Iowa Legislature: 441.82

CHAPTER 82INTERMEDIATE CARE FACILITIES FOR PERSONSWITH AN INTELLECTUAL DISABILITY[Prior to 7/1/83, Social Services[770] Ch 82][Prior to 2/11/87, Human Services[498]]441—82.1(249A) Definition.

"Department" means the Iowa department of human services.

"Intermediate care facility for persons with an intellectual disability (ICF/ID)" means an institution that is primarily for the diagnosis, treatment, or rehabilitation of persons with an intellectual disability or persons with related conditions and that provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination and integration of health or related services to help each person function at the greatest ability and is an approved Medicaid vendor.

"Intermediate care facility for persons with an intellectual disability level of care" means that the individual has a diagnosis of intellectual disability made in accordance with the criteria provided in the current version of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association; or has a related condition as defined in 42 CFR 435.1009 as amended to March 29, 2022; and needs assistance in at least three of the following major life areas: mobility, musculoskeletal skills, activities of daily living, domestic skills, toileting, eating skills, vision, hearing or speech or both, gross/fine motor skills, sensory-taste, smell, tactile, academic skills, vocational skills, social/community skills, behavior, and health care.

"Intermediate care facility for persons with medical complexity" means an intermediate care facility for persons with an intellectual disability which provides health and rehabilitation services to individuals who require a skilled nursing level of care, have either a multiple organ dysfunction or severe single organ dysfunction, and require daily use of medical resources or technology.

"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.

This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 2361C, 4052C, 6776C441—82.2(249A) Licensing and certification. In order to participate in the program, a facility shall be licensed as an intermediate care facility for persons with an intellectual disability by the department of inspections and appeals under the department of inspections and appeals rules found in 481—Chapter 64. The facility shall meet the following conditions of participation: 82.2(1) Governing body and management. a. Governing body. The facility shall identify an individual or individuals to constitute the governing body of the facility. The governing body shall: (1) Exercise general policy, budget, and operating direction over the facility. (2) Set the qualifications (in addition to those already set by state law) for the administrator of the facility. (3) Appoint the administrator of the facility. b. Compliance with federal, state, and local laws. The facility shall be in compliance with all applicable provisions of federal, state and local laws, regulations and codes pertaining to health, safety, and sanitation. c. Client records. (1) The facility shall develop and maintain a record-keeping system that includes a separate record for each client and that documents the clients’ health care, active treatment, social information, and protection of the client’s rights. (2) The facility shall keep confidential all information contained in the clients’ records, regardless of the form or storage method of the records. (3) The facility shall develop and implement policies and procedures governing the release of any client information, including consents necessary from the client or parents (if the client is a minor) or legal guardian. (4) Any individual who makes an entry in a client’s record shall make it legibly, date it, and sign it. (5) The facility shall provide a legend to explain any symbol or abbreviation used in a client’s record. (6) The facility shall provide each identified residential living unit with appropriate aspects of each client’s record. d. Services provided under agreements with outside sources. (1) If a service required under this rule is not provided directly, the facility shall have a written agreement with an outside program, resource, or service to furnish the necessary service, including emergency and other health care. (2) The agreement shall:

Contain the responsibilities, functions, objectives, and other terms agreed to by both parties.
Provide that the facility is responsible for ensuring that the outside services meet the standards for quality of services contained in this rule.

(3) The facility shall ensure that outside services meet the needs of each client. (4) If living quarters are not provided in a facility owned by the ICF/ID, the ICF/ID remains directly responsible for the standards relating to physical environment that are specified in subrule 82.2(7), paragraphs “a” to “g,” “j,” and “k.” e. Disclosure of ownership. The facility shall supply to the licensing agency full and complete information, and promptly report any changes which would affect the current accuracy of the information, as to identify: (1) Each person having a direct or indirect ownership interest of 5 percent or more in the facility and the owner in whole or in part of any property or assets (stock, mortgage, deed of trust, note or other obligation) secured in whole or in part by the facility. (2) Each officer and director of the corporation, if the facility is organized as a corporation. (3) Each partner, if the facility is organized as a partnership. 82.2(2) Client protections. a. Protection of clients’ rights. The facility shall ensure the rights of all clients. Therefore, the facility shall: (1) Inform each client, parent (if the client is a minor), or legal guardian of the client’s rights and the rules of the facility. (2) Inform each client, parent (if the child is a minor), or legal guardian, of the client’s medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment. (3) Allow and encourage individual clients to exercise their rights as clients of the facility, and as citizens of the United States, including the right to file complaints and the right to due process. (4) Allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities. (5) Ensure that clients are not subjected to physical, verbal, sexual, or psychological abuse or punishment. (6) Ensure that clients are free from unnecessary drugs and physical restraints and are provided active treatment to reduce dependency on drugs and physical restraints. (7) Provide each client with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs. (8) Ensure that clients are not compelled to perform services for the facility and ensure that clients who do work for the facility are compensated for their efforts at prevailing wages and commensurate with their abilities. (9) Ensure clients the opportunity to communicate, associate and meet privately with individuals of their choice, and to send and receive unopened mail. (10) Ensure that clients have access to telephones with privacy for incoming and outgoing local and long distance calls except as contraindicated by factors identified within their individual program plans. (11) Ensure clients the opportunity to participate in social, religious, and community group activities. (12) Ensure that clients have the right to retain and use appropriate personal possessions and clothing, and ensure that each client is dressed in the client’s own clothing each day. (13) Permit a husband and wife who both reside in the facility to share a room. b. Client finances. (1) The facility shall establish and maintain a system that ensures a full and complete accounting of clients’ personal funds entrusted to the facility on behalf of clients and precludes any commingling of client funds with facility funds or with the funds of any person other than another client. (2) The client’s financial record shall be available on request to the client, parents (if the client is a minor), or legal guardian. c. Communication with clients, parents, and guardians. The facility shall: (1) Promote participation of parents (if the client is a minor) and legal guardians in the process of providing active treatment to a client unless their participation is unobtainable or inappropriate. (2) Answer communications from clients’ families and friends promptly and appropriately. (3) Promote visits by individuals with a relationship to the client (such as family, close friends, legal guardians and advocates) at any reasonable hour, without prior notice, consistent with the right of that client’s and other clients’ privacy, unless the interdisciplinary team determines that the visit would not be appropriate. (4) Promote visits by parents or guardians to any area of the facility that provides direct client care services to the client, consistent with the right of that client’s and other clients’ privacy. (5) Promote frequent and informal leaves from the facility for visits, trips, or vacations. (6) Notify promptly the client’s parents or guardian of any significant incidents or changes in the client’s condition including, but not limited to, serious illness, accident, death, abuse, or unauthorized absence. d. Staff treatment of clients. (1) The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.

Staff of the facility shall not use physical, verbal, sexual or psychological abuse or punishment.
Staff shall not punish a client by withholding food or hydration that contributes to a nutritionally adequate diet.
The facility shall prohibit the employment of individuals with a conviction or prior employment history of child or client abuse, neglect or mistreatment.

(2) The facility shall ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with state law through established procedures. (3) The facility shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress. (4) The results of all investigations shall be reported to the administrator or designated representative or to other officials in accordance with state law within five working days of the incident, and, if the alleged violation is verified, appropriate corrective action shall be taken. 82.2(3) Facility staffing. a. Qualified intellectual disability professional. Each client’s active treatment program shall be integrated, coordinated and monitored by a qualified intellectual disability professional who has at least one year of experience working directly with persons with an intellectual disability or other developmental disabilities and is one of the following: (1) A doctor of medicine or osteopathy. (2) A registered nurse. (3) An individual who holds at least a bachelor’s degree in a professional category specified in 82.2(3)“b”(5). b. Professional program services. (1) Each client shall receive the professional program services needed to implement the active treatment program defined by each client’s individual program plan. Professional program staff shall work directly with clients and with paraprofessional, nonprofessional and other professional program staff who work with clients. (2) The facility shall have available enough qualified professional staff to carry out and monitor the various professional interventions in accordance with the stated goals and objectives of every individual program plan. (3) Professional program staff shall participate as members of the interdisciplinary team in relevant aspects of the active treatment process. (4) Professional program staff shall participate in ongoing staff development and training in both formal and informal settings with other professional, paraprofessional, and nonprofessional staff members. (5) Professional program staff shall be licensed, certified, or registered, as applicable, to provide professional services by the state in which the staff practices. Those professional program staff who do not fall under the jurisdiction of state licensure, certification, or registration requirements shall meet the following qualifications:

To be designated as an occupational therapist, an individual shall be eligible for certification as an occupational therapist by the American Occupational Therapy Association or another comparable body.
To be designated as an occupational therapy assistant, an individual shall be eligible for certification as an occupational therapy assistant by the American Occupational Therapy Association or another comparable body.
To be designated as a physical therapist, an individual shall be eligible for certification as a physical therapist by the American Physical Therapy Association or another comparable body.
To be designated as a physical therapy assistant, an individual shall be eligible for registration as a physical therapy assistant by the American Physical Therapy Association or be a graduate of a two-year college-level program approved by the American Physical Therapy Association or another comparable body.
To be designated as a psychologist, an individual shall have at least a master’s degree in psychology from an accredited school.
To be designated as a social worker, an individual shall hold a graduate degree from a school of social work accredited or approved by the Council on Social Work Education or another comparable body or hold a bachelor of social work degree from a college or university accredited or approved by the Council on Social Work Education or another comparable body.
To be designated as a speech-language pathologist or audiologist, an individual shall be eligible for a Certificate of Clinical Competence in Speech-Language Pathology or Audiology granted by the American Speech-Language Hearing Association or another comparable body or meet the educational requirements for certification and be in the process of accumulating the supervised experience required for certification.
To be designated as a professional recreation staff member, an individual shall have a bachelor’s degree in recreation or in a specialty area such as art, dance, music or physical education.
To be designated as a professional dietitian, an individual shall be eligible for registration by the Academy of Nutrition and Dietetics.
To be designated as a human services professional, an individual shall have at least a bachelor’s degree in a human services field (including, but not limited to, sociology, special education, rehabilitation counseling or psychology).

(6) If the client’s individual program plan is being successfully implemented by facility staff, professional program staff meeting the qualifications of 82.2(3)“b”(5) are not required except for qualified intellectual disability professionals who must meet the requirements set forth in 82.2(3)“a.” c. Facility staffing. (1) The facility shall not depend upon clients or volunteers to perform direct care services for the facility. (2) There shall be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing: clients for whom a physician has ordered a medical care plan; clients who are aggressive, assaultive or security risks; more than 16 clients; or fewer than 16 clients within a multi-unit building. (3) There shall be a responsible direct care staff person on duty on a 24-hour basis, when clients are present, to respond to injuries and symptoms of illness, and to handle emergencies, in each defined residential living unit housing: clients for whom a physician has not ordered a medical care plan; clients who are not aggressive, assaultive or security risks; and 16 or fewer clients. (4) The facility shall provide sufficient support staff so that direct care staff are not required to perform support services to the extent that these duties interfere with the exercise of their primary direct client care duties. d. Direct care (residential living unit) staff. (1) The facility shall provide sufficient direct care staff to manage and supervise clients in accordance with their individual program plans. (2) Direct care staff are defined as the present on-duty staff calculated over all shifts in a 24-hour period for each defined residential living unit. (3) Direct care staff shall be provided by the facility in the following minimum ratios of direct care staff to clients:

For each defined residential living unit serving children under the age of 12, severely and profoundly intellectually disabled clients, clients with severe physical disabilities, or clients who are aggressive, assaultive, or security risks, or who manifest severely hyperactive or psychotic-like behavior, the staff-to-client ratio is 1 to 3.2.
For each defined residential living unit serving moderately intellectually disabled clients, the staff-to-client ratio is 1 to 4.
For each defined residential living unit serving clients who function within the range of mild intellectual disability, the staff-to-client ratio is 1 to 6.4.
When there are no clients present in the living unit, a responsible staff member must be available by telephone.

e. Staff training program. (1) The facility shall provide each employee with initial and continuing training that enables the employee to perform the employee’s duties effectively, efficiently, and competently. (2) For employees who work with clients, training shall focus on skills and competencies directed toward clients’ developmental, behavioral, and health needs. (3) Staff shall be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients. (4) Staff shall be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client for whom they are responsible. 82.2(4) Active treatment services. a. Active treatment. (1) Each client shall receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this paragraph, that is directed toward: the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status. (2) Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program. b. Admissions, transfers, and discharge. (1) Clients who are admitted by the facility shall be in need of and receiving active treatment services. (2) Admission decisions shall be based on a preliminary evaluation of the client that is conducted or updated by the facility or by outside sources. (3) A preliminary evaluation shall contain background information as well as currently valid assessments of functional developmental, behavioral, social, health and nutritional status to determine if the facility can provide for the client’s needs and if the client is likely to benefit from placement in the facility. (4) If a client is to be either transferred or discharged, the facility shall have documentation in the client’s record that the client was transferred or discharged for good cause and shall provide a reasonable time to prepare the client and the client’s parents or guardian for the transfer or discharge (except in emergencies). (5) At the time of the discharge, the facility shall develop a final summary of the client’s developmental, behavioral, social, health and nutritional status and, with the consent of the client, parents (if the client is a minor) or legal guardian, provide a copy to authorized persons and agencies, and shall provide a post-discharge plan of care that will assist the client to adjust to the new living environment. c. Individual program plan. (1) Each client shall have an individual program plan developed by an interdisciplinary team that represents the professions, disciplines or service areas that are relevant to identifying the client’s needs, as described by the comprehensive functional assessments required in 82.2(4)“c”(3), and designing programs that meet the client’s needs. (2) Appropriate facility staff shall participate in interdisciplinary team meetings. Participation by other agencies serving the client is encouraged. For those clients enrolled with a managed care organization, the client’s case manager shall participate as appropriate and as allowed by the client. Participation by the client, the client’s parents (if the client is a minor), or the client’s legal guardian is required unless that participation is unobtainable or inappropriate. (3) Within 30 days after admission, the interdisciplinary team shall perform accurate assessments or reassessments as needed to supplement the preliminary evaluation conducted prior to admission. The comprehensive functional assessment shall take into consideration the client’s age (for example, child, young adult, elderly person) and the implications for active treatment at each stage, as applicable, and shall:

Identify the presenting problems and disabilities and, where possible, their causes.
Identify the client’s specific developmental strengths.
Identify the client’s specific developmental and behavioral management needs.
Identify the client’s need for services without regard to the actual availability of the services needed.
Include physical development and health, nutritional status, sensorimotor development, affective development, speech and language development, auditory functioning, cognitive development, social development, adaptive behaviors or independent living skills necessary for the client to be able to function in the community, and vocational skills as applicable.

(4) Within 30 days after admission, the interdisciplinary team shall prepare for each client an individual program plan that states the specific objectives necessary to meet the client’s needs, as identified by the comprehensive assessment required by 82.2(4)“c”(3), and the planned sequence for dealing with those objectives. These objectives shall:

Be stated separately, in terms of a single behavioral outcome.
Be assigned projected completion dates.
Be expressed in behavioral terms that provide measurable indices of performance.
Be organized to reflect a developmental progression appropriate to the individual.
Be assigned priorities.

(5) Each written training program designed to implement the objectives in the individual program plan shall specify:

The methods to be used.
The schedule for use of the method.
The person responsible for the program.
The type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives.
The inappropriate client behaviors, if applicable.
Provision for the appropriate expression of behavior and the replacement of inappropriate behavior, if applicable, with behavior that is adaptive or appropriate.

(6) The individual program plan shall also:

Describe relevant interventions to support the individual toward independence.
Identify the location where program strategy information (which shall be accessible to any person responsible for implementation) can be found.
Include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them.
Identify mechanical supports, if needed, to achieve proper body position, balance, or alignment. The plan shall specify the reason for each support, the situations in which each is to be applied, and a schedule for the use of each support.
Provide that clients who have multiple disabling conditions spend a major portion of each waking day out of bed and outside the bedroom area, moving about by various methods and devices whenever possible.
Include opportunities for client choice and self-management.

(7) A copy of each client’s individual program plan shall be made available to all relevant staff, including staff of other agencies who work with the client, and to the client, parents (if the client is a minor) or legal guardian. d. Program implementation. (1) As soon as the interdisciplinary team has formulated a client’s individual program plan, each client shall receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan. (2) The facility shall develop an active treatment schedule that outlines the current active treatment program and that is readily available for review by relevant staff. (3) Except for those facets of the individual program plan that must be implemented only by licensed personnel, each client’s individual program plan shall be implemented by all staff who work with the client, including professional, paraprofessional and nonprofessional staff. e. Program documentation. (1) Data relative to accomplishment of the criteria specified in client individual program plan objectives shall be documented in measurable terms. (2) The facility shall document significant events that are related to the client’s individual program plan and assessments and that contribute to an overall understanding of the client’s ongoing level and quality of functioning. f. Program monitoring and change. (1) The individual program plan shall be reviewed at least by the qualified intellectual disability professional and revised as necessary, including, but not limited to, situations in which the client:

Has successfully completed an objective or objectives identified in the individual program plan.
Is regressing or losing skills already gained.
Is failing to progress toward identified objectives after reasonable efforts have been made.
Is being considered for training toward new objectives.

(2) At least annually, the comprehensive functional assessment of each client shall be reviewed by the interdisciplinary team for relevancy and updated as needed, and the individual program plan shall be revised, as appropriate, repeating the process set forth in 82.2(4)“c.” (3) The facility shall designate and use a specially constituted committee or committees consisting of members of facility staff, parents, legal guardians, clients (as appropriate), qualified persons who have either experience or training in contemporary practices to change inappropriate client behavior, and persons with no ownership or controlling interest in the facility to:

Review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights.
Ensure that these programs are conducted only with the written informed consent of the client, parent (if the client is a minor), or legal guardian.
Review, monitor and make suggestions to the facility about its practices and programs as they relate to drug usage, physical restraints, time-out rooms, application of painful or noxious stimuli, control of inappropriate behavior, protection of client rights and funds, and any other area that the committee believes needs to be addressed.

(4) The provisions of 82.2(4)“f”(3) may be modified only if, in the judgment of the department of inspections and appeals, court decrees, state law or regulations provide for equivalent client protection and consultation. 82.2(5) Client behavior and facility practices. a. Facility practices—conduct toward clients. (1) The facility shall develop and implement written policies and procedures for the management of conduct between staff and clients. These policies and procedures shall:

Promote the growth, development, and independence of the client.
Address the extent to which client choice will be accommodated in daily decision making, emphasizing self-determination and self-management, to the extent possible.
Specify client conduct to be allowed or not allowed.
Be available to all staff, clients, parents of minor children, and legal guardians.

(2) To the extent possible, clients shall participate in the formulation of these policies and procedures. (3) Clients shall not discipline other clients, except as part of an organized system of self-government, as set forth in facility policy. b. Management of inappropriate client behavior. (1) The facility shall develop and implement written policies and procedures that govern the management of inappropriate client behavior. These policies and procedures shall be consistent with the provisions of 82.2(5)“a.” These procedures shall:

Specify all facility-approved interventions to manage inappropriate client behavior.
Designate these interventions on a hierarchy to be implemented ranging from most positive or least intrusive to least positive or most intrusive.
Ensure, prior to the use of more restrictive techniques, that the client’s record documents that programs incorporating the use of less intrusive or more positive techniques have been tried systematically and have been demonstrated to be ineffective.
Address the use of time-out rooms, the use of physical restraints, the use of drugs to manage inappropriate behavior, the application of painful or noxious stimuli, the staff members who may authorize the use of specified interventions, and a mechanism for monitoring and controlling the use of these interventions.

(2) Interventions to manage inappropriate client behavior shall be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected. (3) Techniques to manage inappropriate client behavior shall never be used for disciplinary purposes, for the convenience of staff or as a substitute for an active treatment program. (4) The use of systematic interventions to manage inappropriate client behavior shall be incorporated into the client’s individual program plan, in accordance with 82.2(4)“c”(4) and (5). (5) Standing or as-needed programs to control inappropriate behavior are not permitted. c. Time-out rooms. (1) A client may be placed in a room from which egress is prevented only if the following conditions are met:

The placement is a part of an approved systematic time-out program as required by 82.2(5)“b.”
The client is under the direct constant visual supervision of designated staff.
The door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member to keep the mechanism engaged.

(2) Placement of a client in a time-out room shall not exceed one hour. (3) Clients placed in time-out rooms shall be protected from hazardous conditions including, but not limited to, presence of sharp corners and objects, uncovered light fixtures, unprotected electrical outlets. (4) A record of time-out activities shall be kept. d. Physical restraints. (1) The facility may employ physical restraint only:

As an integral part of an individual program plan that is intended to lead to less restrictive means of managing and eliminating the behavior for which the restraint is applied.
As an emergency measure, but only if absolutely necessary to protect the client or others from injury.
As a health-related protection prescribed by a physician, but only if absolutely necessary during the conduct of a specific medical or surgical procedure, or only if absolutely necessary for client protection during the time that a medical condition exists.

(2) Authorizations to use or extend restraints as an emergency shall be in effect no longer than 12 consecutive hours and shall be obtained as soon as the client is restrained or stable. (3) The facility shall not issue orders for restraint on a standing or as-needed basis. (4) A client placed in restraint shall be checked at least every 30 minutes by staff trained in the use of restraints, shall be released from the restraint as quickly as possible, and a record of these checks and usage shall be kept. (5) Restraints shall be designated and used so as not to cause physical injury to the client and so as to cause the least possible discomfort. (6) Opportunity for motion and exercise shall be provided for a period of not less than ten minutes during each two-hour period in which restraint is employed, and a record of the activity shall be kept. (7) Barred enclosures shall not be more than three feet in height and shall not have tops. e. Drug usage. (1) The facility shall not use drugs in doses that interfere with the individual client’s daily living activities. (2) Drugs used for control of inappropriate behavior shall be approved by the interdisciplinary team and be used only as an integral part of the client’s individual program plan that is directed specifically toward the reduction and eventual elimination of the behaviors for which the drugs are employed. (3) Drugs used for control of inappropriate behavior shall not be used until it can be justified that the harmful effects of the behavior clearly outweigh the potentially harmful effects of the drugs. (4) Drugs used for control of inappropriate behavior shall be monitored closely, in conjunction with the physician and the drug regimen review requirement at 82.2(6)“j,” for desired responses and adverse consequences by facility staff, and shall be gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated. 82.2(6) Health care services. a. Physician services. (1) The facility shall ensure the availability of physician services 24 hours a day. (2) The physician shall develop, in coordination with licensed nursing personnel, a medical care plan of treatment for a client if the physician determines that an individual client requires 24-hour licensed nursing care. This plan shall be integrated in the individual program plan. (3) The facility shall provide or obtain preventive and general medical care as well as annual physical examinations of each client that at a minimum include the following:

Evaluation of vision and hearing.
Immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.
Routine screening laboratory examinations as determined necessary by the physician, and special studies when needed.
Tuberculosis control, appropriate to the facility’s population, and in accordance with the recommendations of the American College of Chest Physicians or the section of diseases of the chest of the American Academy of Pediatrics, or both.

(4) To the extent permitted by state law, the facility may utilize physician assistants and nurse practitioners to provide physician services as described in this subrule. b. Physician participation in the individual program plan. A physician shall participate in: (1) The establishment of each newly admitted client’s initial individual program plan. (2) If appropriate, physicians shall participate in the review and update of an individual program plan as part of the interdisciplinary team process either in person or through written report to the interdisciplinary team. c. Nursing services. The facility shall provide clients with nursing services in accordance with their needs. These services shall include: (1) Participation as appropriate in the development, review, and update of an individual program plan as part of the interdisciplinary team process. (2) The development, with a physician, of a medical care plan of treatment for a client when the physician has determined that an individual client requires such a plan. (3) For those clients certified as not needing a medical care plan, a review of their health status which shall:

Be by a direct physical examination.
Be by a licensed nurse.
Be on a quarterly or more frequent basis depending on client need.
Be recorded in the client’s record.
Result in any necessary action including referral to a physician to address client health problems.

(4) Other nursing care as prescribed by the physician or as identified by client needs. (5) Implementing, with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to:

Training clients and staff as needed in appropriate health and hygiene methods.
Control of communicable diseases and infections, including the instruction of other personnel in methods of infection control.
Training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients.

d. Nursing staff. (1) Nurses providing services in the facility shall have a current license to practice in the state. (2) The facility shall employ or arrange for licensed nursing services sufficient to care for clients’ health needs including those clients with medical care plans. (3) The facility shall utilize registered nurses as appropriate and required by state law to perform the health services specified in this subrule. (4) If the facility utilizes only licensed practical or vocational nurses to provide health services, it shall have a formal arrangement with a registered nurse to be available for verbal or on-site consultation with the licensed practical or vocational nurse. (5) Nonlicensed nursing personnel who work with clients under a medical care plan shall do so under the supervision of licensed persons. e. Dental services. (1) The facility shall provide or make arrangements for comprehensive diagnostic and treatment services for each client from qualified personnel, including licensed dentists and dental hygienists, either through organized dental services in-house or through arrangement. (2) If appropriate, dental professionals shall participate in the development, review and update of an individual program plan as part of the interdisciplinary process either in person or through written report to the interdisciplinary team. (3) The facility shall provide education and training in the maintenance of oral health. f. Comprehensive dental diagnostic services. Comprehensive dental diagnostic services include: (1) A complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client’s oral condition, not later than one month after admission to the facility unless the examination was completed within 12 months prior to admission. (2) Periodic examination and diagnosis performed at least annually, including radiographs when indicated and detection of manifestations of systemic disease. (3) A review of the results of examination and entry of the results in the client’s dental record. g. Comprehensive dental treatment. The facility shall ensure comprehensive dental treatment services that include: (1) The availability for emergency dental treatment on a 24-hour-a-day basis by a licensed dentist. (2) Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health. h. Documentation of dental services. (1) If the facility maintains an in-house dental service, the facility shall keep a permanent dental record for each client, with a dental summary maintained in the client’s living unit. (2) If the facility does not maintain an in-house dental service, the facility shall obtain a dental summary of the results of dental visits and maintain the summary in the client’s living unit. i. Pharmacy services. The facility shall provide or make arrangements for the provision of routine and emergency drugs and biologicals to its clients. Drugs and biologicals may be obtained from community or contract pharmacists or the facility may maintain a licensed pharmacy. j. Drug regimen review. (1) A pharmacist with input from the interdisciplinary team shall review the drug regimen of each client at least quarterly. (2) The pharmacist shall report any irregularities in clients’ drug regimens to the prescribing physician and interdisciplinary team. (3) The pharmacist shall prepare a record of each client’s drug regimen reviews and the facility shall maintain that record. (4) An individual medication administration record shall be maintained for each client. (5) As appropriate, the pharmacist shall participate in the development, implementation, and review of each client’s individual program plan either in person or through written report to the interdisciplinary team. k. Drug administration. The facility shall have an organized system for drug administration that identifies each drug up to the point of administration. The system shall ensure that: (1) All drugs are administered in compliance with the physician’s orders. (2) All drugs, including those that are self-administered, are administered without error. (3) Unlicensed personnel are allowed to administer drugs only if state law permits. (4) Clients are taught how to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective, and if the physician does not specify otherwise. (5) The client’s physician is informed of the interdisciplinary team’s decision that self-administration of medications is an objective for the client. (6) No client self-administers medications until the client demonstrates the competency to do so. (7) Drugs used by clients while not under the direct care of the facility are packaged and labeled in accordance with state law. (8) Drug administration errors and adverse drug reactions are recorded and reported immediately to a physician. l. Drug storage and record keeping. (1) The facility shall store drugs under proper conditions of sanitation, temperature, light, humidity, and security. (2) The facility shall keep all drugs and biologicals locked except when being prepared for administration. Only authorized persons may have access to the keys to the drug storage area. Clients who have been trained to self-administer drugs in accordance with 82.2(6)“k”(4) may have access to keys to their individual drug supply. (3) The facility shall maintain records of the receipt and disposition of all controlled drugs. (4) The facility shall, on a sample basis, periodically reconcile the receipt and disposition of all controlled drugs in Schedules II through IV (drugs subject to the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C. 801 et seq.). (5) If the facility maintains a licensed pharmacy, the facility shall comply with the regulations for controlled drugs. m. Drug labeling. (1) Labeling of drugs and biologicals shall be based on currently accepted professional principles and practices, and shall include the appropriate accessory and cautionary instructions, as well as the expiration date, if applicable. (2) The facility shall remove from use outdated drugs and drug containers with worn, illegible, or missing labels. (3) Drugs and biologicals packaged in containers designated for a particular client shall be immediately removed from the client’s current medication supply if discontinued by the physician. n. Laboratory services. (1) For purposes of this subrule, “laboratory” means an entity for the microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, pathological or other examination of materials derived from the human body, for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or assessment of a medical condition. (2) If a facility chooses to provide laboratory services, the laboratory shall meet the management requirements specified in 42 CFR 493.1407 as amended to March 29, 2022, and provide personnel to direct and conduct the laboratory services.The laboratory director shall be technically qualified to supervise the laboratory personnel and test performance and shall meet licensing or other qualification standards established by the state with respect to directors of clinical laboratories.The laboratory director shall provide adequate technical supervision of the laboratory services and ensure that tests, examinations and procedures are properly performed, recorded and reported.The laboratory director shall ensure that the staff has appropriate education, experience, and training to perform and report laboratory tests promptly and proficiently; is sufficient in number for the scope and complexity of the services provided; and receives in-service training appropriate to the type of complexity of the laboratory services offered.The laboratory technologists shall be technically competent to perform test procedures and report test results promptly and proficiently. (3) The laboratory shall meet the proficiency testing requirements specified in 42 CFR 493.801 as amended to March 29, 2022. (4) If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory shall be an approved Medicare laboratory. 82.2(7) Physical environment. a. Client living environment. (1) The facility shall not house clients of grossly different ages, developmental levels, and social needs in close physical or social proximity unless the housing is planned to promote the growth and development of all those housed together. (2) The facility shall not segregate clients solely on the basis of their physical disabilities. It shall integrate clients who have ambulation deficits or who are deaf, hard of hearing, blind, or have seizure disorders with others of comparable social and intellectual development. b. Client bedrooms. (1) Bedrooms shall:

Be rooms that have at least one outside wall.
Be equipped with or located near toilet and bathing facilities.
Accommodate no more than four clients unless granted a variance under 82.2(7)“b”(3).
Measure at least 60 square feet per client in multiple-client bedrooms and at least 80 square feet in single-client bedrooms.
In all facilities initially certified or in buildings constructed or with major renovations or conversions, have walls that extend from floor to ceiling.

(2) If a bedroom is below grade level, it shall have a window that is usable as a second means of escape by the client occupying the rooms and shall be no more than 44 inches measured to the windowsill above the floor unless the facility is surveyed under the Health Care Occupancy Chapter of the Life Safety Code, in which case the window must be no more than 36 inches measured to the windowsill above the floor. (3) The department of inspections and appeals may grant a variance from the limit of four clients per room only if a physician who is a member of the interdisciplinary team and who is a qualified intellectual disability professional certifies that each client to be placed in a bedroom housing more than four persons is so severely medically impaired as to require direct and continuous monitoring during sleeping hours and documents the reasons why housing in a room of only four or fewer persons would not be medically feasible. (4) The facility shall provide each client with:

A separate bed of proper size and height for the convenience of the client.
A clean, comfortable mattress.
Bedding appropriate to the weather and climate.
Functional furniture appropriate to the client’s needs, and individual closet space in the client’s bedroom with clothes racks and shelves accessible to the client.

c. Storage space in bedroom. The facility shall provide: (1) Space and equipment for daily out-of-bed activity for all clients who are not yet mobile, except those who have a short-term illness or those few clients for whom out-of-bed activity is a threat to health and safety. (2) Suitable storage space, accessible to clients, for personal possessions such as televisions, radios, prosthetic equipment and clothing. d. Client bathrooms. The facility shall: (1) Provide toilet and bathing facilities appropriate in number, size, and design to meet the needs of the clients. (2) Provide for individual privacy in toilets, bathtubs, and showers. (3) In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 degrees Fahrenheit. e. Heating and ventilation. (1) Each client bedroom in the facility shall have at least one window to the outside and direct outside ventilation by means of windows, air conditioning, or mechanical ventilation. (2) The facility shall maintain the temperature and humidity within a normal comfort range by heating, air conditioning or other means and ensure that the heating apparatus does not constitute a burn or smoke hazard to clients. f. Floors. The facility shall have: (1) Floors that have a resilient, nonabrasive, and slip-resistant surface. (2) Nonabrasive carpeting, if the area used by clients is carpeted and serves clients who lie on the floor or ambulate with parts of their bodies, other than feet, touching the floor. (3) Exposed floor surfaces and floor coverings that promote mobility in areas used by clients, and promote maintenance of sanitary conditions. g. Space and equipment. The facility shall: (1) Provide sufficient space and equipment in dining, living, health services, recreation, and program areas (including adequately equipped and sound treated areas for hearing and other evaluations if they are conducted in the facility) to enable staff to provide clients with needed services as required by this rule and as identified in each client’s individual program plan. (2) Furnish, maintain in good repair, and teach clients to use and to make informed choices about the use of dentures, eyeglasses, hearing and other communications aids, braces, and other devices identified by the interdisciplinary team as needed by the client. (3) Provide adequate clean linen and dirty linen storage areas. h. Emergency plan and procedures. (1) The facility shall develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients. (2) The facility shall communicate, periodically review, make the plan available, and provide training to the staff. i. Evacuation drills. (1) The facility shall hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to ensure that all personnel on all shifts are trained to perform assigned tasks; ensure that all personnel on all shifts are familiar with the use of the facility’s fire protection features; and evaluate the effectiveness of emergency and disaster plans and procedures. (2) The facility shall actually evacuate clients during at least one drill each year on each shift; make special provisions for the evacuation of clients with physical disabilities; file a report and evaluation on each evacuation drill; and investigate all problems with evacuation drills, including accidents, and take corrective action. During fire drills, clients may be evacuated to a safe area in facilities certified under the Health Care Occupancies Chapter of the Life Safety Code. (3) Facilities shall meet the requirements of 82.2(7)“i”(1) and (2) for any live-in and relief staff they utilize. j. Fire protection. (1) General.

Except as specified in 82.2(7)“i”(2), the facility shall meet the applicable provisions of either the Health Care Occupancies Chapters or the Residential Board and Care Occupancies Chapter of the Life Safety Code (LSC) of the National Fire Protection Association, 1985 edition, which is incorporated by reference.
The department of inspections and appeals may apply a single chapter of the LSC to the entire facility or may apply different chapters to different buildings or parts of buildings as permitted by the LSC.
A facility that meets the LSC definition of a residential board and care occupancy and that has 16 or fewer beds shall have its evacuation capability evaluated in accordance with the Evacuation Difficulty Index of the LSC (Appendix F).

(2) Exceptions.

For facilities that meet the LSC definition of a health care occupancy, the Centers for Medicare and Medicaid Services may waive, for a period it considers appropriate, specific provisions of the LSC if the waiver would not adversely affect the health and safety of the clients and rigid application of specific provisions would result in an unreasonable hardship for the facility.The department of inspections and appeals may apply the state’s fire and safety code instead of the LSC if the Secretary of the Department of Health and Human Services finds that the state has a code imposed by state law that adequately protects a facility’s clients.Compliance on November 28, 1982, with the 1967 edition of the LSC or compliance on April 18, 1986, with the 1981 edition of the LSC, with or without waivers, is considered to be compliance with this standard as long as the facility continues to remain in compliance with that edition of the code.
For facilities that meet the LSC definition of a residential board and care occupancy and that have more than 16 beds, the department of inspections and appeals may apply the state’s fire and safety code as specified above.

k. Paint. The facility shall: (1) Use lead-free paint inside the facility. (2) Remove or cover interior paint or plaster containing lead so that it is not accessible to clients. l. Infection control. (1) The facility shall provide a sanitary environment to avoid sources and transmission of infections. There shall be an active program for the prevention, control, and investigation of infection and communicable diseases. (2) The facility shall implement successful corrective action in affected problem areas. (3) The facility shall maintain a record of incidents and corrective actions related to infections. (4) The facility shall prohibit employees with symptoms or signs of a communicable disease from direct contact with clients and their food. 82.2(8) Dietetic services. a. Food and nutrition services. (1) Each client shall receive a nourishing, well-balanced diet including modified and specially prescribed diets. (2) A qualified dietitian shall be employed either full-time, part-time or on a consultant basis at the facility’s discretion. (3) If a qualified dietitian is not employed full-time, the facility shall designate a person to serve as the director of food services. (4) The client’s interdisciplinary team, including a qualified dietitian and physician, shall prescribe all modified and special diets including those used as a part of a program to manage inappropriate client behavior. (5) Foods proposed for use as a primary reinforcement of adaptive behavior are evaluated in light of the client’s nutritional status and needs. (6) Unless otherwise specified by medical needs, the diet shall be prepared at least in accordance with the latest edition of the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences, adjusted for age, sex, disability and activity. b. Meal services. (1) Each client shall receive at least three meals daily, at regular times comparable to normal mealtimes in the community with:

Not more than 14 hours between a substantial evening meal and breakfast of the following day, except on weekends and holidays when a nourishing snack is provided at bedtime, 16 hours may elapse between a substantial evening meal and breakfast.
Not less than 10 hours between breakfast and the evening meal of the same day, except as provided under 82.2(8)“b”(1)“1.”

(2) Food shall be served:

In appropriate quantity.
At appropriate temperature.
In a form consistent with the developmental level of the client.
With appropriate utensils.

(3) Food served to clients individually and uneaten shall be discarded. c. Menus. (1) Menus shall:

Be prepared in advance.
Provide a variety of foods at each meal.
Be different for the same days of each week and adjusted for seasonal change.
Include the average portion sizes for menu items.

(2) Menus for food actually served shall be kept on file for 30 days. d. Dining areas and service. The facility shall: (1) Serve meals for all clients, including persons with ambulation deficits, in dining areas, unless otherwise specified by the interdisciplinary team or a physician. (2) Provide table service for all clients who can and will eat at a table, including clients in wheelchairs. (3) Equip areas with tables, chairs, eating utensils, and dishes designed to meet the developmental needs of each client. (4) Supervise and staff dining rooms adequately to direct self-help dining procedure, to ensure that each client receives enough food and to ensure that each client eats in a manner consistent with the client’s developmental level. (5) Ensure that each client eats in an upright position, unless otherwise specified by the interdisciplinary team or physician.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 0582C, 2361C, 5808C, 6776C441—82.3(249A) Conditions of participation for intermediate care facilities for persons with an intellectual disability. All intermediate care facilities for persons with an intellectual disability must enter into a contractual agreement with the department which sets forth the terms under which they will participate in the program. 82.3(1) Procedures for establishing health care facilities as Title XIX facilities. All survey procedures and the certification process shall be in accordance with Department of Health and Human Services publication “Providers Certification State Operations Manual.” a. The facility shall obtain the applicable license from the department of inspections and appeals. b. The facility shall request an application, Form 470-0254, from the Iowa Medicaid provider services unit. c. The department shall transmit an application form and copies of standards to the facility. d. The facility shall complete its portion of the application form and submit it to the department. e. The department shall review the application form and forward it to the department of inspections and appeals. f. The department of inspections and appeals shall schedule and complete a survey of the facility. g. The department of inspections and appeals shall notify the facility of any deficiencies and ask for a plan for the correction of the deficiencies. h. The facility shall submit a plan of correction within ten days after receipt of written deficiencies from the health facilities division, department of inspections and appeals. This plan must be approved before the facility can be certified. i. The department of inspections and appeals shall evaluate the survey findings and plan of correction and either recommend the facility for certification or recommend denial of certification. The date of certification will be the date of approval of the plan of corrections. j. When certification is recommended, the department of inspections and appeals shall notify the department recommending terms and conditions of a provider agreement. k. The department shall review the certification data and: (1) Transmit the provider agreement as recommended, or (2) Transmit the provider agreement for a term less than recommended by the department of inspections and appeals or elect not to execute an agreement for reasons of good cause as defined in 82.3(2)“c.” 82.3(2) Title XIX provider agreements. The health care facility must be recommended for certification by the Iowa department of inspections and appeals for participation as an intermediate care facility for persons with an intellectual disability before a provider agreement may be issued. All survey procedures and certification processes shall be in accordance with Department of Health and Human Services publication “Providers Certification State Operations Manual.” The effective date of a provider agreement may not be earlier than the date of certification. a. Terms of the agreement for facilities without deficiencies are as follows: (1) The provider agreement shall be issued for a period not to exceed 12 months. (2) The provider agreement shall be for the term of and in accordance with the provisions of certification, except that for good cause, the department may elect to execute an agreement for a term less than the period of certification, elect not to execute an agreement for reasons of good cause, or cancel an agreement. b. Terms of the agreement for facilities with deficiencies are as follows: (1) A new provider agreement may be executed for a period not to exceed 60 days from the time required to correct deficiencies up to a period of 12 months. (2) A new provider agreement may be issued for a period of up to 12 months subject to automatic cancellation 60 days following the scheduled date for correction unless required corrections have been completed or unless the survey agency finds and notifies the department that the facility has made substantial progress in correcting the deficiencies and has resubmitted in writing a new plan of correction acceptable to the survey agency. (3) There will be no new agreement when the facility continues to be out of compliance with the same standard(s) at the end of the term of agreement. c. The department may, for good cause, elect not to execute an agreement. Good cause shall be defined as a continued or repeated failure to operate an intermediate care facility for persons with an intellectual disability in compliance with rules and regulations of the program. d. The department may at its option extend an agreement with a facility for two months under either of the following conditions: (1) The health and safety of the residents will not be jeopardized thereby and the extension is necessary to prevent irreparable harm to the facility or hardship to the resident. (2) It is impracticable to determine whether the facility is complying with the provisions and requirements of the provider agreement. e. When it becomes necessary for the department to cancel or refuse to renew a Title XIX provider agreement, federal financial participation may continue for 30 days beyond the date of cancellation if the extension is necessary to ensure the orderly transfer of residents. f. When the department of inspections and appeals survey indicates deficiencies in the areas of the Life Safety Code (LSC) or environment and sanitation, a timetable detailing corrective measures shall be submitted to the department of inspections and appeals before a provider agreement can be issued. This timetable shall not exceed two years from the date of initial certification and shall detail corrective steps to be taken and when corrections will be accomplished. The following shall apply in these instances. (1) The department of inspections and appeals shall determine that the facility can make corrections within the two-year period. (2) During the period allowed for corrections, the facility shall be in compliance with existing state fire safety and sanitation codes and regulations. (3) The facility shall be surveyed at least semiannually until corrections are completed. The facility must have made substantial effort and progress in its plan of correction as evidenced by work orders, contracts, or other evidence. 82.3(3) Appeals of decertification. A facility may appeal a decertification action according to 441—subrule 81.13(28).This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 0582C, 6776C441—82.4 Reserved.441—82.5(249A) Financial and statistical report. All facilities wishing to participate in the program shall submit a Financial and Statistical Report, Form 470-0030, to the department. These reports shall be based on the following rules. 82.5(1) Failure to maintain records. Failure to maintain and submit adequate accounting or statistical records shall result in termination or suspension of participation in the program. 82.5(2) Accounting procedures. Financial information shall be based on that appearing in the audited financial statement. Adjustments to convert to the accrual basis of accounting shall be made when the records are maintained on other accounting bases. Facilities which are a part of a larger health facility extending short-term, intensive, or other health care not generally considered nursing care may submit a cost apportionment schedule prepared in accordance with recognized methods and procedures. The schedule shall be required when necessary for a fair presentation of expense attributable to intermediate care facility patients. 82.5(3) Submission of reports. The facility’s cost report shall be received by the Iowa Medicaid provider cost audit and rate setting unit no later than September 30 each year except as described in subrule 82.5(14). a. The submission shall include a working trial balance that corresponds to all financial data contained on the cost report. The working trial balance must provide sufficient detail to enable the Iowa Medicaid provider cost audit and rate setting unit to reconcile accounts reported on the general ledger to those on the financial and statistical report. For reporting costs that are not directly assigned to the facility in the working trial balance, an allocation method must be identified for each line, including the statistics used in the calculation. Reports submitted without a working trial balance shall be considered incomplete, and the facility shall be subject to the rate reductions set forth in paragraph 82.5(3)“c.” b. If the financial statements have been compiled, reviewed or audited by an outside firm, a copy of the compilation, review or audit, including notes, for the reporting period shall be included with the submission of the financial and statistical report. c. Failure to timely submit the complete report shall reduce payment to 75 percent of the current rate. (1) The reduced rate shall be effective October 1 and shall remain in effect until the first day of the month after the delinquent report is received by the Iowa Medicaid provider cost audit and rate setting unit. (2) The reduced rate shall be paid for no longer than three months, after which time no further payments will be made until the first day of the month after the delinquent report is received by the Iowa Medicaid provider cost audit and rate setting unit. d. Amended reports. The department, in its sole discretion, may reopen a review of a financial and statistical report at any time. No other entity or person has the right to request that the department or its contractor reopen a review of a financial and statistical report, or submit an amended financial and statistical report for review by the department, after the facility is notified of its per diem payment rate following a review of a financial and statistical report. e. When an intermediate care facility for persons with an intellectual disability continues to include in the total costs an item or items which had in a prior period been removed through an adjustment made by the department or its contractor, the contractor shall recommend to the department that the per diem be reduced to 75 percent of the current payment rate for the entire quarter beginning the first day of the fourth month after the facility’s fiscal year end. If the adjustment has been contested and is still in the appeals process, the facility may include the cost, but must include sufficient detail so the Iowa Medicaid provider cost audit and rate setting unit can determine if a similar adjustment is needed in the current period. The department may, after considering the seriousness of the offense, make the reduction. f. Nothing in this subrule relieves a facility of its obligation to immediately inform the department that the facility has retained Medicaid funds to which the facility is not entitled as a result of any cost report process. A facility shall notify the Iowa Medicaid when the facility determines that funds have been incorrectly paid or when an overpayment has been detected. 82.5(4) Payment at new rate. When a new rate is established, payment at the new rate shall be effective with services rendered as of the first day of the month in which the report is postmarked, or if the report was personally delivered, the first day of the month in which the report was received by the department. Adjustments shall be included in the payment the third month after the receipt of the report. 82.5(5) Accrual basis. Facilities not using the accrual basis of accounting shall adjust recorded amounts to the accrual basis. Expenses which pertain to an entire year shall be properly amortized by month in order to be properly recorded for the annual fiscal year report. Records of cash receipts and disbursements shall be adjusted to reflect accruals of income and expense. 82.5(6) Census of Medicaid members. Census figures of Medicaid members shall be obtained on the last day of the month ending the reporting period. 82.5(7) Patient days. In determining inpatient days, a patient day is that period of service rendered a patient between the census-taking hours on two successive days, the day of discharge being counted only when the patient was admitted that same day. 82.5(8) Opinion of accountant. The department may require that an opinion of a certified public accountant or public accountant accompany the report when adjustments made to prior reports indicate disregard of the certification and reporting instructions. 82.5(9) Calculating patient days. When calculating patient days, facilities shall use an accumulation method. a. Census information shall be based on a patient status at midnight each day. A patient whose status changes from one class to another shall be shown as discharged from the previous status and admitted to the new status on the same day. b. When a member is on a reserve bed status and the department is paying on a per diem basis for the holding of a bed, or any day a bed is reserved for a public assistance or nonpublic assistance patient and a per diem rate for the bed is charged to any party, the reserved days shall be included in the total census figures for inpatient days. 82.5(10) Revenues. Revenues shall be reported as recorded in the general books and records. Expense recoveries credited to expense accounts shall not be reclassified in order to be reflected as revenues. a. Routine daily services shall represent the established charge for daily care. Routine daily services are those services which include room, board, nursing services, and such services as supervision, feeding, incontinency, and similar services, for which the associated costs are in nursing service. b. Revenue from ancillary services provided to patients shall be applied in reduction of the related expense. c. Revenue from the sale of medical supplies, food or services to employees or nonresidents of the facility shall be applied in reduction of the related expense. Revenue from the sale to private-pay residents of items or services which are included in the medical assistance per diem will not be offset. d. Investment income adjustment is necessary only when interest expense is incurred, and only to the extent of the interest expense. e. Laundry revenue shall be applied to laundry expense. f. Accounts receivable charged off or provision for uncollectible accounts shall be reported as a deduction from gross revenue. 82.5(11) Limitation of expenses. Certain expenses that are not normally incurred in providing patient care shall be eliminated or limited according to the following rules. a. Federal and state income taxes are not allowed as reimbursable costs. These taxes are considered in computing the fee for services for proprietary institutions. b. Fees paid directors and nonworking officer’s salaries are not allowed as reimbursable costs. c. Personal travel and entertainment are not allowed as reimbursable costs. Certain expenses such as rental or depreciation of a vehicle and expenses of travel which include both business and personal shall be prorated. Amounts that appear excessive may be limited after considering the specific circumstances. Records shall be maintained to substantiate the indicated charges. d. Loan acquisition fees and standby fees are not considered part of the current expense of patient care, but should be amortized over the life of the related loan. e. A reasonable allowance of compensation for services of owners or immediate relatives is an allowable cost, provided the services are actually performed in a necessary function. For this purpose, the following persons are considered immediate relatives: husband and wife; natural parent, child and sibling; adopted child and adoptive parent; stepparent, stepchild, stepbrother and stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and grandchild. Adequate time records shall be maintained. Adjustments may be necessary to provide compensation as an expense for nonsalaried working proprietors and partners. Members of religious orders serving under an agreement with their administrative office are allowed salaries paid persons performing comparable services. When maintenance is provided these persons by the facility, consideration shall be given to the value of these benefits and this amount shall be deducted from the amount otherwise allowed for a person not receiving maintenance. (1) Compensation means the total benefit received by the owner or immediate relative for services rendered. Compensation includes all remuneration, paid currently or accrued, for managerial, administrative, professional and other services rendered during the period. Compensation shall include all items that should be reflected on IRS Form W-2, Wage and Tax Statement, including, but not limited to, salaries, wages, and fringe benefits; the cost of assets and services received; and deferred compensation. Fringe benefits shall include, but are not limited to, costs of leave, employee insurance, pensions and unemployment plans. If the facility’s fiscal year end does not correlate to the period of the W-2, a reconciliation between the latest issued W-2 and current compensation shall be required to be disclosed to the Iowa Medicaid provider cost audit and rate setting unit. Employer portions of payroll taxes associated with amounts of compensation that exceed the maximum allowed compensation shall be considered unallowable for reimbursement. All compensation paid to related parties, including payroll taxes, shall be required to be reported to the Iowa Medicaid provider cost audit and rate setting unit with the submission of the financial and statistical report. If it is determined that there have been undisclosed related-party salaries, the cost report shall be determined to have been submitted incomplete and the facility shall be subject to the penalties set forth in paragraph 82.5(3)“c.” (2) Reasonableness—requires that the compensation allowance be such an amount as would ordinarily be paid for comparable services by comparable institutions and depends upon the facts and circumstances of each case. (3) Necessary—requires that the function be such that had the owner or immediate relative not rendered the services, the facility would have had to employ another person to perform the service, and be pertinent to the operation and sound conduct of the institution. (4) The base maximum allowed compensation for an administrator who is involved in ownership of the facility or who is an immediate relative of an owner of the facility is $1,926 per month plus $20.53 per month per licensed bed capacity for each bed over 60, not to exceed $2,852 per month. An administrator is considered to be involved in ownership of a facility when the administrator has ownership interest of 5 percent or more.On an annual basis, the maximum allowed compensation amounts for these administrators shall be increased or decreased by the inflation factor applied to facility rates. (5) The maximum allowed compensation for an assistant administrator who is involved in ownership of the facility or who is an immediate relative of an owner of the facility in facilities having a licensed capacity of 151 or more beds is 60 percent of the amount allowed for the administrator. An assistant administrator is considered to be involved in ownership of a facility when the assistant administrator has ownership interest of 5 percent or more. (6) The maximum allowed compensation for a director of nursing or any employee who is involved in ownership of the facility or who is an immediate relative of an owner of the facility is 60 percent of the amount allowed for the administrator. Persons involved in ownership or relatives providing professional services shall be limited to rates prevailing in the community not to exceed 60 percent of the allowable rate for the administrator on a semiannual basis. Records shall be maintained in the same manner for an employee involved in ownership as are maintained for any employee of the facility. Ownership is defined as an interest of 5 percent or more. (7) The maximum allowed compensation for employees as set forth in subparagraphs 82.5(11)“e”(4) to 82.5(11)“e”(6) shall be adjusted by the percentage of the average work week that the employee devoted to business activity at the intermediate care facility for persons with an intellectual disability for the fiscal year of the financial and statistical report. The time devoted to the business shall be disclosed on the financial and statistical report and shall correspond to any amounts reported to the Medicare fiscal intermediary. If an owner’s or immediate relative’s time is allocated to the facility from another entity (e.g., home office), the compensation limit shall be adjusted by the percentage of total costs of the entity allocated to the facility. In no case shall the amount of salary for one employee allocated to multiple facilities be more than the maximum allowed compensation for that employee had the salary been allocated to only one facility. f. Management fees and home office costs shall be allowed only to the extent that they are related to patient care and replace or enhance but do not duplicate functions otherwise carried out in a facility. g. Depreciation based upon tax cost using only the straight-line method of computation, recognizing the estimated useful life of the asset as defined in the American Hospital Association Useful Life Guide, may be included as a patient cost. When accelerated methods of computation have been elected for income tax purposes, an adjustment shall be made. For change of ownership, refer to subrule 82.5(12). h. Necessary and proper interest on both current and capital indebtedness is an allowable cost. (1) Interest is the cost incurred for the use of borrowed funds. Interest on current indebtedness is the cost incurred for funds borrowed for a relatively short term. Interest on capital indebtedness is the cost incurred for funds borrowed for capital purposes. (2) “Necessary” requires that the interest be incurred on a loan made to satisfy a financial need of the provider, be incurred on a loan made for a purpose reasonably related to patient care, and be reduced by investment income except where the income is from gifts and grants whether restricted or unrestricted, and which are held separate and not commingled with other funds. (3) “Proper” requires that interest be incurred at a rate not in excess of what a prudent borrower would have had to pay in the money market on the date the loan was made, and be paid to a lender not related through control or ownership to the borrowing organization. (4) Interest on loans is allowable as cost at a rate not in excess of the amount an investor could receive on funds invested in the locality on the date the loan was made. (5) Interest is an allowable cost when the general fund of a provider borrows from a donor-restricted fund, a funded depreciation account of the provider, or the provider’s qualified pension fund, and pays interest to the fund, or when a provider operated by members of a religious order borrows from the order. (6) When funded depreciation is used for purposes other than improvement, replacement or expansion of facilities or equipment related to patient care, allowable interest expense is reduced to adjust for offsets not made in prior years for earnings on funded depreciation. A similar treatment will be accorded deposits in the provider’s qualified pension fund where the deposits are used for other than the purpose for which the fund was established. i. Costs applicable to supplies furnished by a related party or organization are a reimbursable cost when included at the cost to the related party or organization. The cost shall not exceed the price of comparable supplies that could be purchased elsewhere. (1) Related means that the facility, to a significant extent, is associated with or has control of or is controlled by the organization furnishing the services, facilities, or supplies. (2) Common ownership exists when an individual or individuals possess significant ownership or equity in the facility and the institution or organization serving the provider. (3) Control exists where an individual or an organization has power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution. (4) When the facility demonstrates by convincing evidence that the supplying organization is a bona fide separate organization; that a substantial part of its business activity of the type carried on with the facility is transacted with others and there is an open competitive market for the type of services, facilities, or supplies furnished by the organization; that the services, facilities, or supplies are those which commonly are obtained by similar institutions from other organizations and are not a basic element of patient care ordinarily furnished directly to patients by the institutions; and that the charge to the facility is in line with the charge for services, facilities, or supplies in the open market and no more than the charge made under comparable circumstances to others by the organization for the services, facilities, or supplies, the charges by the supplier shall be allowable costs. j. A facility entering into a new or renewed rent or lease agreement on or after June 1, 1994, shall be subject to the provisions of this paragraph.When the operator of a participating facility rents from a nonrelated party, the amount of rent expense allowable on the cost report shall be the lesser of the actual rent payments made under the terms of the lease or an annual reasonable rate of return applied to the cost of the facility. The cost of the facility shall be determined as the historical cost of the facility in the hands of the owner when the facility first entered the Iowa Medicaid program. Where the facility has previously participated in the program, the cost of the facility shall be determined as the historical cost of the facility, as above, less accumulated depreciation claimed for cost reimbursement under the program. The annual reasonable rate of return shall be defined as one and one-half times the annualized interest rate of 30-year Treasury bonds as reported by the Federal Reserve Board on a weekly-average basis, at the date the lease was entered into.When the operator of a participating facility rents the building from a related party, the amount of rent expense allowable on the cost report shall be limited to the lesser of the actual rent payments made under the terms of the lease or the amount of property costs that would otherwise have been allowable under the Iowa Medicaid program to an owner-provider of that facility.The lessee shall submit a copy of the lease agreement, documentation of the cost basis used and a schedule demonstrating that the limitations have been met with the first cost report filed for which lease costs are claimed. k. Each facility which supplies transportation services as defined in Iowa Code section 324A.1, subsection 1, shall provide current documentation of compliance with or exemption from public transit coordination requirements as found in Iowa Code chapter 324A and department of transportation rules 761—Chapter 910 at the time of annual contract renewal. Failure to cooperate in obtaining or in providing the required documentation of compliance or exemption after receipt from the Iowa department of transportation, public transit division, shall result in disallowance of vehicle costs and other costs associated with transporting residents. l. Depreciation, interest and other capital costs attributable to construction of new facilities, expanding existing facilities, or the purchase of an existing facility, are allowable expenses only if prior approval has been gained through the health planning process specified in rules of the public health department, 641—Chapter 201. m. Reasonable legal, accounting, consulting and other professional fees, including association dues, are allowable costs if the fees are directly related to patient care. Legal, accounting, consulting and other professional fees, including association dues, described by the following are not considered to be patient-related and therefore are not allowable expenses: (1) Any fees or portion of fees used or designated for lobbying. (2) Nonrefundable and unused retainers. (3) Fees paid by the facility for the benefit of employees. (4) Legal fees, expenses related to expert witnesses, accounting fees and other consulting fees incurred in an administrative or judicial proceeding. Exception: Facilities may report the reasonable costs incurred in an administrative or judicial proceeding if all of the following conditions are met. Recognition of any costs will be in the fiscal period when a final determination in the administrative or judicial proceeding is made.

The costs have actually been incurred and paid,
The costs are reasonable expenditures for the services obtained,
The facility has made a good-faith effort to settle the disputed issue before the completion of the administrative or judicial proceeding, and
The facility prevails on the disputed issue.

n. Penalties or fines imposed by federal or state agencies are not allowable expenses. o. Penalties, fines or fees imposed for insufficient funds or delinquent payments are not allowable expenses. 82.5(12) Termination or change of owner. a. A participating facility contemplating termination of participation or negotiating a change of ownership shall provide the department with at least 60 days’ prior notice. A transfer of ownership or operation terminates the participation agreement. A new owner or operator shall establish that the facility meets the conditions for participation and enter into a new agreement. The person responsible for transfer of ownership or for termination is responsible for submission of a final financial and statistical report through the date of the transfer. No payment to the new owner will be made until formal notification is received. The following situations are defined as a transfer of ownership: (1) In the case of a partnership which is a party to an agreement to participate in the medical assistance program, the removal, addition, or substitution of an individual for a partner in the association, in the absence of an express statement to the contrary, dissolves the old partnership and creates a new partnership which is not a party to the previously executed agreement and a transfer of ownership has occurred. (2) When a participating nursing home is a sole proprietorship, a transfer of title and property to another party constitutes a change of ownership. (3) When the facility is a corporation, neither a transfer of corporate stock nor a merger of one or more corporations with the participating corporation surviving is a transfer of ownership. A consolidation of two or more corporations resulting in the creation of a new corporate entity constitutes a change of ownership. (4) When a participating facility is leased, a transfer of ownership is considered to have taken place. When the entire facility is leased, the total agreement with the lessor terminates. When only part of the facility is leased, the agreement remains in effect with respect to the unleased portion but terminates with respect to the leased portion. b. No increase in the value of the property shall be allowed in determining the Medicaid rate for the new owner with any change of ownership (including lease agreements). When filing the first cost report, the new owner shall either continue the schedule of depreciation and interest established by the previous owner, or the new owner may choose to claim the actual rate of interest expense. The results of the actual rate of interest expense shall not be higher than would be allowed under the Medicare principles of reimbursement and shall be applied to the allowed depreciable value established by the previous owner, less any down payment made by the new owner. c. Other acquisition costs of the new owner such as legal fees, accounting and administrative costs, travel costs and the costs of feasibility studies attributable to the negotiation or settlement of the sale or purchase of the property shall not be allowed. d. In general, the provisions of Section 1861(v)(1)(0) of the Social Security Act regarding payment allowed under Medicare principles of reimbursement at the time of a change of ownership shall be followed, except that no return on equity or recapture of depreciation provisions shall be employed. e. A new owner or lessee wishing to claim a new rate of interest expense must submit documentation which verifies the amount of down payment made, the actual rate of interest, and the number of years required for repayment with the next semiannual cost report. In the absence of the necessary supportive documentation, interest and other property costs for all facilities which have changed or will change ownership shall continue at the rate allowed the previous owner. 82.5(13) Assessed fee. The fee assessed pursuant to 441—Chapter 36 shall not be an allowable cost for cost reporting and audit purposes. In lieu of treating the fee as an allowable cost, a per diem assessment amount is added to the reimbursement rate calculated under subrule 82.5(14), not subject to the maximum allowable base cost or maximum rate set at the eightieth percentile. The per diem assessment amount will be calculated by dividing the annual assessment paid by the reported total patient days. 82.5(14) Payment to new facility. A facility receiving Medicaid ICF/ID certification on or after July 1, 1992, shall be subject to the provisions of this subrule. a. A facility receiving initial Medicaid certification for ICF/ID level of care shall submit a budget for six months of operation beginning with the month in which Medicaid certification is given. The budget shall be submitted at least 30 days in advance of the anticipated certification date. The Medicaid per diem rate for a new facility shall be based on the submitted budget subject to review by the accounting firm under contract with the department. The rate shall be subject to a maximum set at the eightieth percentile of all participating community-based Iowa ICFs/ID with established base rates. The eightieth percentile maximum rate shall be adjusted July 1 of each year. The state hospital schools shall not be included in the compilation of facility costs. The beginning rates for a new facility shall be effective with the date of Medicaid certification. b. Initial cost report. Following six months of operation as a Medicaid-certified ICF/ID, the facility shall submit a report of actual costs. The rate computed from this cost report shall be adjusted to 100 percent occupancy plus the annual percentage increase of the Consumer Price Index for all urban consumers, U.S. city average (hereafter referred to as the Consumer Price Index). Business start-up and organization costs shall be accounted for in the manner prescribed by the Medicare and Medicaid standards. Any costs that are properly identifiable as start-up costs, organization costs or capitalizable as construction costs must be appropriately classified as such. (1) Start-up costs. In the period of developing a provider’s ability to furnish patient care services, certain costs are incurred. The costs incurred during this time of preparation are referred to as start-up costs. Since these costs are related to patient care services rendered after the time of preparation, the costs must be capitalized as deferred charges and amortized over a five-year period.Start-up costs include, for example, administrative and program staff salaries, heat, gas and electricity, taxes, insurance, mortgage and other interest, employee training costs, repairs and maintenance, and housekeeping. (2) Organization costs. Organization costs are those costs directly related to the creation of a corporation or other form of business. These costs are an intangible asset in that they represent expenditures for rights and privileges which have a value to the enterprise. The services inherent in organization costs extend over more than one accounting period and affect the costs of future periods of operation. Organization costs must be amortized over a five-year period.

Allowable organization costs. Allowable organization costs include, but are not limited to, legal fees incurred in establishing the corporation or other organization (such as drafting the corporate charter and bylaws, legal agreements, minutes of organization meetings, terms of original stock certificates), necessary accounting fees, expenses of temporary directors and organizational meetings of directors and stockholders, and fees paid to states for incorporation.
Unallowable organization costs. The following types of costs are not considered allowable organization costs: costs relating to the issuance and sale of shares of capital stock or other securities, such as underwriters’ fees and commissions, accountant’s or lawyer’s fees; costs of qualifying the issues with the appropriate state or federal authorities; and stamp taxes.

c. Standardization of cost reporting period for new facilities. (1) Facilities receiving initial certification between July 1 and December 31 (inclusive) shall submit three successive six-month cost reports covering their first 18 months of operation. The fourth six-month cost report shall cover the January 1 to June 30 period. Thereafter, the facility shall submit a cost report on an annual basis of July 1 to June 30. (2) Facilities receiving initial certification between January 1 and June 30 (inclusive) shall submit two successive six-month cost reports covering the first 12 months of operation. The third six-month cost report shall cover the January 1 to June 30 period. Thereafter, the facility shall submit a cost report on an annual basis of July 1 to June 30. (3) All facilities shall comply with the requirements of subrule 82.5(3) when submitting reports. d. Completion of 12 months of operation. Following the first 12 months of operation as a Medicaid-certified ICF/ID as described in subrule 82.5(14), the facility shall submit a cost report for the second six months of operation. An on-site audit of facility costs shall be performed by the accounting firm under contract with the department. Based on the audited cost report, a rate shall be established for the facility. This rate shall be considered the base rate until rebasing of facility costs occurs. (1) A new maximum allowable base cost will be calculated each year by increasing the prior year’s maximum allowable base by the annual percentage increase of the Consumer Price Index. (2) Each year’s maximum allowable base cost represents the maximum amount that can be reimbursed. e. Maximum rate. Facilities shall be subject to a maximum rate set at the eightieth percentile of the total per diem cost of all participating community-based ICFs/ID with established base rates. The eightieth percentile maximum rate shall be adjusted July 1 of each year using cost reports on file December 31 of the previous year. f. Incentive factor. New facilities which complete the second annual period of operation that have an annual per unit cost percentage increase of less than the percentage increase of the Consumer Price Index, as described in 82.5(14)“d,” shall be given their actual percentage increase plus one-half the difference of their actual percentage increase compared to the allowable maximum percentage increase. This percentage difference multiplied by the actual per diem cost for the annual period just completed is the incentive factor. (1) The incentive factor will be added to the new reimbursement base rate to be used as the per diem rate for the next annual period of operation. (2) Facilities whose annual per unit cost decreased from the prior year shall be given their actual per unit cost plus one and one-half the percentage increase in the Consumer Price Index as an incentive for cost containment. g. Reimbursement for first annual period. The reimbursement for the first annual period will be determined by multiplying the per diem rate calculated for the base period by the Consumer Price Index plus one. (1) The projected reimbursement for each period thereafter (until rebasing) will be calculated by multiplying the lower of the prior year’s actual or the projected reimbursement per diem by the Consumer Price Index. (2) If a facility experiences an increase in actual costs that exceeds both the actual reimbursement and the maximum allowable base cost as determined for that annual period, the facility shall receive as reimbursement in the following period the maximum allowable base as calculated. (3) All calculated per diem rates shall be subject to the prevailing maximum rate. 82.5(15) Payment to new owner. An existing facility with a new owner shall continue with the previous owner’s per diem rate until a new financial and statistical report has been submitted and a new rate established according to subrule 82.5(16). The facility may submit a report for the period of July 1 to June 30 or may submit two cost reports within the fiscal year provided the second report covers a period of at least six months ending on the last day of the fiscal year. The facility shall notify the department of the reporting option selected. 82.5(16) Payment to existing facilities. The following reimbursement limits shall apply to all non-state-owned ICFs/ID: a. Each facility shall file a cost report covering the period from January 1, 1992, to June 30, 1992. This cost report shall be used to establish a reimbursement rate to be paid to the facility and shall be used to establish the base allowable cost per unit to be used in future reimbursement rate calculations. Subsequent cost reports shall be filed annually by each facility covering the 12 months from July 1 to June 30. b. The reimbursement rate established based on the report covering January 1, 1992, to June 30, 1992, shall be calculated using the method in place prior to July 1, 1992, including inflation and incentive factors. c. The audited per unit cost from the January 1, 1992, to June 30, 1992, cost report shall become the initial allowable base cost. A new maximum allowable base cost will be calculated each year as described in 82.5(14)“d.” d. Facilities which have an annual per unit cost percentage increase of less than the percentage increase of the Consumer Price Index shall be given their actual percentage increase plus one-half the difference of their actual percentage increase compared to the allowable maximum percentage increase. This percentage difference multiplied by the actual per diem costs for the annual period just completed is the incentive factor. (1) The incentive factor will be added to the new reimbursement base rate to be used as the per diem rate for the following annual period. (2) Facilities whose annual per unit cost decreased from the prior year shall receive their actual per unit cost plus one and one-half the percentage increase in the Consumer Price Index as an incentive for cost containment. e. Administrative costs shall not exceed 18 percent of total facility costs. Administrative costs are comprised of those costs incurred in the general management and administrative functions of the facility. Administrative costs include, but are not necessarily limited to, the administrative portion of the following: (1) Administrator wages. (2) Business office wages. (3) Advertising and marketing wages. (4) Employer’s taxes (administrative). (5) Group/life and retirement benefits (administrative staff). (6) Workers’ compensation insurance (administrative staff). (7) Employment advertising and recruitment (administrative staff). (8) Criminal record checks (administrative staff). (9) Education and training (administrative staff). (10) Office supplies (administrative staff). (11) Telephone. (12) Equipment rental. (13) Home office costs. (14) Management fees. (15) Accounting fees. (16) Professional organization dues. (17) Licensing fees. (18) Information technology expenses. (19) Legal fees—direct patient-care-related. (20) Legal fees—other. (21) Working capital interest. (22) General liability insurance. (23) Travel, entertainment and auto expenses. (24) Advertising and public relations. (25) Other. f. Facility rates shall be rebased using the cost report for the year covering state fiscal year 1996 and shall subsequently be rebased each four years. The department shall consider allowing special rate adjustments between rebasing cycles if: (1) An increase in the minimum wage occurs. (2) A change in federal regulations occurs which necessitates additional staff or expenditures for capital improvements, or a change in state or federal law occurs, or a court order with force of law mandates program changes which necessitate the addition of staff or other resources. (3) A decision is made by a facility to serve a significantly different client population or to otherwise make a dramatic change in program structure (documentation and verification will be required). (4) A facility increases or decreases licensed bed capacity by 20 percent or more. g. Total patient days for purposes of the computation shall be inpatient days as determined in subrule 82.5(7) or 80 percent of the licensed capacity of the facility, whichever is greater. The reimbursement rate shall be determined by dividing total reported patient expenses by total patient days during the reporting period. This cost per day will be limited by an inflation increase which shall not exceed the percentage change in the Consumer Price Index. h. State-owned ICFs/ID shall submit semiannual cost reports and shall receive semiannual rate adjustments based on actual costs of operation inflated by the percentage change in the Consumer Price Index. i. The projected reimbursement for the first annual period will be determined by multiplying the per diem rate calculated for the base period by the Consumer Price Index. (1) The projected reimbursement for each period thereafter (until rebasing) will be calculated by multiplying the lower of the prior year’s actual or the projected reimbursement per diem by the Consumer Price Index. (2) If a facility experiences an increase in actual costs that exceeds both the actual reimbursement and the maximum allowable base cost as determined for that annual period, the facility shall receive as reimbursement in the following period the maximum allowable base as calculated. 82.5(17) Wage add-on factor. A wage add-on factor of $8.86 per day for community-based ICFs/ID shall be included in rates effective July 1, 2022, and after, not subject to the maximum allowable cost ceiling in paragraph 82.5(14)“e,” until rates are established using the cost reports for the period ending June 30, 2023. a. In accordance with 2022 Iowa Acts, House File 2578, section 31, the entire wage add-on factor shall be used for wages and associated costs specific to wages, benefits, and required withholding of direct support professionals and frontline management. b. The wage add-on factor of $8.86 per day shall be added to the maximum allowable base rate in subparagraph 82.5(14)“d”(1) until the next rebase using cost reports for the period ending June 30, 2024. c. The wage add-on factor of $8.86 per day shall be added to the maximum allowable cost ceiling, eightieth percentile of costs of all participating facilities in paragraph 82.5(14)“e,” until the eightieth percentile maximum is established using the December 31, 2023, compilation for rates effective beginning July 1, 2024.This rule is intended to implement Iowa Code sections 249A.12 and 249A.16.Related ARC(s): 8207B, 8446B, 0582C, 0995C, 2886C, 6776C, 6852C441—82.6(249A) Eligibility for services. 82.6(1) Interdisciplinary team. The initial evaluation for admission shall be conducted by an interdisciplinary team. The team shall consist of a physician, a social worker, and other professionals. At least one member of the team shall be a qualified intellectual disability professional. 82.6(2) Evaluation. The evaluation shall include a comprehensive medical, social, and psychological evaluation. The comprehensive evaluation shall include: a. Diagnoses, summaries of present medical, social and where appropriate, developmental findings, medical and social family history, mental and physical functional capacity, prognoses, range of service needs, and amounts of care required. b. An evaluation of the resources available in the home, family, and community. c. An explicit recommendation with respect to admission or in the case of persons who make application while in the facility, continued care in the facility. Where it is determined that intermediate care facility for persons with an intellectual disability services are required by an individual whose needs might be met through the use of alternative services which are currently unavailable, this fact shall be entered in the record, and plans shall be initiated for the active exploration of alternatives. d. An individual plan for care shall include diagnosis, symptoms, complaints or complications indicating the need for admission, a description of the functional level of the resident; written objective; orders as appropriate for medications, treatments, restorative and rehabilitative services, therapies, diet, activities, social services, and special procedures designed to meet the objectives; and plans for continuing care, including provisions for review and necessary modifications of the plan, and discharge. e. Written reports of the evaluation and the written individual plan of care shall be delivered to the facility and entered in the individual’s record at the time of admission or, in the case of individuals already in the facility, immediately upon completion. 82.6(3) Certification statement. Eligible individuals may be admitted to an intermediate care facility for persons with an intellectual disability upon the certification of a physician that there is a necessity for care at the facility. For clients enrolled with a managed care organization, authorization for admission must be obtained from the managed care organization prior to admission. Eligibility shall continue as long as a valid need for the care exists.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 0582C, 2361C441—82.7(249A) Initial approval for ICF/ID care. 82.7(1) Referral through targeted case management. Persons seeking ICF/ID placement shall be referred through targeted case management. The case management program shall: a. Identify appropriate service alternatives; b. Inform the person of the alternatives; and c. Refer a person without appropriate alternatives to the department. 82.7(2) Approval of placement by department. a. Within 30 days of receipt of a referral, the department shall: (1) Approve ICF/ID placement; (2) Offer a home- or community-based alternative; or (3) Refer the person back to the targeted case management program for further consideration of service needs. b. Once ICF/ID placement is approved, including approval of ICF/ID level of care as described in subrule 82.7(3), the eligible person, or the person’s representative, is free to seek placement in the facility of the person’s or the person’s representative’s choice, subject to the provision of ICF/ID services through managed care pursuant to 441—Chapter 73. 82.7(3) Approval of level of care. Medicaid payment shall be made for ICF/ID care upon certification of need for this level of care by a licensed physician of medicine or osteopathy and approval by the Iowa Medicaid quality improvement organization (QIO) unit. 82.7(4) Appeal rights. Notice of adverse action and right to appeal shall be given in accordance with 441—Chapter 7 and rule 441—16.3(17A).This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 8207B, 8446B, 0191C, 0359C, 2361C, 4973C, 6776C441—82.8(249A) Determination of need for continued stay. For clients not enrolled with a managed care organization, certification of need for continued stay shall be made according to procedures established by the Iowa Medicaid QIO unit. For all clients enrolled with a managed care organization, the managed care organization shall review the Medicaid client’s need for continued care in an ICF/ID at least annually. The managed care organization must submit documentation to the Iowa Medicaid QIO unit for all reviews that indicate a change in the client’s level of care. The Iowa Medicaid QIO unit shall make a final determination for any reviews that indicate a change in the level of care.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 8207B, 8446B, 2361C, 6776C441—82.9(249A) Arrangements with residents. 82.9(1) Resident care agreement. The ICF/ID Resident Care Agreement, Form 470-0374, shall be used as a three-party contract among the facility, the resident, and the department to spell out the duties, rights, and obligation of all parties. 82.9(2) Financial participation by resident. A resident’s payment for care may include any voluntary payments made by family members toward cost of care of the resident. The resident’s client participation and medical payments from a third party shall be paid toward the total cost of care for the month before any Medicaid payment is made. Medicaid will pay the balance of the cost of care for the remainder of the month. The facility shall make arrangements directly with the resident for payment of client participation. 82.9(3) Personal needs account. When a facility manages the personal needs funds of a resident, it shall establish and maintain a system of accounting for expenditures from the resident’s personal needs funds. The department shall charge back to the facility any maintenance item included in the computation of the audit cost that is charged to the resident’s personal needs account when the charge constitutes double payment. Unverifiable expenditures charged to personal needs accounts may be charged back to the facility. The accounting system is subject to audit by representatives of the department of inspections and appeals and shall meet the following criteria: a. Upon admittance, a ledger sheet shall be credited with the resident’s total incidental money on hand. Thereafter, the ledger shall be kept current on a monthly basis. The facility may combine the accounting with the disbursement section showing the date, amount given the resident, and the resident’s signature. A separate ledger shall be maintained for each resident. b. When something is purchased for the resident and is not a direct cash disbursement, each expenditure item in the ledger shall be supported by a signed, dated receipt. The receipt shall indicate the article furnished for the resident’s benefit. c. Personal funds shall only be turned over to the resident, the resident’s guardian, or other persons selected by the resident. With the consent of the resident, when the resident is able and willing to give consent, the administrator may turn over personal funds to a close relative or friend of the resident to purchase a particular item. A signed, itemized, dated receipt shall be required to be deposited in the resident’s files. d. The receipts for each resident shall be kept until canceled by auditors. e. The ledger and receipts for each resident shall be made available for periodic audits by an accredited department of inspections and appeals representative. Audit certification shall be made by the department’s representative at the bottom of the ledger sheet. Supporting receipts may then be destroyed. f. Upon a member’s death, a receipt shall be obtained from the next of kin or the member’s guardian before releasing the balance of the personal needs funds. When the member has been receiving a grant from the department for all or part of the personal needs, any funds shall revert to the department. The department shall turn the funds over to the member’s estate. 82.9(4) Safeguarding personal property. The facility shall safeguard the resident’s personal possessions. Safeguarding shall include, but is not limited to: a. Providing a method of identification of the resident’s suitcases, clothing, and other personal effects, and listing these on an appropriate form attached to the resident’s record at the time of admission. These records shall be kept current. Any personal effects released to a relative of the resident shall be covered by a signed receipt. b. Providing adequate storage facilities for the resident’s personal effects. c. Ensuring that the resident is accorded privacy and uncensored communication with others by mail and telephone and with persons of the resident’s choice except when therapeutic or security reasons dictate otherwise. Any limitations or restrictions imposed shall be approved by the administrator and the reasons noted shall be made a part of the resident’s record.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 8207B, 8446B, 0582C, 2361C441—82.10(249A) Discharge and transfer. 82.10(1) Notice. When a Medicaid member requests transfer or discharge to a community setting, or another person requests this for the member, the administrator shall promptly notify a targeted case management provider. Names of local providers are available from the department’s local office. This shall be done in sufficient time to permit a case manager to assist in the decision and planning for the transfer or discharge. 82.10(2) Case activity report. A Case Activity Report, Form 470-0042, shall be submitted to the department whenever a Medicaid applicant or member enters the facility, changes level of care, or is discharged from the facility. 82.10(3) Plan. The administrator and staff shall assist the resident in planning for transfer or discharge through development of a discharge plan. 82.10(4) Transfer records. When a resident is transferred to another facility, transfer information shall be summarized from the facility’s records in a copy to accompany the resident. This information shall include: a. A transfer form of diagnosis. b. Aid to daily living information. c. Transfer orders. d. Nursing care plan. e. Physician’s or qualified intellectual disability professional’s orders for care. f. The resident’s personal records. g. When applicable, the personal needs fund record. 82.10(5) Income refund. When a resident leaves the facility during the month, any unused portion of the resident’s income shall be refunded.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 8207B, 8446B, 0582C441—82.11(249A) Continued stay review. Rescinded ARC 2361C, IAB 1/6/16, effective 1/1/16.441—82.12(249A) Quality of care review. Rescinded ARC 2361C, IAB 1/6/16, effective 1/1/16.441—82.13(249A) Records. 82.13(1) Content. The facility shall at a minimum maintain the following records: a. All records required by the department of public health and the department of inspections and appeals. b. Medical records as required by Section 1902(a)(31) of Title XIX of the Social Security Act. c. Records of all treatments, drugs and services for which vendors’ payments have been made or are to be made under the medical assistance program, including the authority for and the date of administration of the treatment, drugs, or services. d. Documentation in each resident’s records which will enable the department to verify that each charge is due and proper prior to payment. e. Financial records maintained in the standard, specified form including the facility’s most recent audited cost report. f. All other records as may be found necessary by the department in determining compliance with any federal or state law or rule or regulation promulgated by the United States Department of Health and Human Services or by the department. g. Census records to include the date, number of residents at the beginning of each day, names of residents admitted, and names of residents discharged. (1) Census information shall be provided for residents in skilled, intermediate, and residential care. (2) Census figures for each type of care shall be totaled monthly to indicate the number admitted, the number discharged, and the number of patient days. (3) Failure to maintain acceptable census records shall result in the per diem rate being computed on the basis of 100 percent occupancy and a request for refunds covering indicated recipients of nursing care which have not been properly accounted for. h. Resident accounts. i. Inservice education program records. j. Inspection reports pertaining to conformity with federal, state, and local laws. k. Residents’ personal records. l. Residents’ medical records. m. Disaster preparedness reports. 82.13(2) Retention. Records shall be retained in the facility for a minimum of five years or until an audit is performed on those records, whichever is longer. 82.13(3) Change of owner. All records shall be retained within the facility upon change of ownership.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 6776C441—82.14(249A) Payment procedures. 82.14(1) Method of payment. Facilities shall be reimbursed under a cost-related vendor payment program. A per diem rate shall be established based on information submitted according to rule 441—82.5(249A). 82.14(2) Reserved. 82.14(3) Reserved. 82.14(4) Periods authorized for payment. a. Payment shall be made on a per diem basis for the portion of the month the resident is in the facility. b. Payment will be authorized as long as the resident is certified as needing care in an intermediate care facility for persons with an intellectual disability. c. Payment will be approved for the day of admission but not the day of discharge or death. d. Payment will be approved for periods the resident is absent to visit home for a maximum of 30 days annually. Additional days may be approved for special programs of evaluation, treatment or habilitation outside the facility. Documentation as to the appropriateness and therapeutic value of resident visits and outside programming, signed by a physician or qualified intellectual disability professional, shall be maintained at the facility. e. Payment will be approved for a period not to exceed ten days in any calendar month when the resident is absent due to hospitalization. Medicaid payment to the facility may not be initiated while a resident is on reserve bed days unless the person was residing in the facility as a private pay resident prior to the hospitalization and returns to the facility as a resident. f. Payment for periods when residents are absent for visitation or hospitalization from facilities with more than 15 beds will be made at 80 percent of the allowable audited costs for those beds. Facilities with 15 or fewer beds will be reimbursed at 95 percent of the allowable audited costs for those beds. 82.14(5) Supplementation. Only the amount of client participation may be billed to the resident for the cost of care. No supplementation of the state payment shall be made by any person.Exception: The resident, the resident’s family or friends may pay to hold the resident’s bed in cases where a resident spends over 30 days on yearly visitation or spends over 10 days on a hospital stay. When the resident is not discharged from the facility, the payments shall not exceed 80 percent of the allowable audited costs for the facility, not to exceed the maximum reimbursement rate. When the resident is discharged, the facility may handle the holding of the reserved bed in the same manner as a private paying resident.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 0191C, 0359C, 0582C, 6776C441—82.15(249A) Billing procedures. 82.15(1) Claims. Claims for service for clients not enrolled with a managed care organization must be sent to the Iowa Medicaid after the month of service and within 365 days of the date of service. Such claims must be submitted electronically through Iowa Medicaid’s electronic clearinghouse. a. A remittance advice of the claims paid may be obtained through the Iowa Medicaid portal access (IMPA) system. b. Adjustments to claims may be made electronically as provided for by the Iowa Medicaid. 82.15(2) Reserved.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 2361C, 6776C441—82.16(249A) Closing of facility. When a facility is planning on closing, the department and the department’s contracted managed care organizations with which the facility is enrolled shall be notified at least 60 days in advance of the closing. Plans for the transfer of residents receiving Medicaid shall be approved by the resident’s managed care organization or by the Iowa Medicaid enterprise for residents not enrolled with a managed care organization.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 2361C441—82.17(249A) Audits. 82.17(1) Audits of financial and statistical report. Authorized representatives of the department or the Department of Health and Human Services shall have the right, upon proper identification, to audit, using generally accepted auditing procedures, the general financial records of a facility to determine if expenses reported on the Financial and Statistical Report, Form 470-0030, are reasonable and proper according to the rules set forth in 441—82.5(249A). These audits may be done either on the basis of an on-site visit to the facility, their central accounting office, or office(s) of their agents. a. When a proper per diem rate cannot be determined, through generally accepted auditing procedures, the auditor shall examine and adjust the report to arrive at what appears to be an acceptable rate and shall recommend to the department that the indicated per diem should be reduced to 75 percent of the established payment rate for the ensuing fiscal period and if the situation is not remedied on the subsequent Financial and Statistical Report, Form 470-0030, the facility shall be suspended and eventually canceled from the intermediate care facility program, or b. When a facility continues to include as an item of cost an item or items which had in a prior audit been removed by an adjustment in the total audited costs, the auditor shall recommend to the department that the per diem be reduced to 75 percent of the current payment rate for the ensuing fiscal period. The department may, after considering the seriousness of the exception, make the reduction. 82.17(2) Auditing of proper billing and handling of patient funds. a. Iowa Medicaid, the department’s contracted managed care organizations, field auditors of the department of inspections and appeals and representatives of the U.S. Department of Health and Human Services, upon proper identification, shall have the right to audit billings to the department and receipts of client participation, to ensure that the facility is not receiving payment in excess of the contractual agreement and that all other aspects of the contractual agreement are being followed, as deemed necessary. b. Iowa Medicaid, the department’s contracted managed care organizations, field auditors of the department of inspections and appeals and representatives of the U.S. Department of Health and Human Services, upon proper identification, shall have the right to audit records of the facility to determine proper handling of patient funds in compliance with subrule 82.9(3). c. The auditor shall recommend and the department shall request repayment by the facility to either the department or the resident(s) involved, such sums inappropriately billed to the department or collected from the resident. d. The facility shall have 60 days to review the audit and repay the requested funds or present supporting documentation which would indicate that the requested refund amount, or part thereof, is not justified. e. When the facility fails to comply with paragraph “d” the requested refunds may be withheld from future payments to the facility. The withholding shall not be more than 25 percent of the average of the last six monthly payments to the facility. The withholding shall continue until the entire requested refund amount is recovered. If in the event the audit results indicate significant problems, the audit results may be referred to the attorney general’s office for whatever action may be deemed appropriate. f. When exceptions are taken during the scope of an audit which are similar in nature to the exceptions taken in a prior audit, the auditor shall recommend and the department may, after considering the seriousness of the exceptions, reduce payment to the facility to 75 percent of the current payment rate.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 2361C, 6776C441—82.18(249A) Out-of-state facilities. Payment will be made for care in out-of-state intermediate care facilities for persons with an intellectual disability. Out-of-state facilities shall abide by the same policies as in-state facilities with the following exceptions: 82.18(1) Out-of-state providers will be reimbursed at the same intermediate care facility rate they are receiving for their state of residence. 82.18(2) Out-of-state facilities shall not submit financial and statistical reports as required in rule 441—81.6(249A). 82.18(3) Payment for periods when residents are absent for visitation or hospitalization will be made to out-of-state facilities at 80 percent of the rate paid to the facility by the Iowa Medicaid program. Out-of-state facilities with 15 or fewer beds shall be reimbursed at 95 percent of the rate paid to the facility by the Iowa Medicaid program.This rule is intended to implement Iowa Code section 249A.12.Related ARC(s): 0582C441—82.19(249A) State-funded personal needs supplement. A Medicaid member living in an intermediate care facility for persons with an intellectual disability who has countable income for purposes of rule 441—75.16(249A) of less than $50 per month shall receive a state-funded payment from the department for the difference between that countable income and $50 if the legislature has appropriated funding specifically for this purpose. This payment shall not be considered a benefit under Title XIX of the Social Security Act.This rule is intended to implement Iowa Code section 249A.30A.Related ARC(s): 0582CRelated ARC(s): 8207B, 8446B, 0191C, 0359C, 0582C, 0995C, 2361C, 2886C, 4052C, 4973C, 5808C, 6776C, 6852C

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