plans. (II, III)  b.  Qualified mental health professional. The ICF/PMI shall, by direct employment or contract, provide for sufficient services of a qualified mental health professional to attain or maintain the highest practicable mental and psychosocial well-being of each resident. Attainment shall be determined by resident assessment and individual plans of care. (I, II, III) Responsibilities of the QMHP shall include, but not be limited to:  (1)  Approval of each resident’s individual program plan; (II, III)  (2)  Monitoring the implementation of each resident’s individual program plan, including periodic personal contact; (II, III) and  (3)  Participation on each resident’s interdisciplinary team. (II, III)  c.  Nursing staff. Each facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Attainment shall be determined by resident assessments and individual plans of care.  (1)  The director of nursing (DON) shall be a registered nurse who is employed by the facility at least 40 hours per week. This person shall have two years’ experience in direct care or supervision of people with mental illness. (II, III)  (2)  The facility shall provide 24-hour service by licensed nurses, including at least one registered nurse on the day tour of duty, seven days a week. (II, III)  (3)  If the DON has other institutional responsibilities, a qualified registered nurse shall serve as the DON’s assistant so there is the equivalent of a full-time nursing supervisor on duty. (II, III)  (4)  The department shall 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 as indicated on the résumé of care and as required for implementation of individual program plans. (II, III)  (5)  The DON shall not serve as charge nurse in a facility with an average daily total occupancy of 60 or more residents. (II, III)  (6)  A waivered licensed practical nurse shall not be allowed as a charge nurse on any shift. (II, III)  (7)  There shall be at least two people capable of rendering nursing service awake, dressed, and on duty at all times. (II, III)  d.  Activity staff. Each ICF/PMI shall employ a recreational therapist, occupational therapist or activity coordinator to direct the activity program both inside and outside the facility in accordance with each resident’s individual program plan. (III)Staff for the activity program shall be based on the needs of the residents being served as identified on the IPP. (III)  (1)  The activity program director shall attend workshops or educational programs which relate to activity programming. These shall total a minimum of ten contact hours per year. (III)  (2)  Personnel coverage shall be provided when the activity program director is absent during scheduled activities. (III)  (3)  The activity program director shall have access to all information about residents necessary to carry out the program. (III)  e.  Responsibilities of the activity program director shall include:  (1)  Coordinating all activities, including volunteer or auxiliary activities and religious services; (III)  (2)  Ensuring that all records required are kept; (III)  (3)  Coordinating the activity program with all other services in the facility; (III) and  (4)  Participating in the in-service training program in the facility. This shall include attending as well as presenting sessions. (III)  65.9(4)  Personnel record.  a.  A personnel record shall be kept for each employee. (III)  b.  The record shall include the employee’s:  (1)  Name and address, (III)  (2)  Social security number, (III)  (3)  Date of birth, (III)  (4)  Date of employment, (III)  (5)  References, (III)  (6)  Position in the facility, (III)  (7)  Job description, (III)  (8)  Documentation of experience and education, (III)  (9)  Staff development plan, (III)  (10)  Annual performance evaluation, (II, III)  (11)  Documentation of disciplinary action, (II, III)  (12)  Date and reason for discharge or resignation, (III) and  (13)  Current physical examination. (III)  65.9(5)  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 as amended by 2013 Iowa Acts, Senate File 347, 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)This rule is intended to implement Iowa Code sections 135C.14(2) and 135C.14(6).Related ARC(s): 0663C, 0903C, 1205C481—65.10(135C)  General admission policies.  There shall be admission policies which address the following:
    1. No resident shall be admitted or retained who is in need of greater services than the facility can provide. (II, III)
    2. Residents shall be admitted only on a written order signed by a physician. (II, III)
    3. A preplacement visit shall be completed prior to admission, except in case of an emergency admission or readmission, to familiarize the applicant with the facility and services offered. The policies and procedures may allow for waiving the requirement at the request of a person seeking admission when the completion of the visit would create a hardship for the person seeking admission. If the distance to be traveled makes it impossible to complete the visit in an eight-hour day, this may be considered to create a hardship. (III)
    4. Prior to admission of an applicant, the facility shall obtain sufficient information to determine if its program is appropriate and adequate to meet the person’s needs. (III)
    5. Admission criteria shall include, but not be limited to, age, sex, current diagnosis from an American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, substance abuse, dual diagnosis and criteria that are consistent with the résumé of care. (III)
    6. Each facility shall maintain a waiting list with selection priorities identified. (III)
    7. No ICF/PMI may admit more residents than the number of beds for which it is licensed. (II, III)
    8. There shall be a written, organized orientation program for all residents which shall be planned and implemented to resolve or reduce personal, family, business, and emotional problems that may interfere with the health care, recovery, and rehabilitation of the individual and which shall be available for review by the department. (III)
    9. Infants and children under the age of 18 shall not be admitted as residents to an ICF/PMI for adults unless given prior written approval by the department. A distinct part of an ICF/PMI, segregated from the adult section, may be established based on a résumé 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)
    10. 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. (II, III)
    This rule is intended to implement Iowa Code sections 135C.3 and 135C.23.    481—65.11(135C)  Evaluation services.  Each resident admitted shall have a physical examination and tuberculin test no more than 30 days before admission and a physical examination annually after that. Each annual examination shall be sufficient to ensure the resident has no physical condition which precludes living in the facility. If the resident is admitted directly from a hospital, a copy of the hospital admission physical and discharge summary may meet this requirement. (II, III)  65.11(1)  In addition to the required initial physical examination, each resident shall be evaluated to identify physical health, current level of functioning and the need for services. This evaluation shall be completed within 30 days of admission and annually after that. Information from other sources may be used in the evaluation if the information meets the requirements of subrules 65.11(2) and 65.11(3). (II, III)  65.11(2)  The portion of the evaluation which describes the resident’s physical health shall:  a.  Identify current illnesses and disabilities and include recommendations for physical and physiological treatment and services; (II, III)  b.  Include a description of the resident’s ability for health maintenance; (II)  c.  Include a mental status examination and history of mental health and treatments; (II, III) and  d.  Be performed by a physician with a valid license to practice medicine and surgery, osteopathic medicine and surgery or osteopathy in Iowa. If the evaluation is not conducted in Iowa, it must be by a physician who holds a current license in the state in which the examination is performed. If the doctor is not a psychiatrist, a psychiatrist or health service provider in psychology licensed under Iowa Code section 154B.7 shall be consulted regarding the results of the mental status examination. (II, III)  65.11(3)  The portion of the evaluation which describes the resident’s current functioning level and need for services shall:  a.  Identify the functioning level and need for services in self-care, community living skills, psychotherapeutic treatment, vocational skills, and academic skills as appropriate; (II, III)  b.  Contain sufficient detail about skills and needs to determine appropriate placement; (II, III)  c.  Be made without regard to the availability of services; (III) and  d.  Be performed by a QMHP, consulting with an interdisciplinary team. (III)  65.11(4)  Results of all evaluations shall be in writing and maintained in resident records. After the initial evaluation, all subsequent evaluations shall contain sufficient detail to determine changes in the resident’s physical and mental health, skills, and need for services. (II, III)  65.11(5)  A narrative social history shall be completed for each resident within 30 days of admission. The social history shall be completed and approved by the qualified mental health professional before the IPP is developed. (III)  a.  When a social history is secured from another provider, the information shall be reviewed within 30 days of admission. The date of the review and a summary of significant changes in the information shall be entered in the resident’s record. The social worker who reviews the history shall sign it. (III)  b.  An annual review of the social history information shall be incorporated in the individual program plan progress notes. (III)  c.  The social history shall address at least the following areas:  (1)  Referral source and reason for admission; (II, III)  (2)  Legal status; (II, III)  (3)  Previous living arrangements; (III)  (4)  Services received previously and current service involvements; (II, III)  (5)  Significant medical and mental health conditions including at least illnesses, hospitalizations, past and current drug therapy, and special diets; (II, III)  (6)  Substance abuse history; (II, III)  (7)  Work history; (III)  (8)  Education history; (II)  (9)  Relationship with family, significant others, and other support systems; (III)  (10)  Cultural, ethnic and religious background; (II, III)  (11)  Hobbies and leisure time activities; (III)  (12)  Likes, dislikes, habits, and patterns of behavior; (II, III)  (13)  History of aggressive or suicidal behavior; (I, II, III) and  (14)  Impressions and recommendations. (II, III)This rule is intended to implement Iowa Code section 135C.14(7).481—65.12(135C)  Individual program plan (IPP).  An initial program plan shall be developed within 24 hours of admission. This plan shall be based on information gained from the resident, family, physician or referring facility. Services to be provided shall be addressed. Intervention to be provided, if and when the need arises, shall also be addressed in the IPP. The plan shall be followed until the IPP required in subrule 65.12(1) is complete. The initial plan shall be completed by a registered nurse, a qualified social worker or a QMHP. (II, III)  65.12(1)  An individual program plan for each resident shall be developed by an interdisciplinary team. The resident or the resident’s legal guardian has the ultimate authority to accept or reject the plan unless otherwise determined by the court. The IPP shall be approved and have implementation monitored by the QMHP. (II, III)  a.  The IPP shall be based on the individual service plan of the referring agency, if available, the information contained in the social history, the need for services identified in the evaluation, and any other pertinent information. (III)  b.  The facility shall assist the resident in obtaining access to academic services, community living skills training, legal services, self-care training, support services, transportation, treatment, and vocational education as needed. These services may be provided by the facility or obtained from other providers. (III)  c.  Services to the resident shall be provided in the least restrictive environment and shall incorporate the principle of normalization. (III)  d.  If needed services are not available and accessible, the facility shall document the actions taken to locate and obtain those services. The documentation shall identify needs which will not be met because of the lack of available services. (III)  e.  The IPP shall be developed within 30 days following admission to the facility and renewed at least annually. (II, III)  f.  The IPP shall be written, dated, signed by the interdisciplinary team members, and maintained in the resident’s record. (III)  g.  Written notice of the meeting to develop an IPP shall be mailed or delivered to everyone included in the interdisciplinary team conference at least two weeks before the scheduled meeting. (III)  65.12(2)  The IPP shall include the following:  a.  Goals, (III)  b.  Objectives, (III)  c.  Specific services to be provided, (III)  d.  People or agency responsible for providing services, (III)  e.  Beginning date, (III) and  f.  Anticipated duration of services. (III)  65.12(3)  The IPP shall set out the procedure to be used to evaluate whether objectives are achieved. This procedure shall incorporate a process for ongoing review and revision. (III)  65.12(4)  The interdisciplinary team shall review the IPP at a team meeting at least quarterly and when the resident’s condition changes. (II, III)  a.  The interdisciplinary team shall develop a written report which addresses:  (1)  The resident’s progress toward objectives; (II, III)  (2)  The need for continued services; (II, III)  (3)  Recommendations concerning alternative services or living arrangements; (II, III) and  (4)  Any recommended change in guardianship, conservatorship or commitment status. (II, III)  b.  The report shall reflect those involved in the review, the date of the review, and be maintained in the resident’s record. (III)  65.12(5)  There shall be procedures for recording the activities of each service provider and a mechanism to coordinate the activities of all service providers. Resident response to all activities shall be recorded. (III)  a.  Staff shall create a record at the time of a service required by the IPP. If this is not possible, the record shall be written no more than seven days later. (III)  b.  When the services are provided more than once a week, staff may make a monthly summarized entry in the resident’s record. (III)  c.  Entries shall be dated and signed by the person who provides the service. (III)  d.  Entries shall be made when incidents occur. (III)  e.  Entries shall be written in terms of behavioral observations and specific activities. Entries that involve subjective interpretations of a resident’s behavior or progress shall be clearly identified and shall be supplemented with descriptions of behavior upon which the interpretation was based. (III)This rule is intended to implement Iowa Code section 135C.14.481—65.13(135C)  Activity program.  Each ICF/PMI shall have an organized activity program which is directed by a person qualified as required by 65.9(3)“d.”  65.13(1)  An activity program plan for the facility shall be based on needs identified in IPPs and on other interests expressed by residents. The activity program shall include leisure time management. (III)  65.13(2)  Activities shall be offered at least daily during the daytime hours if residents are present, twice weekly in the evening and twice on the weekend. (III)  65.13(3)  Activities offered shall be varied and shall be planned for individuals, small groups or large groups. (III)  65.13(4)  Monthly calendars shall be prepared in advance and shall be kept for review by the department. Substitutions and cancellations shall be noted. (III)  65.13(5)  Activities department personnel shall coordinate programs with other facility personnel. (III)481—65.14(135C)  Crisis intervention.  There shall be written policies and procedures concerning crisis intervention. (II) These policies and procedures shall be:
    1. Directed to maximizing the growth and development of the individual by incorporating a hierarchy of available alternative methods that emphasize positive approaches; (II, III)
    2. Available in each program area and living unit; (II, III)
    3. Available to individuals and their families; (II, III) and
    4. Developed with the participation, as appropriate, of individuals served. (II, III)
      65.14(1)  Corporal punishment, physical abuse, and verbal abuse, for example, shouting, screaming, swearing, name calling, or any other activity which might damage an individual’s self-respect shall be prohibited. All residents shall be treated with fairness and respect as required by rule 481—65.25(135C). (II)  65.14(2)  Medication shall not be used as punishment, for the convenience of staff, or as a substitute for a program. Direct care staff shall monitor residents on medication and notify the physician if a resident is too sedated to participate in the IPP. (I, II)    481—65.15(135C)  Restraint or seclusion.  Physician’s orders are required to use any kind of mechanical restraints or seclusion. (I, II, III) Restraints are defined as the following:
    1. Type I is physical restraint which uses equipment to promote the safety of the individual. It is not applied directly to a person. Examples: divided doors and side rails.
    2. Type II is mechanical restraint applied to someone’s body. A device is applied to the body to promote safety of the individual. Examples: vests or soft tie devices, hand socks, geriatric chairs.
    3. Type III is mechanical restraint applied to any part of the body which inhibits only the movement of that part of the body. Examples: wrist, ankle or leg restraints and waist straps.
      65.15(1)  Temporary restraint of residents shall be used only to prevent injury to the resident or to others. (I, II)  65.15(2)  Temporary seclusion may be used:  a.  To prevent injury to the resident or to others; (I, II)  b.  To prevent serious disruption to the treatment program of other residents; (I, II)  c.  To decrease stimulation which contributes to psychotic behavior; (I, II) and  d.  When other interventions have failed. (I, II)Restraint and seclusion shall not be used for punishment, for the convenience of staff, or as a substitution for supervision of program. Seclusion shall be used only in a department approved seclusion room. (I, II)  65.15(3)  Restraints shall be stored in an area easily accessible to staff. (I, II, III) Type II and Type III restraints shall be specifically designed, manufactured, and customarily used to restrain individuals hospitalized in licensed psychiatric hospitals. Metal and plastic handcuffs, rope and makeshift devices are prohibited. (I, II)  65.15(4)  Under no circumstances shall a resident be allowed to participate in the restraint of another resident. (I, II)  65.15(5)  There shall be written policies that address the basic assumption and philosophy that govern the use of seclusion and physical and mechanical restraint. These shall:  a.  Define the uses of seclusion and mechanical restraints; (III)  b.  Designate staff who may authorize its use; (III)  c.  Identify procedures to follow when implementing the policy which shall include provisions to ensure privacy and safety for restrained residents; (III) and  d.  A written plan for treatment following the use of restraint or seclusion.  65.15(6)  The physician and QMHP shall be notified immediately of the resident’s need for placement in restraint or seclusion. An order for restraint or seclusion identifying the type, purpose and duration of use shall be obtained from the physician. If the resident is in seclusion longer than four hours, the physician and qualified mental health professional shall visit and evaluate the resident before the seclusion order is continued. If the resident is in restraint for two hours, the physician shall be called before the restraint order can be continued. If the resident is in restraint longer than four hours, the physician and QMHP shall visit and evaluate the resident before a restraint order is continued. Standing or PRN orders for seclusion or restraint are prohibited. (I, II)  65.15(7)  If a resident is restrained with Type II or Type III restraints for 6 hours or secluded for 12 hours in a 24-hour period; or if the resident is secluded or restrained with Type II or Type III restraints for any amount of time in three consecutive 24-hour periods, the physician and QMHP shall visit the resident and assess the resident’s need for a higher level of care. If the need for restraint or seclusion continues, the resident shall be transferred to an acute level of care. (I, II)  65.15(8)  During any period of mechanical restraint or seclusion, the facility shall provide for the emotional and physical needs of the resident. (I, II)  65.15(9)  The resident shall be informed of the reason for seclusion and restraint and conditions for release. The resident’s guardian shall be notified when Type II or Type III restraints or seclusion is used. The facility shall also notify the resident’s family or other significant person if the resident has previously signed a form granting consent to do so. (I, II, III)  65.15(10)  Each resident’s record shall contain all information about restraints or seclusion. The administrator shall maintain a daily record of seclusion use. This record shall be available for review by the department. (II, III)Documentation of each incident of restraint or seclusion shall include at least:  a.  Clinical assessment before the resident is secluded or restrained; (I, II)  b.  Circumstances that led to seclusion or restraint; (I, II)  c.  Explanation of less restrictive measures used before restraint or seclusion; (I, II)  d.  Physician’s order; (I, II)  e.  Visual observation of the resident every 15 minutes, or more frequently if needed, to monitor general well-being including respirations, circulation, positioning and alertness as indicated; (I, II)  f.  Description of the resident’s activity at the time of observation to include verbal exchange and behavior; (I, II)  g.  Description of safety procedures taken (removal of dangerous objects, etc.); (I, II)  h.  Vital signs, including blood pressure, pulse and respiration unless contraindicated by resident behavior and reasons documented; (I, II)  i.  Release of each mechanical restraint and exercise and massage every two hours; (I, II, III)  j.  Record of intake of food and fluid; (I, II, III)  k.  Use of toilet; (II, III) and  l.  Number of hours and minutes in seclusion. (II, III)  65.15(11)  The facility shall educate staff on restraint and seclusion theory and techniques. The training shall be conducted by people with experience and documented education in the appropriate use of restraint and seclusion. (II, III)  a.  The facility shall keep a record of the training for review by the department and shall include attendance. (II, III)  b.  Only staff who have documented training in restraint and seclusion theory and techniques shall be authorized to assist with seclusion or restraint of a resident. (I, II, III)  65.15(12)  The facility shall maintain a record of the hours and minutes of each type of restraint and seclusion used on a monthly basis.    481—65.16(135C)  Discharge or transfer.  Procedures for the discharge or transfer of the resident shall be established and followed. (II, III)  65.16(1)    Discharge plan.  The decision to discharge a person and the plan for doing so shall be established through the participation of the resident, members of the interdisciplinary team and other resource personnel as appropriate for the welfare of the individual. (II, III)  a.  Discharge planning shall begin within 30 days of admission and be carried out in accordance with the IPP. (II, III)  b.  As changes occur in a resident’s physical or mental condition necessitating services or care which cannot be adequately provided by the facility, the resident shall be transferred promptly to another appropriate facility pursuant to subrule 65.10(1). (II, III)  c.  Notification shall be made to the next of kin, legal representative, attending physician, and sponsoring agency, if any, prior to transfer or discharge of any resident. (III)  d.  Proper arrangements shall be made for the welfare of the resident prior to the transfer or discharge in the event of an emergency or inability to reach the next of kin or legal representative. (III)  e.  The licensee shall not refuse to discharge or transfer a resident when directed by the physician, resident, legal representative, or court. (II, III)  f.  Advanced notification by telephone shall be made to the receiving facility prior to the transfer of any resident. (III)  g.  When a resident is transferred or discharged, the current evaluation and treatment plan and progress notes for the last 30 days, as set forth in these rules, shall accompany the resident. (II, III)  h.  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)  i.  A discharge or transfer authorization and summary shall be prepared for each resident who has been discharged or transferred from the facility. It shall be disseminated to appropriate persons to ensure continuity of care and in accordance with the requirements to ensure confidentiality. (II, III)  j.  A transfer to a part of a facility that has a different license must be handled the same way as a transfer to another facility, and not as an intrafacility transfer. (II, III)  65.16(2)    Intrafacility transfer.  Residents shall not be arbitrarily moved from room to room within a health care facility. (II, III)  a.  Involuntary relocation may occur only to implement goals and objectives in the IPP and in the following situations:  (1)  Incompatibility with or behavior disturbing to roommates, as documented in the residents’ records; (I, II)  (2)  To allow a new admission to the facility which would otherwise not be possible due to separation of roommates by sex; (II, III)  (3)  Reasonable and necessary administrative decisions regarding the use and functioning of the building. (II, III)  b.  Unreasonable and unjustified reasons for changing a resident’s room without the concurrence of the resident or legal guardian include:  (1)  Punishment or behavior modification; (II) and  (2)  Discrimination on the basis of race or religion. (II, III)  c.  If intrafacility relocation is necessary for reasons outlined in paragraph “a,” the resident shall be notified at least 48 hours prior to the transfer and the reason shall be explained. The legal guardian shall be notified as soon as possible. The notification shall be documented in the resident’s record and signed by the resident or legal guardian within seven days unless documentation indicates that it was not possible to contact the legal guardian or obtain their signature. (II, III)  d.  If emergency relocation is required to protect the safety or health of the resident or other residents, the notification requirements may be waived. The conditions of the emergency shall be documented. The family and legal guardian shall be notified immediately, or as soon as possible, of the condition requiring emergency relocation, and the notification shall be documented. (II, III)  e.  A transfer to a part of a facility that has a different license must be handled the same way as a transfer to another facility and not as an intrafacility transfer. (II, III)  65.16(3)    Involuntary discharge or transfer permitted.  A facility may involuntarily discharge or transfer a resident for only one of the following reasons:  a.  Medical reasons, based on the resident’s needs and determined and documented in the resident’s record by the primary care provider;  b.  The resident’s social, emotional or physical well-being or that of other residents, as documented by the administrator or designee with specific information to support the determination that the resident’s continued presence in the facility would adversely affect the resident’s own well-being or that of other residents;   c.  Due to action pursuant to Iowa Code chapter 229; or  d.  Nonpayment for the resident’s stay, as described in the admission agreement for the resident’s stay. (I, II, III)  65.16(4)    Involuntary transfer or discharge—written notice.  Involuntary transfer or discharge of a resident from a facility shall be preceded by a written notice to the resident or the resident’s legal representative. (II, III)  a.  The notice shall contain all of the following information:  (1)  The stated reason for the proposed transfer or discharge. (II)  (2)  The effective date of the proposed transfer or discharge. (II)  (3)  A statement, in not less than 12-point type, that reads as follows:You have a right to appeal the facility’s decision to transfer or discharge you. If you think you should not have to leave this facility, you may request a hearing, in writing or verbally, with the Iowa department of inspections and appeals (hereinafter referred to as “department”) within 7 days after receiving this notice. You have a right to be represented at the hearing by an attorney or any other individual of your choice. If you request a hearing, it will be held no later than 14 days after the department’s receipt of your request and you will not be transferred before a final decision is rendered. In emergency circumstances, provision may be made for extension of the 14-day requirement upon request to the department designee. If you lose the hearing, you will not be transferred before the expiration date of either (1) 30 days following your receipt of the original notice of the discharge or transfer, or (2) no sooner than 5 days following final decision of such hearing, including the exhaustion of all appeals, whichever occurs later. To request a hearing or receive further information, call the department at (515)281-4115 or you may write to the department to the attention of: Administrator, Division of Health Facilities, Iowa Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa 50319. (II)  b.  The notice shall be personally delivered to the resident, and a copy shall be placed in the resident’s record. A copy shall also be transmitted to the department, the resident’s legal representative, primary care provider, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility. The notice shall indicate that copies have been transmitted to the required parties by using the abbreviation “cc:” and listing the names of all parties to whom copies were sent. (II)  c.  The notice required by paragraph 65.16(4)“a” shall be provided at least 30 days in advance of the proposed transfer or discharge unless one of the following occurs:  (1)  An emergency transfer or discharge is mandated by the resident’s health care needs and is in accordance with the written orders and medical justification of the primary care provider. Emergency transfers or discharges may also be mandated in order to protect the health, safety, or well-being of other residents and staff. (II)  (2)  The transfer or discharge is subsequently agreed to by the resident or the resident’s legal representative, and notification is given to the legal representative, the resident’s primary care provider, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility. (II)  d.  A hearing requested pursuant to this subrule shall be held in accordance with subrule 65.16(6).  65.16(5)    Involuntary transfer or discharge—emergency transfer or discharge.  In the case of an emergency transfer or discharge, the resident must be given a written notice prior to or within 48 hours following the transfer or discharge. (II, III)  a.  A copy of this notice must be placed in the resident’s file. The notice must contain all of the following information:  (1)  The stated reason for the transfer or discharge. (II)  (2)  The effective date of the transfer or discharge. (II)  (3)  A statement, in not less than 12-point type, that reads:You have a right to appeal the facility’s decision to transfer or discharge you on an emergency basis. If you think you should not have to leave this facility, you may request a hearing, in writing or verbally, with the Iowa department of inspections and appeals (hereinafter referred to as “department”) within 7 days after receiving this notice. You have a right to be represented at the hearing by an attorney or any other individual of your choice. If you request a hearing, it will be held no later than 14 days after the department’s receipt of your request. You may be transferred or discharged before the hearing is held or before a final decision is rendered. If you win the hearing, you have the right to be transferred back into the facility. To request a hearing or receive further information, call the department at (515)281-4115, or write to the department to the attention of: Administrator, Division of Health Facilities, Department of Inspections and Appeals, Lucas State Office Building, Des Moines, Iowa 50319-0083. (II)  b.  The notice shall be personally delivered to the resident, and a copy shall be placed in the resident’s record. A copy shall also be transmitted to the department, the resident’s legal representative, the resident’s primary care provider, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility. The notice shall indicate that copies have been transmitted to the required parties by using the abbreviation “cc:” and listing the names of all parties to whom copies were sent.  c.  A hearing requested pursuant to this subrule shall be held in accordance with subrule 65.16(6).  65.16(6)    Involuntary transfer or discharge—hearing.    a.  Request for hearing.  (1)  The resident must request a hearing within 7 days of receiving written notice.  (2)  The request must be made to the department, either in writing or verbally.  b.  The hearing shall be held no later than 14 days after the department’s receipt of the request unless either party requests an extension due to emergency circumstances.  c.  Except in the case of an emergency discharge or transfer, a request for a hearing shall stay a transfer or discharge pending a final decision, including the exhaustion of all appeals. (II)  d.  The hearing shall be heard by a department of inspections and appeals administrative law judge pursuant to Iowa Code chapter 17A and 481—Chapter 9. The hearing shall be public unless the resident or representative requests in writing that the hearing be closed. In a determination as to whether a transfer or discharge is authorized, the burden of proof by a preponderance of evidence rests on the party requesting the transfer or discharge.  e.  Notice of the date, time, and place of the hearing shall be sent by certified mail or delivered in person to the facility, the resident and the resident’s legal representative not later than five full business days after the department’s receipt of the request. The notice shall also inform the facility and the resident or the resident’s legal representative that they have a right to appear at the hearing in person or be represented by an attorney or other individual. The appeal shall be dismissed if neither party is present or represented at the hearing. If only one party appears or is represented, the hearing shall proceed with one party present.  f.  The administrative law judge’s written decision shall be sent by certified mail to the facility, resident, and resident’s legal representative within 10 working days after the hearing has been concluded.  65.16(7)    Nonpayment.  If nonpayment is the basis for involuntary transfer or discharge, the resident shall have the right to make full payment up to the date that the discharge or transfer is to be made and then shall have the right to remain in the facility. (II)  65.16(8)    Discussion of involuntary transfer or discharge.  Within 48 hours after notice of involuntary transfer or discharge has been received by the resident, the facility shall discuss the involuntary transfer or discharge with the resident, the resident’s legal representative, and the person or agency responsible for the resident’s placement, maintenance, and care in the facility. (II)  a.  The facility administrator or other appropriate facility representative serving as the administrator’s designee shall provide an explanation and discussion of the reasons for the resident’s involuntary transfer or discharge. (II)  b.  The content of the explanation and discussion shall be summarized in writing, shall include the names of the individuals involved in the discussion, and shall be made part of the resident’s record. (II)  c.  The provisions of this subrule do not apply if the involuntary transfer or discharge has already occurred pursuant to subrule 65.16(6) and emergency notice is provided within 48 hours.  65.16(9)    Involuntary discharge or transfer—transfer or discharge planning.    a.  The facility shall develop a plan to provide for the orderly and safe transfer or discharge of each resident to be transferred or discharged. (II)  b.  To minimize the possible adverse effects of the involuntary transfer, the resident shall receive counseling services by the sending facility before the involuntary transfer and by the receiving facility after the involuntary transfer. Counseling shall be documented in the resident’s record. (II)  c.  The counseling requirement in paragraph 65.16(9)“b” does not apply if the discharge has already occurred pursuant to subrule 65.16(5) and emergency notice is provided within 48 hours.  d.  Counseling, if required, shall be provided by a licensed mental health professional as defined in Iowa Code section 228.1(6). (II)  e.  The health care facility that receives a resident who has been involuntarily transferred shall immediately formulate and implement a plan of care which takes into account possible adverse effects the transfer may cause. (II)  65.16(10)    Transfer upon revocation of license or voluntary closure.  Residents shall not have the right to a hearing to contest an involuntary discharge or transfer resulting from the revocation of the facility’s license by the department of inspections and appeals. In the case of the voluntary closure of a facility, a period of 30 days must be allowed for an orderly transfer of residents to other facilities.This rule is intended to implement Iowa Code section 135C.14(8).Related ARC(s): 1205C, 1752C, 3523C481—65.17(135C)  Medication management.  Medications shall be prescribed on an individual basis by a person who is authorized by Iowa law to prescribe. (I, II)
    1. Medication orders shall be correctly implemented by qualified personnel. (II)
    2. Qualified staff shall ensure that residents are able to take their own medication. (I, II)
    3. Each physician order allowing a resident to self-administer medications shall specify whether this self-medication shall be without supervision or under the supervision of qualified staff as defined in 65.17(2). (I, II)
      65.17(1)  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.  f.  Unit dose medication shall remain in the identifiable unit dose package until given to the resident. (II)  g.  Medications that are not contained in unit dose packaging shall be set up, identified by resident name and medication name, and administered by the same person. The medications shall be administered within one hour of preparation. (II)  h.  The person administering medications must observe and check to make sure the resident swallows oral medications and must record the date, time, amount and name of each medication given. (II)  i.  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 prepare and inject the resident’s own insulin. (II)  j.  Current and accurate records must be kept on the receipt and disposition of all Schedule II drugs. (II, III)  65.17(2)  For each resident who is taking medication with or without supervision, there shall be documentation on the individual’s record to include:  a.  Name of resident; (II, III)  b.  Name of drug, dose, and schedule; (II, III)  c.  Method of administration; (II, III)  d.  Identified drug allergies and observed adverse reactions; (I, II)  e.  Special precautions for that resident; (I, II) and  f.  Documentation of resident’s continuing ability to administer own medication. (I, II)  65.17(3)  Medication counseling shall be provided for all residents in accordance with the IPP on an ongoing basis and as part of discharge planning unless contraindicated in writing by the physician with reasons and pursuant to 65.12(2)“c.” (II, III)Each resident and when appropriate, a family member or other identified caregiver, shall be given verbal and written information about all medications the resident is currently using, including over-the-counter medications. A suggested reference is “USPDI, Advice for the Patient.” (II, III)The information shall include:  a.  Name, reason for, and amount of medication to be taken; (II)  b.  Time medication is to be taken and reason that the schedule was established; (II)  c.  Possible benefits, risks and side effects of each medication, including over-the-counter medications; (II)  d.  A list of resources in the community qualified to answer questions about medications; (II, III) and  e.  A list of available resources or agencies which may assist the resident to obtain medication after discharge. (III)  65.17(4)  Residents who have been certified in writing by the physician as capable of taking their own medications may retain these medications in a secure centralized location. Individual locked storage shall be utilized. (II, III)  a.  Drug storage for residents who are unable to take their own medications and require supervision shall meet the following requirements:  (1)  Adequate size cabinet with lock which can be used for storage of drugs, solutions, and prescriptions. A locked drug cart may be used. (II, III)  (2)  A bathroom shall not be used for drug storage. (II, III)  (3)  The drug storage cabinet shall be kept locked when not in use. (II, III)  (4)  The drug storage cabinet key shall be in the possession of the employee charged with the responsibility of administering medication. (II, III)  (5)  Medications requiring refrigeration which are stored in a common refrigerator shall be kept in a locked box properly labeled, and separated from food and other items. (II, III)  (6)  Drugs for external use shall be stored separately from drugs for internal use. External medications are those to be applied to the outside of the body and include, but are not limited to, salves, ointments, gels, paste, soaps, baths, and lotions. Internal medications are those to be applied inside the body or ingested and include, but are not limited to, oral and injectable medications, eye drops and ointments, ear drops and ointments, and suppositories. Also, eye drops and ear drops shall be separated from each other as well as from other internal and external medications. (II, III)  (7)  All potent, poisonous, or caustic materials shall be stored in a separate room from the medications. (II, III)  (8)  Inspection of the condition of stored drugs shall be made by the administrator and a licensed pharmacist not less than once every three months. The inspection shall be verified by a report signed by the administrator and the pharmacist and filed with the administrator. The report shall include, but need not be limited to, certifying absence of the following: expired drugs, deteriorated drugs, improper labeling, drugs for which there is no current order, and drugs improperly stored. (III)  (9)  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 seven-day supply and a missing dose can be readily detected but must be kept in a locked medication cabinet. Quantities in excess of a seven-day supply must be double-locked. (II)  b.  Bulk supplies of prescription drugs shall not be kept. (III)  65.17(5)  All labels on medications must be legible. If labels are not legible, the medication shall be sent back to the dispenser as defined in Iowa Code section 147.107 for relabeling. (II, III)  a.  The medication for each resident shall be kept or stored in the original dispensed containers. (II, III)  b.  The facility shall adopt policies and procedures to destroy unused prescription drugs for residents who die. The policies and procedures shall include, but not be limited to, the following:  (1)  Drugs shall be destroyed by the person in charge in the presence of the administrator or the administrator’s designee or, if a unit dose system is used, the drugs shall be returned to the supplying pharmacist; (III)  (2)  Notation of the destruction shall be made in the resident’s chart, with signatures of the persons involved in the destruction; (III)  (3)  The manner in which the drugs are disposed of shall be identified (i.e., incinerator, sewer, landfill). (II, III)  c.  Reserved.  d.  The facility shall also adopt policies and procedures for the disposal of controlled substances as defined by the Iowa board of pharmacy dispensed to residents whose administration has been discontinued by the prescriber. These policies and procedures shall include, but not be limited to, the following:  (1)  Procedures for obtaining a release from the resident; (II, III)  (2)  The manner in which the drugs were destroyed and by whom, including witnesses to the destruction; (II, III)  (3)  Mechanisms for recording the destruction; (II, III)  (4)  Procedures to be used when the resident or the conservator or guardian refuses to grant permission for destruction. (II, III)  e.  The facility shall adopt policies and procedures for the disposal of unused, discontinued medication. The procedures shall include, but not be limited to:  (1)  A specified time after which medication must be destroyed, sent back to the dispenser or placed in long-term storage; (II, III)  (2)  Procedures for obtaining permission of the resident, or the conservator or guardian; (II, III)  (3)  Procedures to be used when the resident, conservator or guardian refuses to grant permission for disposal; (II, III)  (4)  Unused, discontinued medication shall be locked and shall be separate from current medication. (II, III)  f.  Reserved.  g.  Residents shall not keep any prescription or over-the-counter medication in their possession unless the resident has been determined to be capable of self-administration of medications. (I, II, III)  h.  No prescription drugs shall be administered to a resident without a written order signed by a person qualified to prescribe the medication and renewed quarterly. (II)  i.  Prescription drugs shall be reordered only with the permission of the attending prescriber. (II, III)  j.  No medications prescribed for one resident may be administered to or allowed in the possession of another resident. (II)  65.17(6)  Each facility shall establish policies and procedures to govern the administration of prescribed medications to residents 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. 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. (II, III)  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. (II, III)  c.  Medication distributed as described in this subrule may be issued only by facility personnel responsible for administering medication. (II, III)  65.17(7)  Each ICF/PMI that administers controlled substances shall annually obtain a registration from the Iowa board of pharmacy examiners pursuant to Iowa Code section 204.302(1). (III)This rule is intended to implement Iowa Code section 135C.14.    Related ARC(s): 1050C481—65.18(135C)  Resident property and personal affairs.  The admission of a resident does 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 guardian. (II, III)  65.18(1)  The admission of a resident shall not grant the ICF/PMI the authority or responsibility to manage the personal affairs of the resident except as may be necessary for the resident’s safety and for safe and orderly management of the facility as required by these rules and in accordance with the IPP. (III)  65.18(2)  An ICF/PMI 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)  65.18(3)  Residents’ funds held by the ICF/PMI shall be in a trust account and kept separate from funds of the facility. (III)  65.18(4)  No administrator, employee or their representative shall act as guardian, trustee, or conservator for any resident or the resident’s property, unless the resident is related to the person acting as guardian within the third degree of consanguinity. (III)  65.18(5)  If a facility is a county care facility, upon the verified petition of the county board of supervisors, the district court may appoint, without fee, the administrator of a county care facility as conservator or guardian, or both, of a resident of such a county care facility. The administrator may establish either separate or common bank accounts for cash funds of these residents. (III)This rule is intended to implement Iowa Code section 135C.24.481—65.19(135C)  Financial affairs.  Residents who have not been assigned a guardian or conservator by the court may manage their personal financial affairs, and to the extent, under written authorization by the residents that the facility assists in management, the management shall be carried out in accordance with Iowa Code section 135C.24. (II)  65.19(1)    Written account of resident funds.  The facility shall maintain a written account of all residents’ funds received by or deposited with the facility. (II)  a.  An employee shall be designated in writing to be responsible for resident accounts. (II)  b.  The facility shall keep on deposit personal funds over which the resident has control when requested by the resident. (II)  c.  If the resident requests these funds, they shall be given to the resident with a receipt maintained by the facility and a copy to the resident. If a conservator or guardian has been appointed for the resident, the conservator or guardian shall designate the method of disbursing the resident’s funds. (II)  d.  If the facility makes a financial transaction on a resident’s behalf, the resident or the resident’s legal guardian or conservator must receive or acknowledge having seen an itemized accounting of disbursements and current balances at least quarterly. A copy of this statement shall be maintained in the resident’s financial or business record. (II)  65.19(2)    Contracts.  There shall be a written contract between the facility and each resident which meets the following requirements:  a.  States the base rate or scale per day or per month, the services included, and the method of payment; (III)  b.  Contains a complete schedule of all offered services for which a fee may be charged in addition to the base rate; (III)  c.  Stipulates that no further additional fees shall be charged for items not contained in complete schedule of services listed in this subrule; (III)  d.  States the method of payment of additional charges; (III)  e.  Contains an explanation of the method of assessment of additional charges and an explanation of the method of periodic reassessment, if any, resulting in changing such additional charges; (III)  f.  States that additional fees may be charged to the resident for nonprescription drugs, other personal supplies, and services by a barber, beautician, etc.; (III)  g.  Contains 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 program assessment at the time of admission, which is determined in consultation with the administrator; (III)  h.  Includes the total fee to be charged initially to the specific resident; (III)  i.  States the conditions whereby the facility may make adjustments to its overall fees for residential care as a result of changing costs. (III) Furthermore, the contract shall provide that the facility shall give:  (1)  Written notification to the resident and responsible party, when appropriate, of changes in the overall rates of both base and additional charges at least 30 days prior to the effective date of changes; (III)  (2)  Notification to the resident and payer, when appropriate, of changes in additional charges based on a change in the resident’s condition. Notification must occur prior to the date the 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) and  (3)  The terms of agreement in regard to refund of all advance payments, in the event of transfer, death, or voluntary or involuntary discharge; (III)  j.  States the terms of agreement concerning holding and charging for a bed in the event of temporary absence of the resident, which terms shall include, at a minimum, the following provisions:  (1)  If a resident has a temporary absence from a facility for medical treatment, the facility shall hold the bed open and shall receive payment for the absent period in accordance with provisions of the contract between the resident or the legal guardian and the facility. (II)  (2)  If a resident has a temporary absence from a facility in accordance with the IPP, the facility shall ask the resident and payer if they wish the bed held open. This shall be documented in the resident’s record including the response. The bed shall be held open and the facility shall receive payment for the absent periods in accordance with the provisions of the contract between the resident or the legal guardian and the facility. (II)  k.  States the conditions under which the involuntary discharge or transfer of a resident would be affected; (III)  l.  States the conditions of voluntary discharge or transfer; (III) and  m.  Sets forth any other matters deemed appropriate by the parties to the contract. No contract or any provision 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)  65.19(3)    Contract—copy to party.  Each party shall receive a copy of the signed contract. (III)  65.19(4)  The contract shall 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 legal representative.  a.  The facility shall ask the resident or legal representative if they want 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)This rule is intended to implement Iowa Code sections 135C.23(1) and 135C.24.481—65.20(135C)  Records.    65.20(1)    Resident record.  The licensee shall keep a permanent record about each resident with all entries current, dated, and signed. (II) The record 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 the person to be notified in case of emergency; (III)  h.  Funeral director, telephone number, and address; (III)  i.  Pharmacy name, telephone number, and address; (III)  j.  Results of evaluation pursuant to rule 481—65.11(135C); (III)  k.  Certification by the physician that the resident requires no higher level of care than the facility is licensed to provide; (III)  l.  Physician’s orders for medication and treatments in writing, signed by the physician quarterly and diet orders renewed yearly; (III)  m.  A notation of yearly or other visits to physician or other professionals, all consultation reports and progress notes; (III)  n.  Any change in the resident’s condition; (II, III)  o.  A notation describing the resident’s condition on admission, transfer, and discharge; (III)  p.  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)  q.  A copy of instructions given to the resident, legal representative, or facility in the event of discharge or transfer; (III)  r.  Disposition of personal property; (III)  s.  Copy of IPP pursuant to subrule 65.12(1); (III) and  t.  Progress notes pursuant to subrules 65.12(4) and 65.12(5). (III)  65.20(2)    Confidentiality of resident records.  The facility shall have policies and procedures providing that each resident shall be ensured confidential treatment of all information, including information contained in an automatic data bank. The resident’s or the resident’s legal guardian’s written informed consent shall be required for the release of information to persons not otherwise authorized under law to receive it. (II)A release of information form shall be used which includes to whom the information shall be released, the reason for the information being released, how the information is to be used, and the period of time for which the release is in effect. A third party, not requesting the release, shall witness the signing of the release of information form. (II)  a.  The facility shall limit access to any resident records to staff and consultants providing professional service to the resident. Information shall be made available to staff only to the extent that the information is relevant to the staff person’s responsibilities and duties. (II)Only those personnel concerned with financial affairs of the residents may have access to the financial information. This is not meant to preclude access by representatives of state or federal regulatory agencies. (II)  b.  The resident, or the resident’s legal guardian, shall be entitled to examine all information and shall have the right to secure full copies of the record at reasonable cost upon request, unless the physician or QMHP determines the disclosure of the record or section is contraindicated in which case this information will be deleted prior to making the record available to the resident. This determination and the reasons for it must be documented in the resident’s record by the physician or qualified mental health professional in collaboration with the resident’s interdisciplinary team. (II)  65.20(3)    Incident records.  Each ICF/PMI shall maintain an incident record report and shall have available incident report forms. (II, III)  a.  The report of every incident shall be in detail on a printed incident report form. (II, III)  b.  The person in charge at the time of the incident shall oversee the preparation and sign the report. (III)  c.  A copy of the incident report shall be kept on file in the facility available for review and a part of administrative records. (III)  65.20(4)    Retention of records.  Records shall be retained in the facility for five years following termination of services to the resident even when there is a change of ownership. (III)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)This rule is intended to implement Iowa Code section 135C.24.481—65.21(135C)  Health and safety.    65.21(1)    Physician.  Each resident shall have a designated licensed physician who may be called when needed. (III)  65.21(2)    Emergency care.  Each facility shall have written policies and procedures for emergency medical or psychiatric care to include:  a.  A written agreement with a hospital or psychiatric facility or documentation of attempt to obtain a written agreement for the timely admission of a resident who, in the opinion of the attending physician, requires inpatient services; (II, III)  b.  Provisions consistent with Iowa Code chapter 229; (II, III) and  c.  Immediate notification by the person in charge to the physician or QMHP, as appropriate, of any accident, injury or adverse change in the resident’s condition. (I, II)  65.21(3)    First-aid kit.  A first-aid emergency kit shall be available on each floor in every facility. (II, III)  65.21(4)    Infection control.  Each facility shall have a written and implemented infection control program addressing the following:  a.  Techniques for hand washing consistent with Guidelines for Handwashing and Hospital Control, 1985, Centers for Disease Control, U.S. Department of Health and Human Services, PB85-923404; (I, II, III)  b.  Techniques for handling of blood, body fluids, and body wastes consistent with Guideline for Isolation Precautions in Hospitals, Centers for Disease Control, U.S. Department of Health and Human Services, PB96-138102; (I, II, III)  c.  Decubitus care; (I, II, III)  d.  Infection identification; (I, II, III)  e.  Resident care procedures to be used when there is an infection present consistent with Guideline for Isolation Precautions in Hospitals, Centers for Disease Control, U.S. Department of Health and Human Services, PB96-138102; (I, II, III)  f.  Sanitation techniques for resident care equipment; (I, II, III)  g.  Techniques for sanitary use and reuse of enteral feeding bags, feeding syringes and urine collection bags; (I, II, III)  h.  Techniques for use and disposal of needles, syringes, and other sharp instruments consistent with Guideline for Isolation Precautions in Hospitals, Centers for Disease Control, U.S. Department of Health and Human Services, PB96-138102; (I, II, III) and  i.  Aseptic techniques when using:  (1)  Intravenous or central line catheter consistent with Guideline for Prevention of Intravascular Device Related Infections, Centers for Disease Control, U.S. Department of Health and Human Services, PB97-130074, (I, II, III)  (2)  Urinary catheter, (I, II, III)  (3)  Respiratory suction, oxygen or humidification, (I, II, III)  (4)  Dressings, soaks, or packs, (I, II, III)  (5)  Tracheostomy, (I, II, III)  (6)  Nasogastric or gastrostomy tubes, (I, II, III)  (7)  Sanitary use and reuse of feeding syringes and single-resident uses and reuse of urine collection bags. (I, II, III)CDC Guidelines may be obtained from the U.S. Department of Commerce, Technology Administration, National Technical Information Service, 5285 Port Royal Rd., Springfield, Virginia 22161 (1-800-553-6847).  65.21(5)    Disposable items.  There shall be disposable or one-time use items available with provisions for proper disposal to prevent reuse except as allowed by 65.21(4)“g.”  65.21(6)    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)These rules are intended to implement Iowa Code sections 135C.14(3), 135C.14(5) and 135C.14(8).  65.21(7)    Dental services.  The facility shall assist residents to obtain regular and emergency dental services and provide necessary transportation. Dental services shall be performed only on the request of the resident or legal guardian. The resident’s physician shall be advised of the resident’s dental problems. (III)  65.21(8)    Safe environment.  The licensee of an ICF/PMI is responsible for the provision and maintenance of a safe environment for residents and personnel. (I, II) The ICF/PMI may have locked exit doors and shall meet the fire and safety rules and regulations as promulgated by the state fire marshal. (I, II)  65.21(9)    Disaster.  The licensee shall have a written emergency plan to be followed in the event of fire, tornado, explosion, or other emergency. (II, III)  a.  The plan shall be posted. (II, III)  b.  Training shall be provided to ensure that all employees and residents are knowledgeable of the emergency plan. The training shall be documented. (II, III)  c.  Residents shall be permitted to smoke only in posted areas where proper facilities are provided. Smoking by residents considered to be careless shall be prohibited except under direct supervision and in accordance with the IPP. (II, III)  65.21(10)    Safety precautions.  The facility shall take reasonable measures to ensure the safety of residents and shall involve the residents in learning the safe handling of household supplies and equipment in accordance with the policies and procedures established by the facility. (II)All potent, poisonous, or caustic materials shall be plainly labeled and stored in a specific locked, well-illuminated cabinet, closet, or storeroom and made accessible only to authorized persons. (I, II)  65.21(11)    Hazards.  Entrances, exits, steps, and outside steps and walkways shall be cleared of ice and snow as soon as possible, and kept free of other hazards. (II, III)  65.21(12)    Laundry.  All soiled linens shall be collected in and transported to the laundry room in closed, leakproof laundry bags or covered, impermeable containers. (III)  a.  Except for related activities, the laundry room shall not be used for other purposes. (III)  b.  Personal laundry shall be marked with an identification unless the residents are responsible for doing their own laundry as indicated in the individual program plan. (III)  c.  There shall be an adequate supply of clean, stain-free linens so that each resident shall have at least three washcloths, hand towels, and bath towels per week. (III)  d.  Each bed shall be provided with clean, stain-free washable bedspreads and sufficient lightweight serviceable blankets. A complete change of bed linens shall be available for each bed. Linens on beds shall be clean, stain-free and in good repair at all times. (III)  65.21(13)    Supplies, equipment, and storage.  Each facility shall provide a variety of supplies and equipment of a nature calculated to fit the needs and interests of the residents. These may include: books (standard and large print), magazines, newspapers, radio, television, bulletin boards, board games, game equipment, songbooks, cards, craft supplies, record player, movie projector, piano, and outdoor equipment. Supplies and equipment shall be appropriate to the chronological age of the residents. (III)Storage shall be provided for recreational equipment and supplies. (III)This rule is intended to implement Iowa Code section 135C.14(1).481—65.22(135C)  Nutrition.  There shall be policies and procedures written and implemented for dietary staffing.
    1. The person responsible for planning menus and monitoring the kitchens in each facility shall have completed training, approved by the department, in sanitation and food preparation. (III)
    2. In facilities licensed for over 15 beds, food service personnel shall be on duty during a 12-hour span extending from the preparation of breakfast through supper. (III)
    3. There shall be written work schedules and time schedules covering each type of job in the food service department for facilities over 15 beds. These work and time schedules shall be posted or kept in a notebook which is available for use in the food service area. (III)
      65.22(1)    Nutrition and menu planning.  Residents shall be encouraged to the maximum extent possible to participate in meal planning, shopping, and in preparing and serving the meal and cleaning up. The facility shall be responsible for helping residents become knowledgeable of what constitutes a nutritionally adequate diet. (III)  a.  Menus shall be planned and served to meet nutritional needs of residents in accordance with the physician’s diet orders which shall be renewed yearly. Menus shall be planned and served to include foods and amounts necessary to meet the recommended daily dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Other foods shall be included to meet energy requirements (calories) to add to the total nutrients and variety of meals. (II, III)  b.  At least three meals or their equivalent shall be made available to each resident daily, consistent with those times normally existing in the community. (II, III)  (1)  There shall be no more than a 14-hour span between the substantial evening meal and breakfast. (III)  (2)  To the extent medically possible, bedtime nourishments, containing a protein source, shall be offered routinely to all residents. Special nourishments shall be available when ordered by the physician. (II, III)  c.  Menus shall include a variety of foods prepared in various ways. The same menus shall not be repeated on the same day of the following week. (III)  d.  If modified diets are ordered by the physician, the person responsible for writing the menus shall have completed department-approved training in simple therapeutic diets. A copy of a modified diet manual approved by the department and written within the past five years shall be available in the facility. (II, III)  e.  Therapeutic diets shall be served accurately. (II, III)  f.  Menus shall be written at least one week in advance. The current menu shall be located in an accessible place in the dietetic service department for easy use by persons purchasing, preparing, and serving food. (III)  g.  Records of menus as served shall be filed and maintained for 30 days and shall be available for review by departmental personnel. When substitutions are necessary, they shall be of similar nutritive value and recorded on the menu or in a notebook. (III)  h.  A file of tested recipes adjusted to the number of people to be fed in the facility shall be maintained. (III)  65.22(2)    Dietary storage, food preparation, service.  In each stage, food shall be handled with maximum care for safety and good health.  a.  The use of foods from salvaged, damaged, or unlabeled containers is prohibited. (II, III)  b.  No perishable food shall be allowed to stand at room temperature any longer than is required to prepare and serve. (II, III)  c.  Canning food is prohibited. The facility may freeze fruits, vegetables, and meats provided strict sanitary procedures are followed and in accordance with recommendations in the “Food Service Sanitation Manual,” revised 1976, U.S. Department of Health, Education, and Welfare, Public Health Service, U.S. Government Printing Office, Washington, D.C. (II)  d.  Supplies of staple foods for a minimum of a one-week period and of perishable foods for a minimum of a three-day period shall be maintained on the premises. (III)  e.  If family-style service is used, all leftover prepared food that has been on the table shall be safely handled. (III)  f.  Poisonous compounds shall not be kept in food storage or preparation areas except for a sanitizing agent which shall be kept in a locked cabinet. (II, III)  65.22(3)    Sanitation in food preparation area.  The facility shall develop and implement policies and procedures to address sanitation, meal preparation and service in accordance with recommendations in the “Food Service Sanitation Manual” reference in 65.22(2)“c,” which shall be used as the established, nationally recognized reference for establishing and determining satisfactory compliance with the department’s food service and sanitation rules. (III)  a.  In facilities of 15 beds or fewer, residents may be allowed in the food preparation area in accordance with their IPP. (III)  b.  In facilities licensed for over 15 beds, the kitchen shall not be used for serving meals to residents, food service personnel, or other staff. (III)  c.  All appliances and work areas shall be kept clean and sanitary. (III)  d.  There shall be written procedures established for cleaning all work and serving areas in facilities over 15 beds and a schedule of duties to be performed daily shall be posted in each food area. (III)  e.  The food service area shall be located so it will not be used as a passageway by residents, guests, or nonfood service staff in facilities over 15 beds. (III)  f.  Dirty linen shall not be carried through the food service area unless it is in sealed, leakproof containers. (III)  g.  Mops, scrub pails, and other cleaning equipment used in the resident areas shall not be stored or used in the dietary area. (III)  65.22(4)    Hygiene of food service personnel.  If food service employees are assigned duties outside the dietetic service, these duties shall not interfere with sanitation, safety, or time required for dietetic work assignments. (II, III)  a.  Employees shall wear clean, washable uniforms that are not used for duties outside the food service area in facilities over 15 beds. (III)  b.  Hair nets shall be worn by all food service personnel and residents who do work in the kitchen in facilities over 15 beds and effective hair restraints in facilities with fewer than 15 beds. (III)  c.  People who handle food shall use correct hand-washing and food-handling techniques as identified in the “Food Service Sanitation Manual.” People who handle dirty dishes shall not handle clean dishes without washing their hands. (III)This rule is intended to implement Iowa Code section 135C.14.    481—65.23(135C)  Physical facilities and maintenance.    65.23(1)    Housekeeping.  The facility shall have written procedures for daily and weekly cleaning (III) which include, but need not be limited to:  a.  All rooms including furnishings, all corridors, storage areas, linen closets, attics, and basements shall be kept in a clean, orderly condition, free of unserviceable furniture and equipment or accumulations of refuse. (III)  b.  All resident bedrooms, including furnishings, shall be cleaned and sanitized before use by another resident. (III)  c.  Polishes used on floors shall provide a slip-resistant finish. (III)  65.23(2)    Equipment.  Housekeeping and maintenance personnel shall be provided with well-constructed and properly maintained equipment appropriate to the function for which it is to be used. (III)  a.  All facilities shall be provided with clean and sanitary storage for cleaning equipment, supplies, and utensils. In facilities over 15 beds, a janitor’s closet shall be provided. It shall be equipped with water for filling scrub pails and a janitor’s sink for emptying scrub pails. A hallway or corridor shall not be used for storage of equipment. (III)  b.  Sufficient numbers of noncombustible trash containers, which have covers, shall be available. (III)  c.  All containers for trash shall be watertight, rodent-proof, and have tight-fitting covers and shall be thoroughly cleaned each time a container is emptied. (III)  d.  All wastes shall be properly disposed of in compliance with the local ordinances and state codes. (III)  65.23(3)    Bedrooms.  Each resident shall be provided with a bed, substantially constructed and in good repair. (III)  a.  Rollaway beds, metal cots, or folding beds are not acceptable. (III)  b.  Each bed shall be equipped with the following: casters or glides; clean springs in good repair; a clean, comfortable, well-constructed mattress approximately 5 inches thick and standard in size for the bed; and clean, comfortable pillows of average bed size. (III)  c.  There shall be a comfortable chair, either a rocking chair or arm chair, per resident bed. The resident’s personal wishes shall be considered and documented. (III)  d.  There shall be drawer space for each resident’s clothing. In a multiple bedroom, drawer space shall be assigned each resident. (III)  e.  There shall be a bedside table with a drawer and a reading lamp for each resident. (III)  f.  All furnishings and equipment shall be durable, cleanable, and appropriate to its function. (III)  g.  All resident areas shall be decorated, painted, and furnished to provide a homelike atmosphere and in a manner which is age and culture appropriate. (III)  h.  Upholstery materials shall be moisture- and soil-resistant, except on furniture which is provided and owned by the resident. (III)  i.  Beds and other furnishings shall not obstruct free passage to and through doorways. (III)  j.  Beds shall not be placed with the side of the bed against a radiator or in close proximity to it unless the radiator is covered to protect the resident from contact with it or from excessive heat. (III)  65.23(4)    Bath and toilet facilities.  All lavatories shall have nonreusable towels or an air dryer and an available supply of soap. (III)  65.23(5)    Dining and living rooms.  Dining rooms and living rooms shall be available for use by residents at appropriate times to allow social, diversional, individual, and group activities. (III)  a.  Every facility shall have a dining room and a living room easily accessible to all residents which are never used as bedrooms. (III)  b.  A combination dining room and living room may be permitted if the space requirements of a multipurpose room as provided in 481—subrule 61.6(2) are met. (III)  c.  Living rooms shall be suitably furnished and maintained for the use of residents and their visitors and may be used for recreational activities. (III)  d.  Dining rooms shall be furnished with dining tables and chairs appropriate to the size and function of the facility. These rooms and furnishings shall be kept clean and sanitary. (III)  65.23(6)    Family and employee accommodations.  Resident bedrooms shall not be occupied by employees, family members of employees, or family members of the licensee. (III)  a.  In facilities where the total occupancy of family, employees, and residents is five or fewer, one toilet and one tub or shower is the minimum requirement. (III)  b.  In all health care facilities, if the family or employees live within the facility, living quarters shall be required for the family or employees separate from areas provided for residents. (III)  65.23(7)    Pets—policies.  Any facility in which a pet is living shall implement written policies and procedures addressing the following:  a.  Vaccination schedule; (III)  b.  Veterinary visit schedule; (III)  c.  Housing or sleeping quarters; (III) and  d.  Assignment of responsibility for feeding, bathing and cleanup. (III)  65.23(8)    Maintenance.  Each facility shall establish a program to ensure continued maintenance of the facility, to promote good housekeeping procedures, and to ensure sanitary practices throughout. In facilities over 15 beds, this program shall be in writing and be available for review by the department. (III)  a.  The buildings, furnishings and grounds shall be maintained in a clean, orderly condition and be in good repair. (III)  b.  The buildings and grounds shall be kept free of flies, other insects, rodents, and their breeding areas. (III)  65.23(9)    Buildings, furnishings, and equipment.    a.  Battery-operated, portable emergency lights in good working condition shall be available at all times, at a ratio of one light per employee on duty from 6 p.m.to 6 a.m.(III)  b.  All windows shall be supplied with curtains and shades or drapes which are kept in good repair. (III)  c.  Wherever glass sliding doors or transparent panels are used, they shall be marked conspicuously and decoratively. (III)  65.23(10)    Water supply.  Every facility shall have an adequate water supply from an approved source. A municipal source of water shall be considered as meeting this requirement. Private sources of water to a facility shall be tested annually and the report submitted with the annual application for license. (III)  a.  A bacterially unsafe source of water shall be grounds for denial, suspension, or revocation of license. (III)  b.  The department may require testing of private sources of water to a facility at its discretion in addition to the annual test. The facility shall supply reports of tests as directed by the department. (III)This rule is intended to implement Iowa Code section 135C.14.481—65.24(135C)  Care review committee.  Rescinded ARC 1205C, IAB 12/11/13, effective 1/15/14.481—65.25(135C)  Residents’ rights in general.  Each facility shall ensure that policies and procedures are written and implemented which include at least provisions in subrules 65.25(1) to 65.25(21). These shall govern all services provided to staff, residents, their families or legal representatives. The policies and procedures shall be available to the public and shall be reviewed annually. (II)  65.25(1)    Grievances.  Written policies and procedures shall include a method for submitting grievances and recommendations by residents or their legal representatives and for ensuring a response and disposition by the facility. The written procedure shall ensure protection of the resident from any form of reprisal or intimidation and shall include:  a.  An employee or an alternate designated to be responsible for handling grievances and recommendations; (II)  b.  Methods to investigate and assess the validity of a grievance or recommendation; (II) and  c.  Methods to resolve grievances and take action. (II)  65.25(2)    Informed of rights.  Policies and procedures shall include a provision that residents be fully informed of their rights and responsibilities as residents and of all rules governing resident conduct and responsibilities. This information must be provided upon admission, or when the facility adopts or amends residents’ rights policies. It shall be posted in locations accessible to all residents. (II)  a.  The facility shall make known to residents what they may expect from the facility and its staff, and what is expected from residents. The facility shall communicate these expectations during a period not more than two weeks before or later than five days after admission. The communication shall be in writing in a separate handout or brochure describing the facility. It shall be interpreted verbally, as part of a preadmission interview, resident counseling, or in individual or group orientation sessions after admission. (II)  b.  Residents’ rights and responsibilities shall be presented in language understandable to residents. If the facility serves residents who are non-English-speaking or deaf or hard of hearing, steps shall be taken to translate the information into a foreign or sign language. Blind residents shall be provided either Braille or a recording. Residents shall be encouraged to ask questions about their rights and responsibilities. Their questions shall be answered. (II)  c.  A statement shall be signed by the resident and legal guardian, if applicable, to indicate the resident understands these rights and responsibilities. The statement shall be maintained in the record. The statement shall be signed no later than five days after admission. A copy of the signed statement shall be given to the resident or legal guardian. (II)  d.  All residents, next of kin, or legal guardian shall be advised within 30 days of changes made in the statement of residents’ rights and responsibilities. Appropriate means shall be used to inform non-English-speaking, deaf or hard-of-hearing, or blind residents of changes. (II)  65.25(3)    Resident abuse prohibited.  Each resident shall receive kind and considerate care at all times and shall be free from physical, sexual, mental and verbal abuse, exploitation, neglect, and physical injury. (I, II)  65.25(4)    Allegations of dependent adult abuse.  Allegations of dependent adult abuse shall be reported and investigated pursuant to Iowa Code chapter 235E and 481—Chapter 52. (I, II, III)  65.25(5)    Report of abuse.  Rescinded IAB 12/11/13, effective 1/15/14.  65.25(6)    Informed of health condition.  Each resident or legal guardian shall be fully informed by a physician of the health and medical condition of the resident unless a physician documents reasons not to in the resident’s record. (II)  65.25(7)    Research.  The resident or legal guardian shall decide whether a resident participates in experimental research. Participation shall occur only when the resident or guardian is fully informed and signs a consent form. (II, III)Any clinical investigation involving residents must be sponsored by an institution with a human subjects review board functioning in accordance with the requirement of Public Law 93-348, as implemented by Part 46 of Title 45 of the Code of Federal Regulations, as amended December 1, 1981 (45 CFR 46). (III)  65.25(8)    Resident work.  Services performed by the resident for the facility shall be in accordance with the IPP. (II)  a.  Residents shall not be used to provide a source of labor for the facility against the resident’s will. Physician’s approval is required for all work programs and must be renewed yearly. (II, III)  b.  If the individual program plan requires activities for therapeutic or training reasons, the plan for these activities must be professionally developed and implemented. Therapeutic or training goals must be clearly stated and measurable and the plan shall be time limited and reviewed at least quarterly. (II, III)  c.  A resident engaged in work programs in the ICF/PMI shall be paid wages commensurate with wage and hour regulations for comparable work and productivity. (II)  d.  The resident shall have the right to employment options commensurate with training and skills. (II)  e.  Residents performing work shall not be used to replace paid employees to fulfill staff requirements. (II)  65.25(9)    Encouragement to exercise rights.  Residents shall be encouraged and assisted throughout their period of stay to exercise resident and citizen rights. Residents may voice grievances and recommend changes in policies and services to administrative staff or to an outside representative of their choice free from interference, coercion, discrimination, or reprisal. (II)  65.25(10)    Posting of names.  The facility shall post in a prominent area the name, telephone number, and address of the survey agency, local law enforcement agency, administrator, members of the board of directors, corporate headquarters, and the protection and advocacy agency designated pursuant to Iowa Code section 135C.2(4) and the text of Iowa Code section 135C.46 to provide to residents another course of redress. (II)  65.25(11)    Dignity preserved.  Residents shall be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and in care of personal needs. (II)  a.  Staff shall display respect for residents when speaking with, caring for, or talking about them as constant affirmation of the individuality and dignity of human beings. (II)  b.  Schedules of daily activities shall allow maximum flexibility for residents to exercise choice about what they will do and when they will do it. Residents’ individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, entertainment, sleeping, eating, and times to retire at night and arise in the morning shall be elicited and considered by the facility. The facility shall make every effort to match nonsmokers with other nonsmokers. (II)  c.  Residents shall not have their personal lives regulated beyond reasonable adherence to meal schedules, bedtime hours, and other written policies which may be necessary for the orderly management of the facility and as required by these rules; however, residents shall be encouraged to participate in recreational programs. (II)  d.  Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door shall shield the resident from passersby. People not involved in the care of a resident shall not be present without the resident’s consent during examination or treatment. (II)  e.  Privacy for each person shall be maintained when residents are being taken to the toilet or being bathed and while they are being helped with other types of personal hygiene, except as needed for resident safety or assistance. (II)  f.  Staff shall knock and be acknowledged before entering a resident’s room unless the resident is not capable of response. This does not apply under emergency conditions. (II)  65.25(12)    Communications.  Each resident may communicate, associate, and meet privately with persons of the resident’s choice, unless to do so would infringe upon the rights of other residents. Each resident may send and receive personal mail unopened unless prohibited in the IPP which has explicit approval of the resident or legal guardian. Telephones consistent with ANSI standards 42 CFR 405.1134(c) (10-1-86) shall be available and accessible for residents to make and receive calls with privacy. Residents who need help shall be assisted in using the telephone. (II)Arrangements shall be made to provide assistance to residents who require help in reading or sending mail. (II)  65.25(13)    Visiting policies and procedures.  Subject to reasonable scheduling restrictions, visiting policies and procedures shall permit residents to receive visits from anyone they wish. Visiting hours shall be posted. (II)  a.  Reasonable, regular visiting hours shall not be less than 12 hours per day and shall take into consideration the special circumstances of each visitor. A particular visitor(s) may be restricted by the facility for one of the following reasons:  (1)  The resident refuses to see the visitor(s). (II)  (2)  The visit would not be in accordance with the IPP. (II)  (3)  The visitor’s behavior is unreasonably disruptive to the functioning of the facility. (II)Reasons for denial of visitation shall be documented in resident records. (II)  b.  Decisions to restrict a visitor shall be reevaluated at least quarterly by the QMHP or at the resident’s request. (II)  c.  Space shall be provided for residents to receive visitors in comfort and privacy. (II)  65.25(14)    Resident activities.  Each resident may participate in activities of social, religious, and community groups as desired unless contraindicated for reasons documented by the attending physician or qualified mental health professional, as appropriate, in the resident’s record. (II)Residents who wish to meet with or participate in activities of social, religious or community groups in or outside the facility shall be informed, encouraged, and assisted to do so. (II)Residents shall be permitted to leave the facility and environs at reasonable times unless there are justifiable reasons established in writing by the attending physician, QMHP, or facility administrator for refusing permission. (II)  65.25(15)    Resident property.  Each resident may retain and use personal clothing and possessions as space permits and provided use is not otherwise prohibited in these rules. (II)  a.  Residents shall be permitted to keep reasonable amounts of personal clothing and possessions for their use while in the facility. The personal property shall be kept in a secure location which is convenient to the resident. (II)  b.  Residents shall be advised, prior to or at the time of admission, of the kinds and amounts of clothing and possessions permitted for personal use, and whether the facility will accept responsibility for maintaining these items, e.g., cleaning and laundry. (II)  c.  Any personal clothing or possession retained by the facility for the resident shall be identified and recorded on admission and the record placed on the resident’s chart. The facility shall be responsible for secure storage of items. They shall be returned to the resident promptly upon request or upon discharge from the facility. (II)  65.25(16)    Sharing rooms.  Residents, including spouses staying in the same facility, shall be permitted to share a room, if available, if requested by both parties, unless reasons to the contrary are in the IPP. Reasons for denial shall be documented in the resident’s record. (II)  65.25(17)    Choice of physician and pharmacy.  Each resident shall be permitted free choice of a physician and a pharmacy. The facility may require the pharmacy selected to use a drug distribution system compatible with the system currently used by the facility. (II)This rule is intended to implement Iowa Code section 135C.14 and Iowa Code chapter 235E.Related ARC(s): 1205C, 1204C, 5711C481—65.26(135C)  Incompetent residents.  Each facility shall provide that all rights and responsibilities of incompetent residents devolve to the legal guardian when a hearing has been held and the resident is judged incompetent in accordance with state law. (II)A facility is not absolved from advising incompetent residents of their rights to the extent the resident is able to understand them. The facility shall also advise the legal guardian, if any, and acquire a statement indicating an understanding of resident’s rights. (II)This rule is intended to implement Iowa Code sections 135C.14(8) and 135C.24.481—65.27(135C)  County care facilities.  In addition to these rules, county care facilities licensed as intermediate care facilities for persons with mental illness must also comply with department of human services rules 441—Chapter 37. Violation of any standard established by the department of human services is a Class II violation pursuant to 481—56.2(135C).This rule is intended to implement Iowa Code section 227.4.481—65.28(135C)  Violations.  Classification of violations is I, II and III, determined by the division using the provisions in 481—Chapter 56, “Fining and Citations,” to enforce a fine to cite a facility.481—65.29(135C)  Another business or activity in a facility.  A facility is allowed to have another business or activity in a health care facility or in the same physical structure of the facility, if the other business or activity is under the control of and is directly related to and incidental to the operation of the health care facility, or the business or activity is approved by the department and the state fire marshal.To obtain the approval of the department and the state fire marshal, the facility must submit to the department a written request for approval which identifies the service(s) to be offered by the business and addresses the factors outlined in paragraphs “a” through “j” of this rule. (I, II, III)  65.29(1)  The following factors will be considered by the department in determining whether a business or activity will interfere with the use of the facility by residents, interfere with services provided to residents, or be disturbing to residents:  a.  Health and safety risks for residents;  b.  Compatibility of the proposed business or activity with the facility program;  c.  Noise created by the proposed business or activity;  d.  Odors created by the proposed business or activity;  e.  Use of entrances and exits for the business or activity in regard to safety and disturbance of residents and interference with delivery of services;  f.  Use of the facility’s corridors or rooms as thoroughfares to the business or activity in regard to safety and disturbance of residents and interference with delivery of services;  g.  Proposed staffing for the business or activity;  h.  Sharing of services and staff between the proposed business or activity and the facility;  i.  Facility layout and design; and  j.  Parking area utilized by the business or activity.  65.29(2)  Approval of the state fire marshal shall be obtained before approval of the department will be considered.  65.29(3)  A business or activity conducted in a health care facility or in the same physical structure as a health care facility shall not reduce space, services or staff available to residents below minimums required in these rules and 481—Chapter 61. (I, II, III)481—65.30(135C)  Respite care services.  Respite care services means an organized program of temporary supportive care provided for 24 hours or more to a person in order to relieve the usual caregiver of the person from providing continual care to the person. A facility which chooses to provide respite care services must meet the following requirements related to respite care services and must be licensed as a health care facility.  65.30(1)  A facility which chooses to provide respite care services is not required to obtain a separate license or pay a license fee.  65.30(2)  Rules regarding involuntary discharge or transfer rights do not apply to residents who are being cared for under a respite care contract.  65.30(3)  The facility shall have a contract with each resident in the facility. When the resident is there for respite care services, the contract shall specify the time period during which the resident will be considered to be receiving respite care services. At the end of that period, the contract may be amended to extend that period of time. The contract shall specifically state the resident may be involuntarily discharged while being considered as a respite care resident. The contract shall meet other requirements for contracts between a health care facility and resident, except the requirements concerning the holding and charging for a bed when a resident is hospitalized or leaves the facility temporarily for recreational or therapeutic reasons.  65.30(4)  Respite care services shall not be provided by a facility to persons requiring a level of care which is higher than the level of care the facility is licensed to provide.These rules are intended to implement Iowa Code sections 135C.2(6), 135C.4, 135C.6(2), 135C.6(3), 135C.7, 135C.8, 135C.14, 135C.16(2), 135C.23, 135C.24, 135C.25, 135C.31, and 227.4.    Related ARC(s): 0663C, 0766C, 0903C, 1050C, 1205C, 1204C, 1752C, 3523C, 5711C, 5719C