Assisted living Administrative rules, trends and updates Iowa Department of Inspections and Appeals Linda Kellen, Bureau Chief Adult Services Bureau

ASB Staff Linda Kellen, Bureau Chief (515) 281-7624 linda.kellen@dia.iowa.gov Catie Campbell, Program Coordinator (A-L) (515)281-3759 catie.cambell@dia.iowa.gov Deb Dixon, Program Coordinator (M-Z) (515) 281-4081 deb.dixon@dia.iowa.gov

ASB Staff Tamara Brockob, Administrative Assistant (515) 281-5721 tamara.brockob@dia.iowa.gov Doran Pruisner, Facilities Engineer (515) 725-6152 doran.pruisner@dia.iowa.gov ASB FAX (515) 242-5022

Monitors Stephanie Cummins Margaret Kaltefleiter Jana Smith Mary Hildreth Michael Rohner Stephanie Radabaugh

Purpose and intent Important part of long-term care continua in Iowa Emphasizes independence and dignity Provide services in a cost-effective manner Safe, home-like environment for those who don’t require continuous health- related care Social model of service delivery and consumer driven quality of service The Department will take a consultative approach to assist with compliance

Certification Each ALP operating in Iowa shall be certified by the Department. If voluntarily accredited by a recognized accrediting entity, the Program will be certified based on the accreditation. Services can be delivered directly by ALP staff or through contracting agencies Certification period-2 years Monitoring visits include entrance conference, tours, interviews, observations, file reviews, and exit conference Talk about the certification time frame changes. Recert visit versus when the recert app and certificate is received and sent.

Occupancy Agreement Contract to spell out what the ALP will provide, rights, Landlord Tenant Act, and what tenant is responsible for.

Occupancy Agreement 231C.5, 69.21 Written agreement between the Program and the tenant and/or tenant’s legal representative Includes but not limited to: Clear definition of rights and responsibilities of the tenant and the Program Description of all fees and charges 30 day notice of changes to the agreement Confidentiality Criteria for retention, involuntary transfer and transfer criteria Internal appeals process for involuntary transfer Policies on grievances and retaliation Emergency response policy

Occupancy Agreement Staffing and nurse delegation Description of services to address needs of tenants related to life skills and social activities (Dementia specific units) Billing, payment and refunds Copy of OA must be provided to the public upon request.

Program Policies and Procedures ALP run amuck-reason for P & P and Irs

Program Policies and procedures Incident Reports- (231B, 231C, 231D) Forms available to staff Detailed information Person in charge at the time of the incident (on the premises on each shift) shall prepare and sign the report Statements from witnesses All accidents or unusual occurrences within the program’s building or on the premises that affect tenants shall be reported as incidents (med errors, falls, elopements, accidents, etc). Report should be kept on the premises for a minimum of three (3) years.

Program Policies and Procedures Dependent Adult Abuse (235E) Reporting requirements for staff and employees, and Requirements that the victim and alleged abuser be separated

Program notification to the Department Chapter 67.4 The Director /designee shall be notified within 24 hours or the next business day of: “Major injury”- any injury that results in: Death; or Requires admission to a higher level of care for treatment Primary Care Provider (PCP) determines “major injury” based on the circumstances of the accident, previous functioning, and prognosis Report to the complaint unit Online* Hotline 1-877-686-0027 Fax (515) 281-7106 Prefer to have reported on line. If Program doesn’t have an online account, contact Terry Ventling at DIA.

Program notification The following are not reportable: Ambulatory tenant who falls when neither the Program or it’s employee has culpability, even if the tenant sustains a major injury Spontaneous fractures; or Hairline fractures

Program notification Other reportable incidents: Damage to the program by natural or other disaster An act that causes major injury to a tenant or when a program has knowledge of a pattern of acts committed by the same tenant on another individual that results in physical injury (pattern=two or more times in 30 day period) Elopement from the Program Tenant attempts suicide, injury or not Fire that requires emergency services ,or full or partial evacuation of the Program, or causes injury to a tenant Defect or failure in the fire sprinkler or fire alarm system for more than 4 hours in a 24- hour period. (Notification to the state fire marshal as well) Additional reporting requirements under 235B and 235E (such as dependent adult abuse)

Tenant Rights 231B, 231C, 231D, 67.3 Free from Restraint- “Restraint” means any chemical or manual method which restricts freedom of movement or normal access to one’s body or any physical or mechanical device, material or equipment which is attached or adjacent to tenant’s body that the tenant cannot remove easily and which restricts freedom of movement or normal access to one’s body. Consideration, respect, dignity, autonomy Receive care, treatment and services that are adequate and appropriate Privacy-personal and medical records

Tenant Rights Free from mental and physical abuse Reasonable response from staff and managers for any requests Associate and communicate privately with people of tenant’s choice Manage own finances Present grievances without fear of reprisal

Evaluations Functional-Activities of Daily Living Cognitive-Scored, objective tool (If moderate cognitive decline and risk the Global Deterioration Scale (GDS) will be used next evaluation) Health Prior to occupancy Within 30 days of occupancy Change of Condition Annually

Evaluations May be performed by- RN Health Care Professional (Physician, PA, RN, or ARNP licensed by Iowa) or Human Service Professional (Bachelor’s in human field such as gerontology, social work, sociology, psychology, human services, or family science).* LPN if delegated by the RN and no change of condition *Two years of experience in the human services field may be substituted for up to 2 years of education.

Service Plans 69.26 (1) Service plans developed for each tenant based on evaluations and designed to meet specific needs of the tenant---at least annually and whenever changes are needed. 69.26(2) Prior to the tenant signing the OA and taking occupancy of the unit, a SP should be developed by HCP or HSP and signed and dated by the tenant and/or legal representative and anyone who assisted in the development of the plan. 69.26(3) If a tenant needs personal care or health-related care, the service plan shall be updated within 30 days of the tenant’s occupancy and as needed with significant change, but not less than annually. If significant change triggers a review and update of the plan, it should be signed and dated by all parties.

Service Plans If significant change does not occur, the Program may, after nurse review, add minor discretionary changes to the plan with out comprehensive evaluations or obtaining signatures. If a significant change relates to a recurring or chronic condition, a previous evaluation and SP of the recurring condition may be utilized without new signatures. 69.26(4) SP shall be individualized and indicate at a minimum: Tenant’s identified needs and preferences for assistance; Services and care to be provided according to OA; Service provider(s) (if other than the Program)such as hospice, home health, therapies; Example-if chronic exacerbation of UTI, nurse review is adequate to institute the previously written eval and SP

Service Plans For tenants who are unable to plan their own activities, including tenants with dementia, a list of person-centered planned and spontaneous activities based on the tenant’s abilities and personal interests; and Preferences, if any, of the tenant/legal representative for nursing facility care if needed.

Criteria for admission and retention May not be admitted or retained in ALP-69.23 Bed-bound Requires routine two -person assistance with standing, transfer or evacuation Danger to self or other tenants or staff , including but not limited to a tenant who: Despite intervention chronically elopes, is sexually or physically aggressive or abusive, or displays unmanageable verbal abuse or aggression; or Displays behavior that places another tenant at risk; or Is in acute state of alcoholism, drug addiction, or uncontrolled mental illness; Requires more than part-time or intermittent care; or Has unmanageable incontinence on a routine basis despite an individualized toileting program;

Criteria for Admission and retention Has unmanageable incontinence on a routine basis, despite an individualized toileting program; or Is medically unstable; or Requires maximal assistance with daily activities of daily living; or Despite intervention, chronically urinates or defecates in places that are not considered acceptable according to societal norms (potted plant, etc.) Programs may have additional occupancy or transfer criteria and should be contained in the OA Program shall provide assistance to a tenant/legal representative to ensure a safe and orderly transfer to another program

Waiver for Retention of tenant 67.7 Informed intent of tenant or legal rep to remain in the program Program can provide staff to meet tenant’s service needs and those of the other tenants Will not jeopardize the health, safety, and security or welfare of the tenant, staff or other tenants; and Tenant diagnosed with a terminal illness and admitted to hospice, exceeds criteria for retention and admission for a temporary period of less than six months. Department will respond within 15 working days of receipt If you have someone decline suddenly, call me at the office before completing app for waiver.

Nurse Reviews 69.27(1) If a tenant doesn’t receive personal or health-related care, but has an observed significant change in their condition, a nurse review needs to be conducted. If a tenant receives personal or health-related care, the Program shall provide an RN to: Monitor, at least every 90 days, or after significant change in the tenant’s condition, any tenant who receives program-administered medications for adverse reactions to the medications and to make appropriate interventions or referrals, to ensure medication orders are current and administered consistently with the orders Ensure HCP orders are current for those tenants who receive HCP directed care from the Program

Nurse reviews Assess and document the health status of each tenant , to make recommendations and referrals, and to monitor progress relating to previous recommendations at least every 90 days and whenever there are changes in the tenant’s health status; and Provide the Program with written documentation of the nurse review, showing the time, date and signature. 69.27(2) An LPN, via nurse delegation may complete the nurse review except when a tenant experiences significant change in condition.

Medications 67.5 Each Program shall follow its own written medication policy, which shall include the following: The Program shall not prohibit a tenant from self-administering medications (a tenant taking personal responsibility for all phases of medication except for any component assigned to the program under medication setup, and may include the tenant’s use of an automatic pill dispenser). A tenant shall self-administer medications unless: The tenant or the tenant’s legal representative delegates in the OA or service plan any portion of medication setup to the Program. The tenant delegates medication setup to someone other than the Program. The Program assumes partial control of medication setup at the direction of the tenant. The medication plan shall not be implemented by the Program unless the Program’s registered nurse deems it appropriate under applicable requirements (including those in Iowa Code section 231C 16A and sub-rule 67.9 (4).

medications A tenant shall keep medications in his/her possession unless the tenant or the legal representative delegates in the OA or service plan, partial or complete control of medications to the Program. The service plan shall include the tenant’s choice related to storage. When a tenant has delegated medication administration to the Program, the Program shall maintain a list of the tenant’s medications. If the tenant self- administers medications, the tenant may choose to maintain a list of medications to the Program for the purpose of emergency response. If the tenant discloses a medication list in case of an emergency, the tenant remains responsible for the accuracy of the list. When medication setup is delegated to the Program by the tenant, staff, via nurse delegation, may transfer medications from the original prescription containers or unit dosing into the medication reminder boxes or medication cups.

Medications 67.5(6) When medications are administered traditionally by the Program: The administration of medications shall be provided by an RN, LPN, or ARNP or an unlicensed assistive personnel in accordance with sub-rule 67.9(4). Medications shall be kept in a locked place or container that is not accessible to persons other than employees responsible for the administration or storage of such medications. The Program shall maintain a list of each tenant’s medications and document the medications administered. Medications shall be administered as prescribed by the tenant’s physician, ARNP, or PA

Narcotics Narcotics protocol shall be determined by the RN and should include narcotic destruction and reconciliation

Tenant Records 69.25 Documentation for each tenant shall be maintained and retained for a minimum of three years after the transfer or death of a tenant and be protected from loss, damage, unauthorized use. List such as tenant’s name, diagnosis, emergency contacts, medication, evaluations, service plans, incident reports, legal, OA, orders, meds, ROI, etc.

Staffing 67.9(1) Sufficient number of trained staff available at all times to fully meet tenants’ needs. 67.9(2) All staff should be able to implement accident, fire safety, and emergency procedures. 67.9(3) Maintain documentation of staffing schedules and documentation of training received by certified and non-certified staff on nurse delegation procedures. 67.9(4) The Program’s RN should ensure certified and non-certified staff are competent to meet the needs of the tenants. Delegation should include at a minimum the following: Newly hired RN should within 60 days of beginning employment document a review to ensure staff are sufficiently trained and competent in all tasks that are assigned or delegated.

Staffing All Program staff should receive training by the RN within 30 days of employment Non-certified staff are trained at a minimum on ADLs and IADLs Certified and non-certified staff shall receive training regarding SP tasks in accordance with medical or nursing directives and acuity of tenants’ condition The RN shall provide direct or indirect supervision of all certified and non- certified staff as needed in the professional judgement of the Program’s RN Services are provided in according with the training System in place for written communication between staff and RN re: health, cognitive, and functional status of tenants. Retained by the Program for 3 years. If RN is absent due to vacation or other temporary circumstances, the replacing nurse should have access to staff training Communication log doesn’t include IRs

Staffing Staff cannot be designated as attorney-in-fact, guardian, conservator, or representative payee for a tenant unless the staff member is related to the tenant by blood, marriage, or adoption. Staff shall receive Dependent Adult Abuse Training (2 hours) according to Iowa Code Section 235B.16

Staffing 69.29(1) Each tenant should have access to a 24-hour personal emergency response system that automatically identifies the tenant in distress and can be activated with one touch 69.29(2) In lieu of providing access to a personal emergency response system, a program serving one or more tenants with cognitive disorder or dementia shall follow a system, program, or written staff procedures that address how the program will respond to the emergency needs of the tenant(s). 69.29(4) A dementia-specific ALP shall have one or more staff persons who monitor tenants as indicated in each tenant’s service plan. THE STAFF SHALL BE AWAKE AND ON DUTY 24 HOURS A DAY ON SITE AND IN THE PROXIMATE (within 5 minutes) AREA. Staff shall check on tenants as indicated in the tenants’ service plans. PERS-won’t necessarily look at timeframes for answering PERS unless there is a complaint or an outcome PERS are meant to be used for emergencies not on a routine basis

Dementia Specific Program Dementia-Specific Assisted Living Program means a Program that: Serves fewer than 55 tenants and has 5 or more tenants who have dementia between Stages 4 and 7 on the Global Deterioration Scale (GDS), or Serves 55 or more tenants and 10 percent or more of the tenants have dementia between Stages 4 and 7 on the GDS, or Holds itself out as providing specialized care for persons with dementia , such as Alzheimer’s disease, in a dedicated setting. For 2 consecutive certification periods.

Dementia specific training 69.29(4) A non-dementia specific assisted living program shall have one or more staff persons who monitor tenants as indicated in each tenant’s service plan. The staff shall be able to respond to a call light or other emergent tenant needs and be in the proximate area 24 hours a day on site. The staff shall check on tenants as indicated in the tenant’s service plans. 69.30(1) All personnel employed by or contracting with a dementia-specific program shall receive a minimum of eight (8) hours of dementia-specific education and training within 30 days of either employment or the beginning date of the contract, as applicable. 69.30(3) All other personnel employed by or contracting with a dementia-specific program shall receive a minimum of two (2) hours of dementia-specific training annually

Dementia Specific Training Direct-contact personnel employed by or contracting with a dementia-specific program or employed by a contracting agency providing staff to a dementia- specific program shall receive a minimum of eight hours of dementia-specific training annually The contracting agency may provide the program with documentation of dementia-specific continuing education that meets the requirements of this rule. Contracted personnel who have no contact with tenants are not required to receive the two hours of training Shall include hands-on training and may include classroom, web-based instruction or case studies of tenants in the Program.

Managed Risk 69.31 Managed Risk policy provided to the tenant with the OA and should include the following: Acknowledgment of the shared responsibility for identifying and meeting the needs of the tenant and the process for managing risk and for upholding tenant autonomy when tenant decision making results in poor outcomes for the tenant or others; Consensus based process to address risk situations. Program staff and tenants participate. Shall contain signature of the tenant and anyone else who participated in the process. Kept in tenant’s file. Look at GDS (below 5) Managed Risk agreement cannot be made with the legal rep. Has to be with the tenant.

Food Service 69.28 (1) Provide or coordinate with other community providers to provide a hot or other appropriate meal(s) at least once a day. 69.28(2) Meals and snacks provided by the Program but not prepared on site shall be provided by an entity that meets standards of state and local health laws. 69.28(3) Each meal shall provide 1/3 of the RDA minimum daily allowances. 69.28(4) Therapeutic diets can be provided 69.28(5) Staff who are employed by or contracted with the Program and who are responsible for food prep or service shall have an orientation on sanitation and safe food handling (annually thereafter) One person directly responsible for food prep shall complete a state-approved safe food protection program Other food service rules as found in Iowa Cope Chapter 137F Dietary manager ANSI Food Protection professional

Life Safety 69.32(2) Operating alarm system on each exit door of a dementia specific program 69.32(3) Approval from SFM before installation of any delayed-egress specialized locking systems. Fire Safety Procedures Evacuation-drills and actual Fire Watch-if fire alarm system non-functional for 4 or more hours, 30 minute fire watch and document

Monitoring Visits At least every 24 months 67.10(2) All records and areas of the Program necessary to determine compliance with applicable requirements shall be accessible to the Department for purposes of monitoring. 67.10(3) Use a preponderance of evidence when determining whether an RI exists. Preponderance means that the evidence considered and compared with the evidence opposed to it produces the belief in a reasonable mind that the allegations are more likely true than not.

Investigations 481—67.11 (231B, 231C, 231D) 67.11(1) Complaints By mail, phone, fax, or online The Department will forward to appropriate entity if outside of authority As much information as possible from the complainant is helpful, will keep anonymous. 67.11(2) Self reported incidents http://dia-hfd.iowa.gov/DIA under the complaints tab Mail, complaint hotline 877-686-0027, or fax 515-281-7106

Exit conference Face to Face Recommendations may change in the office Program has 2 working days to submit additional or rebuttal information to the Department. Final report within 10 working days Plan of Correction Within 10 working days following receipt of the final report, the Program shall submit a POC to the Department, including the date the RI will be corrected, measures to be taken so incident doesn’t recur, how will the Program ensure compliance. The Department shall review the plan and may request additional information. May or may not conduct a revisit

Civil Penalties 67.17 (1) Civil penalties my be issued when the Director finds that any of the following has occurred: Non-compliance results in imminent danger or substantial probability of resultant death or physical harm A program has failed to comply and the non-compliance has a direct relationship to the health, safety, or security of tenants. The Program prevents or interferes with enforcement If a Program discriminates or retaliates in any way against a tenant, tenant’s family, or an employee of the Program who has initiated or participated in any proceeding authorized by the State of Iowa A Program that continues to fail or refuses to comply within a specific time frame-no more than $5000 $1,000 – 10,000

Civil Penalties 67.14 Response to the final report Within 20 working days of the final report being issued and assessment of civil penalty, if any, the Program shall respond by: 67.14(1) If not contesting the final report, pay the 35% reduced civil penalty (if a fine is assessed). 67.14(2) If contesting the final report and civil penalty, the Program shall notify the Department in writing that it desires to contest the final report and civil penalty and shall do one of the following: Request an informal conference with an independent reviewer pursuant to sub-rule 67.14(3); or Request a contested case hearing in the manner provided by Iowa Code chapter 17A for contested cases.

Trends Background checks-67.19(1) -67.19(11) Criminal, dependent adult abuse, and child abuse record checks Iowa Code section 135C.33 requires Programs to request criminal, child and dependent adult abuse record checks of prospective employees prior to employment Can’t be older than 30 days SING-Patsy Tallman (515) 281-5503 DHS Record Check Evaluations: Russ Saunders (515) 362-7440 Rex Hall (515) 362-7441

Trends 481—67.3 (1) Tenant Rights—treated with consideration, respect, and full recognition of personal dignity and autonomy (2)-receive care, treatment and services which are adequate and appropriate Background checks Level of Care-Maximal assistance with ADLs-routine total dependence on staff for the performance of a minimum of four ADLs for a period that exceeds 21 days and/or consistently require assistance of 2 for transfer Increase in waivers to exceed level of care Insufficient dementia training Updating service plans

Questions The Future of ALPs