This Iowa regulation (481 IAC Chapter 69) establishes the certification requirements and operating standards for Assisted Living Programs under Iowa Code chapter 231C. It covers the full lifecycle of program certification—including application, initial certification, recertification, accreditation pathways, change of ownership, and decertification—as well as operational requirements such as tenant evaluation and admission criteria, occupancy agreements, service planning, nurse review, food service, and staffing. Operators must meet all applicable requirements set forth in this chapter and related rules, display current certificates, and comply with building code and fire safety standards.
View official sourceCHAPTER 69 ASSISTED LIVING PROGRAMS Chapter rescission date pursuant to Iowa Code section 17A.7: 3/11/31 481—69.1(231C) Definitions. In addition to the definitions in 481—Chapter 67 and Iowa Code chapter 231C, the following definitions apply: “Applicable requirements” means the requirements in Iowa Code chapter 231C, this chapter, and 481—Chapter 67 and includes any other applicable administrative rules and provisions of the Iowa Code. “CARF” means the Commission on Accreditation of Rehabilitation Facilities. “Cognitive disorder” means a disorder characterized by cognitive dysfunction presumed to be the result of illness that does not meet the criteria for dementia, delirium, or amnestic disorder. “Dementia-specific assisted living program” means an assisted living program certified under this chapter that: 1. 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 2. Serves 55 or more tenants and 10 percent or more of the tenants have dementia between Stages 4 and 7 on the GDS, or 3. Holds itself out as providing specialized care for persons with dementia, such as Alzheimer’s disease, in a dedicated setting. “Dwelling unit” means a single unit that provides complete, independent living facilities for one or more persons, including permanent provisions for living, sleeping and sanitation, and that may include permanent provisions for eating and cooking. “Sanitation” for purposes of this definition means bathroom fixtures as required by this chapter. “Maximal assistance with activities of daily living” means routine total dependence on staff for the performance of a minimum of four activities of daily living for a period that exceeds 21 days. “Medically unstable” means that a tenant has a condition or conditions: 1. Indicating physiological frailty as determined by the program’s staff in consultation with a physician or physician extender; 2. Resulting in three or more significant hospitalizations within a consecutive three-month period for more than observation; and 3. Requiring frequent supervision of the tenant for more than 21 days by a registered nurse. For example, a tenant who has a condition such as congestive heart failure that results in three or more significant hospitalizations during a quarter and that requires that the tenant receive frequent supervision may be considered medically unstable. “Unmanageable incontinence” means a condition that requires staff provision of total care for an incontinent tenant who lacks the ability to assist in bladder or bowel continence care. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.2(231C) Program certification. A program may obtain certification by meeting all applicable requirements or may be voluntarily accredited by a recognized accreditation entity. 69.2(1) Posting requirements. A program’s current certificate shall be visibly displayed within the designated operation area of the program. The latest monitoring report, fire safety bureau report, and food establishment inspections report issued pursuant to Iowa Code chapter 137F shall be made available to the public by the program upon request. 69.2(2) Dementia-specific programs. If a program meets the definition of a dementia-specific assisted living program during two sequential certification monitorings, the program shall meet all requirements for a dementia-specific program, including the requirements set forth in rule 481—69.30(231C); subrules 69.29(2), 69.29(4), 69.32(2), and 69.32(3); and paragraph 69.35(1)“d,” within 90 days of receiving the final report from the second sequential certification monitoring. If the number of tenants served who have dementia between Stages 4 and 7 on the GDS goes below that which is required by the definition of dementia-specific program at any time after the program has been deemed dementia-specific by definition Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.1 and the program is not holding itself out as providing dementia care in a specialized setting, the program will no longer be considered dementia-specific. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.3(231C) Certification of a nonaccredited program—application process. 69.3(1) The applicant shall complete an application packet obtained from the department’s health facilities division website at dia-hfd.iowa.gov; by mail from the Department of Inspections, Appeals, and Licensing, Adult Services Bureau, 6200 Park Avenue, Des Moines, Iowa 50321; or by telephone at 515.381.7272. 69.3(2) The applicant shall submit one copy of the completed application and all supporting documentation to the department at least 90 calendar days prior to the expected date of beginning operation. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.4(231C) Nonaccredited program—application content. An application for certification or recertification of a nonaccredited program shall include the following: 69.4(1) The names, addresses, and percentage of stock, shares, partnership or other equity interest of all officers, members of the board of directors and trustees, as well as stockholders, partners or any individuals who have greater than a 10 percent equity interest in each of the following, as applicable: a. The real estate owner or lessor; b. The lessee; c. The management company responsible for the day-to-day operation of the program. The program will notify the department of any changes in the list no later than ten working days after the effective date of the change. 69.4(2) A statement disclosing whether the individuals listed in subrule 69.4(1) have been convicted of a felony or an aggravated or serious misdemeanor or found to be in violation of the child abuse or dependent adult abuse laws of any state. 69.4(3) A statement disclosing whether any of the individuals listed in subrule 69.4(1) meet the criteria set out in Iowa Code section 231C.10(1)“g,” including for licensed health care facility as defined in Iowa Code section 135C.1 or licensed hospital as defined in Iowa Code section 135B.1. 69.4(4) The tenant occupancy agreement and all attachments. 69.4(5) If the program contracts for personal care or health-related care services from a certified home health agency, a mental health center or a licensed health care facility, a copy of that entity’s current license or certification. 69.4(6) A copy of the state license for the entity that provides food service, whether the entity is the program or an outside entity or a combination of both. 69.4(7) The fee set forth in Iowa Code section 231C.18. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.5(231C) Initial certification process for a nonaccredited program. 69.5(1) Upon receipt of all completed documentation, including building code and fire safety bureau approval and structural and evacuation review approval, the department will determine whether the proposed program meets applicable requirements. 69.5(2) If the department determines the proposed program meets the requirements for certification, a provisional certification will be issued to the program to begin operation and accept tenants. 69.5(3) Within 180 calendar days following issuance of provisional certification, the department will conduct a monitoring to determine the program’s compliance with applicable requirements. 69.5(4) If a regulatory insufficiency is identified as a result of the monitoring, the process in rule 481—67.10(17A,231B,231C,231D) will be followed. 69.5(5) The department will make a final certification decision based on the results of the monitoring and review of an acceptable plan of correction. Inspections, Appeals, and Licensing[481]Ch 69, p.2 IAC 9/30/26 69.5(6) The department will notify the program of a final certification decision within ten working days following the finalization of the monitoring report or receipt of an acceptable plan of correction, whichever is applicable. 69.5(7) If the decision is to continue certification, the department will issue a full two-year certification effective from the date of the original provisional certification. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.6(231C) Expiration of the certification of a nonaccredited program. Unless conditionally issued, suspended or revoked, certification of a program will expire at the end of the time period specified on the certificate. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.7(231C) Recertification process for a nonaccredited program. To obtain recertification, a program shall: 69.7(1) Submit one copy of the completed application, associated documentation, and the recertification fee as listed in Iowa Code section 231C.18 to the department at least 30 calendar days prior to the expiration of the program’s certification. 69.7(2) Submit additional documentation that each of the following has been inspected by a qualified professional and found to be maintained in conformance with the manufacturer’s recommendations and nationally recognized standards: heating system, cooling system, water heater, electrical system, plumbing, sewage system, artificial lighting, and ventilation system and, if located on site, garbage disposal, kitchen appliances, washing machines and dryers, and elevators. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.8(231C) Notification of recertification for a nonaccredited program. 69.8(1) The department will review the application and associated documentation and fees. After all finalized documentation is received, including building code and fire safety bureau approval, the department will determine the program’s compliance with applicable requirements. 69.8(2) If the facility is in good standing, the department will issue the program a two-year certification effective from the date of the expiration of the previous certification. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.9(231C) Certification or recertification of an accredited program—application process. An applicant for certification or recertification of a program accredited by a recognized accrediting entity shall: 69.9(1) Submit a completed application packet obtained from the department health facilities division website at dia-hfd.iowa.gov; by mail from the Department of Inspections, Appeals, and Licensing, Adult Services Bureau, 6200 Park Avenue, Des Moines, Iowa 50321; or by telephone at 515.281.7272. 69.9(2) Submit a copy of the current accreditation outcome from the recognized accrediting entity. 69.9(3) Maintain compliance with the building code and fire safety bureau’s requirements. 69.9(4) Submit the appropriate fees as set forth in Iowa Code section 231C.18. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.10(231C) Certification or recertification of an accredited program—application content. An application for certification or recertification of an accredited program shall comply with rule 481—69.3(231C) and include a copy of the current accreditation outcome from the recognized accrediting entity. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.11(231C) Initial certification process for an accredited program. 69.11(1) Within 20 working days of receiving all finalized documentation, including building code and fire safety bureau approval, the department will notify the accredited program whether the program meets applicable requirements and whether certification will be issued. Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.3 69.11(2) If the decision is to certify, a certification will be issued for the term of the accreditation not to exceed three years unless the certification is conditionally issued, suspended or revoked by either the department or the recognized accrediting entity. 69.11(3) If the decision is to deny certification, the department will provide the applicant an opportunity for hearing in accordance with rule 481—67.13(17A,231B,231C,231D). 69.11(4) Unless conditionally issued, suspended or revoked, certification for a program will expire at the end of the time period specified on the certificate. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.12(231C) Recertification process for an accredited program. 69.12(1) To obtain recertification, an accredited program shall comply with rule 481—69.9(231C) at least 30 calendar days prior to the expiration of the program’s certification. 69.12(2) If the facility is in good standing, a full certification will be issued for the term of the accreditation not to exceed three years unless the certification is conditionally issued, suspended or revoked by either the department or the recognized accrediting entity. 69.12(3) If the decision is to deny recertification, the department will provide the applicant an opportunity for hearing in accordance with rule 481—67.14(17A,231B,231C,231D). [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.13(231C) Listing of all certified programs. The department will maintain a list of all certified programs, which is available online at dia-hfd.iowa.gov. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.14(231C) Recognized accrediting entity. 69.14(1) The department designates CARF as a recognized accrediting entity for programs. 69.14(2) To apply for designation by the department as a recognized accrediting entity for programs, an entity shall submit a letter of request, and its standards shall meet the applicable requirements for programs. 69.14(3) The designation will remain in effect for as long as the accreditation standards meet the applicable requirements for programs. 69.14(4) An accrediting entity shall provide annually to the department, at no cost, a current edition of the applicable standards manual and survey preparation guide, and training thereon, within 120 working days after the publications are released. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.15(231C) Requirements for an accredited program. Each accredited program that is certified by the department shall: 69.15(1) Provide the department a copy of all survey reports, including outcomes, quality improvement plans and annual conformance to quality reports generated or received, as applicable, within ten working days of receipt of the reports. 69.15(2) Notify the department by the most expeditious means possible of all credible reports of alleged improper or inappropriate conduct or conditions within the program and any actions taken by the accrediting entity with respect thereto. 69.15(3) Notify the department immediately of the expiration, suspension, revocation or other loss of the program’s accreditation. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.16(231C) Maintenance of program accreditation. 69.16(1) An accredited program will continue to be recognized for certification by the department if both of the following requirements are met: a. The program complies with the requirements outlined in rule 481—69.15(231C). b. The program maintains its voluntary accreditation status for the duration of the time-limited certification period. Inspections, Appeals, and Licensing[481]Ch 69, p.4 IAC 9/30/26 69.16(2) A program that does not maintain its voluntary accreditation status must become certified by the department prior to any lapse in accreditation or cease operation as a program. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.17(231C) Change of ownership—notification to the department. 69.17(1) Certification, unless conditionally issued, suspended or revoked, may be transferable. If the program’s certification has been conditionally issued, the department must approve a change of ownership prior to the transfer of the certification. 69.17(2) In order to transfer certification, the applicant must: a. Meet the requirements of the rules, regulations and standards contained in Iowa Code chapter 231C and 481—Chapter 67 and this chapter; b. At least 30 days prior to the change of ownership of the program, provide application and supporting documentation to the department. 69.17(3) The department may conduct a monitoring within 90 days following a change in the program’s ownership to ensure that the program complies with applicable requirements. If a regulatory insufficiency is found, the department will take any necessary enforcement action authorized by applicable requirements. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.18(231C) Plan reviews of a building for a new program. 69.18(1) Before a building is constructed or remodeled for use in a new program, the state building code and fire safety bureau of the department shall review the construction documents and do fire inspections for compliance with requirements pursuant to this chapter. Construction or remodeling includes new construction, remodeling of any part of an existing building, addition of a new wing or floor to an existing building, or conversion of an existing building. 69.18(2) A program applicant shall submit construction documents to the building code bureau’s online portal at dial.iowa.gov/licenses/building/plan-review. 69.18(3) The plan review fee must be paid before construction documents are uploaded to the project folder. 69.18(4) The building code bureau of the department will notify the Iowa-licensed architect or Iowa-licensed engineer in writing regarding the status of compliance with requirements. 69.18(5) The Iowa-licensed architect or Iowa-licensed engineer shall respond to the building code bureau regarding how any noncompliance will be resolved. 69.18(6) Upon final notification by the building code bureau that the construction documents meet the bureau’s requirements, construction or remodeling of the building may commence. 69.18(7) The fire safety bureau will schedule an on-site visit of the building site with the contractor, or Iowa-licensed architect or Iowa-licensed engineer, during the construction or remodeling process to ensure compliance with the approved construction documents. Any noncompliance must be resolved prior to approval for certification. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.19(231C) Plan review prior to the remodeling of a building for a certified program. 69.19(1) Before a building for a certified program is remodeled as defined in subrule 69.18(1), the building code bureau will review the construction documents for compliance with requirements set forth in rule 481—69.35(231C). 69.19(2) A certified program shall submit construction documents to the building code bureau’s online portal at dial.iowa.gov/licenses/building/plan-review. 69.19(3) The plan review fee must be paid before construction documents are uploaded to the project folder. 69.19(4) Upon final notification by the building code bureau that the construction documents meet structural and life safety requirements, remodeling of the building may commence. 69.19(5) The building code and fire safety bureaus shall schedule an on-site visit of the building with the contractor, or Iowa-licensed architect or Iowa-licensed engineer, during the remodeling process to Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.5 ensure compliance with the approved construction documents. Any noncompliance must be resolved prior to approval for continued certification or recertification of the program. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.20(231C) Cessation of program operation that includes seeking decertification. 69.20(1) At least 90 days in advance of cessation, the program shall provide to the department and the office of long-term care ombudsman written notification of the date on which the program will cease operation or decertify. 69.20(2) At the time a program decides to cease operation, the program shall submit a plan to the department and make arrangements for the safe and orderly transfer or transition of all tenants within the 90-day period specified by subrule 69.20(1). 69.20(3) The department may conduct a monitoring during the 90-day period to ensure the safety of tenants during the transfer process or transition process. 69.20(4) When a program ceases operation, representatives from the office of long-term care ombudsman shall be allowed by the program to privately meet with tenants to provide education and service options. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.21(231C) Occupancy agreement. 69.21(1) The occupancy agreement shall be in 12-point type or larger, written in plain language using commonly understood terms and be easy for the tenant or the tenant’s legal representative to understand. 69.21(2) In addition to the requirements of Iowa Code section 231C.5, the written occupancy agreement shall include the following information in the body of the agreement or in the supporting documents and attachments: a. The telephone number for filing a complaint with the department. b. The telephone number for the office of long-term care ombudsman. c. The telephone number for reporting dependent adult abuse. d. A copy of the program’s statement on tenants’ rights. e. A statement that the tenant landlord law applies to assisted living programs. f. A statement that the program will notify the tenant at least 90 days in advance of any planned program cessation, except in cases of emergency. 69.21(3) The occupancy agreement shall be reviewed and updated as necessary to reflect any change in services or financial arrangements. 69.21(4) A copy of the occupancy agreement shall be provided to the tenant or the tenant’s legal representative, if any, and a copy kept by the program. 69.21(5) A copy of the most current occupancy agreement shall be made available to the general public upon request. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.22(231C) Evaluation of tenant. 69.22(1) Evaluation prior to occupancy. A program shall evaluate each prospective tenant’s functional, cognitive and health status prior to the tenant’s signing the occupancy agreement and taking occupancy of a dwelling unit in order to determine the tenant’s eligibility for the program, including whether the services needed are available. The cognitive evaluation shall utilize a scored, objective tool. When the score from the cognitive evaluation indicates moderate cognitive decline and risk, the GDS shall be used at all subsequent intervals, if applicable. If the tenant subsequently returns to the tenant’s mildly cognitively impaired state, the program may discontinue the GDS and revert to a scored cognitive screening tool. The evaluation shall be conducted by a health care professional, a human service professional, or a licensed practical nurse via nurse delegation. 69.22(2) Evaluation within 30 days of occupancy. A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy. The evaluation shall be conducted by a health care professional, a human service professional, or a licensed practical nurse via nurse delegation. Inspections, Appeals, and Licensing[481]Ch 69, p.6 IAC 9/30/26 69.22(3) Evaluation annually and with significant change. A program shall evaluate each tenant’s functional, cognitive and health status as needed with significant change, but not less than annually, to determine the tenant’s continued eligibility for the program and to determine any changes to services needed. The evaluation shall be conducted by a health care professional, a human service professional, or a licensed practical nurse via nurse delegation. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.23(231C) Criteria for admission and retention of tenants. 69.23(1) Persons who may not be admitted or retained. A program shall not knowingly admit or retain a tenant who: a. Is bed-bound; or b. Requires routine, two-person assistance with standing, transfer or evacuation; or c. Is dangerous to self or other tenants or staff, including but not limited to a tenant who: (1) Despite intervention, chronically elopes or is sexually, verbally, or physically aggressive or abusive; or (2) Displays behavior that places another tenant at risk; or d. Is in an acute stage of alcoholism, drug addiction, or uncontrolled mental illness; or e. Is under the age of 18; or f. Requires more than part-time or intermittent health-related care; or g. Has unmanageable incontinence on a routine basis despite an individualized toileting program; or h. Is medically unstable; or i. Requires maximal assistance with activities of daily living; or j. Despite intervention, chronically urinates or defecates in places that are not considered acceptable according to societal norms. 69.23(2) Disclosure of additional occupancy and transfer criteria. A program may have additional occupancy or transfer criteria if the criteria are disclosed in the written occupancy agreement prior to the tenant’s occupancy. 69.23(3) Assistance with transfer from the program. A program shall assist a tenant and the tenant’s legal representative, if applicable, to ensure a safe and orderly transfer from the program when the tenant exceeds the program’s criteria for admission and retention. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.24(231C) Involuntary transfer from the program. 69.24(1) Program initiation of transfer. The program shall comply with Iowa Code section 231C.6 and the following: a. The program will provide the tenant, or the tenant’s legal representative, the contact information for the office of long-term care ombudsman. b. The program will immediately provide to the office of long-term care ombudsman, by mail or email, a copy of the notification and notify the tenant’s treating physician, if any. c. Pursuant to statute, the office of long-term care ombudsman will offer the notified tenant or tenant’s legal representative assistance with the program’s internal appeal process. 69.24(2) Transfer pursuant to results of monitoring or complaint or program-reported incident investigation by the department. If one or more tenants are identified as exceeding the admission and retention criteria for tenants and need to be transferred as a result of a monitoring or a complaint or program-reported incident investigation conducted by the department, the following procedures shall apply. a. Program agreement with the department’ s finding. If the program agrees with the department’s finding and the program begins involuntary transfer proceedings, the program’s internal appeal process in subrule 69.24(1) will be utilized for appeals. b. Program disagreement with the department’ s finding. If the program does not agree with the department’s finding that the tenant exceeds admission and retention criteria, the program may appeal the department’s final report as provided in rule 481—67.14(17A,231B,231C,231D,85GA,HF2365). If an appeal is filed, the tenant who exceeds admission and retention criteria will be allowed to continue living at the program until all administrative appeals have been exhausted. Appeals filed that relate to the tenant’s Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.7 exceeding admission and retention criteria will be heard within 30 days of receipt, and appropriate services to meet the tenant’s needs will be provided during that period of time. c. Request for waiver of criteria for retention of a tenant in a program. To allow a tenant to remain in the program, the program may request a waiver of criteria for retention of a tenant pursuant to rule 481—67.7(231B,231C,231D) from the department within ten working days of the receipt of the report. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.25(231C) Tenant documents. 69.25(1) Documentation for each tenant shall be maintained by the program and include: a. An occupancy record, including the tenant’s name, birth date, and home address; identification numbers; date of occupancy; name, address and telephone number of health professional(s); diagnosis; and names, addresses and telephone numbers of family members, friends or other designated people to contact in the event of illness or an emergency; b. Application forms; c. The initial evaluations and updates; d. A nutritional assessment as necessary; e. The initial individual service plan and updates; f. Signed authorizations for permission to release medical information, photographs, or other media information as necessary; g. A signed authorization for the tenant to receive emergency medical care as necessary; h. A signed managed risk policy and signed managed risk consensus agreements, if any; i. When any personal or health-related care is delegated to the program, the medical information sheet; documentation of health professionals’ orders, such as those for treatment, therapy, and medication; and nurses’ notes written by exception; j. Medication lists, which will be maintained in conformance with 481—paragraph 67.5(2)“d”; k. Advance health care directives as applicable; l. A complete copy of the tenant’s occupancy agreement, including any updates; m. A written acknowledgment that the tenant or the tenant’s legal representative, if applicable, has been fully informed of the tenant’s rights; n. A copy of guardianship, durable power of attorney for health care, power of attorney, or conservatorship or other documentation of a legal representative; o. Incident reports involving the tenant, including but not limited to those related to medication errors, accidents, falls, and elopements (such reports need not be included in the tenant’s medical record); p. A copy of waivers of admission or retention criteria, if any; q. When the tenant is unable to advocate on the tenant’s own behalf or the tenant has multiple service providers, including hospice care providers, accurate documentation of the completion of routine personal or health-related care is required on task sheets. If tasks are doctor-ordered, the tasks will be part of the medication administration records (MARs); r. Authorizations for the release of information, if any. 69.25(2) The program records relating to a tenant shall be retained for a minimum of three years after termination of services. 69.25(3) All records shall be protected from loss, damage and unauthorized use. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.26(231C) Service plans. 69.26(1) A service plan shall be developed for each tenant based on the evaluations conducted in accordance with rule 481—69.22(231C) and be designed to meet the specific needs of the individual tenant. 69.26(2) Prior to the tenant’s signing the occupancy agreement and taking occupancy of a dwelling unit, a preliminary service plan shall be developed by a health care professional or human service professional in consultation with the tenant and, at the tenant’s request, with other individuals identified by the tenant, and, if applicable, with the tenant’s legal representative. All persons who develop the plan and the tenant or the tenant’s legal representative shall sign the plan. Inspections, Appeals, and Licensing[481]Ch 69, p.8 IAC 9/30/26 69.26(3) When 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. The service plan shall be signed by all parties, including the tenant or tenant’s legal representative. a. If a significant change does not exist, the program may, after nurse review, add minor discretionary changes to the service plan without a comprehensive evaluation and without obtaining signatures on the service plan. b. If a significant change relates to a recurring or chronic condition, a previous evaluation and service plan of the recurring condition may be utilized without new signatures being obtained. 69.26(4) The service plan shall be individualized and indicate: a. The tenant’s identified needs and preferences for assistance; b. Any services and care to be provided pursuant to the occupancy agreement; c. The service provider(s), if other than the program; d. 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; e. Preferences, if any, of the tenant or the tenant’s legal representative for nursing facility care, if the need for nursing facility care presents itself during the assisted living program occupancy. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.27(231C) Nurse review. 69.27(1) If a tenant does not receive personal or health-related care but an observed significant change in the tenant’s condition occurs, a nurse review shall be conducted. 69.27(2) If a tenant receives personal or health-related care, the program shall provide for a registered nurse or a licensed practical nurse via nurse delegation: a. To monitor, at least every 90 days, or after a significant change in the tenant’s condition, any tenant who receives program-administered prescription medications for adverse reactions to the medications and to make appropriate interventions or referrals, and to ensure that the prescription medication orders are current and that the prescription medications are administered consistent with such orders; b. To ensure that health care professionals’ orders are current for tenants who receive professional- directed health care from the program; c. To assess and document the health status of each tenant, to make recommendations and referrals as appropriate, and to monitor progress relating to previous recommendations at least every 90 days and whenever there are changes in the tenant’s health status; d. To provide the program with written documentation of the nurse review, showing the time, date and signature. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.28(231C) Food service. 69.28(1) The program shall provide or coordinate with other community providers to provide a hot or other appropriate meal(s) at least once a day or arrange for the availability of meals. 69.28(2) Meals and snacks provided by the program but not prepared on site shall be obtained from or provided by an entity that meets the standards of state and local health laws and ordinances concerning the preparation and serving of food. 69.28(3) Menus shall be planned to provide the following percentage of the daily recommended dietary allowances as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences based on the number of meals provided by the program: a. A minimum of 33⅓ percent if the program provides one meal per day; b. A minimum of 66⅔ percent if the program provides two meals per day; and c. One hundred percent if the program provides three meals per day. 69.28(4) Therapeutic diets may be provided by a program. If therapeutic diets are provided, they shall be prescribed by a physician, physician associate, advanced registered nurse practitioner or ordered by a licensed dietitian authorized by a qualified medical provider. A therapeutic diet provides food, fluids or nutrients by oral, enteral, or parenteral routes and is used in the treatment of a disease or clinical Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.9 condition to modify, eliminate, decrease or increase specific macro- or micronutrients, or to provide mechanically altered food when medically indicated. The thirteenth edition of the Iowa Simplified Diet Manual published by the Iowa dietetic association shall be available and used in the planning and serving of therapeutic diets. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and for reviewing procedures for food preparation and service for therapeutic diets. 69.28(5) Personnel who are employed by or contract with the program and who are responsible for food preparation or service, or both food preparation and service, shall have an orientation on sanitation and safe food handling prior to handling food and have annual in-service training on food protection. a. In addition to the requirements above, a minimum of one person directly responsible for food preparation shall have successfully completed a state-approved food protection program by: (1) Obtaining certification as a dietary manager; or (2) Obtaining certification as a food protection professional; or (3) Successfully completing an ANSI-accredited certified food protection manager program meeting the requirements for a food protection program included in the Food Code adopted pursuant to Iowa Code chapter 137F. Another program may be substituted if the program’s curriculum includes substantially similar competencies to a program that meets the requirements of the Food Code and the provider of the program files with the department a statement indicating that the program provides substantially similar instruction as it relates to sanitation and safe food handling. b. If the person is in the process of completing a course or certification listed in paragraph 69.28(5) “a,” the requirement relating to completion of a state-approved food protection program will be considered to have been met. 69.28(6) Programs engaged in the preparation and service of meals and snacks shall meet the standards of state and local health laws and ordinances pertaining to the preparation and service of food and be licensed pursuant to Iowa Code chapter 137F. The department will not require the program to be licensed as a food establishment if the program limits food activities to the following: a. All main meals and planned menu items will be prepared offsite and transferred to the program kitchen for service to tenants. b. Baked goods that do not require temperature control for safety and single-service juice or milk may be stored in the program’s kitchen and provided as part of a continental breakfast. c. Ingredients used for food-related activities with tenants may be stored in the program’s kitchen. Tenant activities may include the preparation and cooking of food items in the program’s kitchen if the activity occurs on an irregular or sporadic basis and the items prepared are not part of the program’s menu. d. Appropriately trained staff may prepare in the program’s kitchen individual quantities of tenant- requested menu-substitution food items that require limited or no preparation, such as peanut butter or cheese sandwiches or a single-service can of soup. The food items necessary to prepare the menu substitution may be stored in the program’s kitchen. These food items may not be cooked in the program’s kitchen but may be reheated in a microwave. A two- or four-slice toaster may be used for tenant-requested menu-substitution items, but there will be no bare-hand contact. e. Tenants may take food items left over from a meal back to their apartments, but no leftovers will be stored in the program’s kitchen. f. Warewashing may be done in the program’s kitchen as long as the program utilizes a commercial dishwasher and documents daily testing of sanitizer chemical ppm and proper water temperatures. Verification by the department of these practices may be conducted during on-site visits. 69.28(7) All perishable or potentially hazardous food shall be cooked to recommended temperatures and held at safe temperatures of 41°F (5°C) or below, or 135°F (57°C) or above. [ARC 0065D, IAB 2/4/26, effective 3/11/26; Editorial change: IAC Supplement 6/10/26] 481—69.29(231C) Staffing. In addition to the general staffing requirements in rule 481—67.9(231B,231C,231D), the following requirements apply to staffing in programs. 69.29(1) Each tenant will have access to a 24-hour personal emergency response system that automatically identifies the tenant in distress and can be activated with one touch. Inspections, Appeals, and Licensing[481]Ch 69, p.10 IAC 9/30/26 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 will 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(3) The owner or management corporation of the program is responsible for ensuring that all personnel employed by or contracting with the program receive training appropriate to assigned tasks and the target population. 69.29(4) A dementia-specific assisted living program will have one or more staff persons who monitor tenants as indicated in each tenant’s service plan. The staff will be awake and on duty 24 hours a day on site and in the proximate area. A non-dementia-specific assisted living program will have one or more staff persons who monitor tenants as indicated in each tenant’s service plan, 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. 69.29(5) All programs employing a new program manager after January 1, 2010, will require the manager within six months of hire to complete an assisted living management class whose curriculum includes at least six hours of training specifically related to Iowa rules and laws on assisted living programs. Managers who have completed a similar training prior to January 1, 2010, will not be required to complete additional training to meet this requirement. 69.29(6) All programs employing a new delegating nurse after January 1, 2010, will require the delegating nurse within six months of hire to complete an assisted living manager class or assisted living nursing class whose curriculum includes at least six hours of training specifically related to Iowa rules and laws on assisted living. A minimum of one delegating nurse from each program will complete the training. If there are multiple delegating nurses and only one delegating nurse completes the training, the delegating nurse who completes the training will train the other delegating nurses in the Iowa rules and laws on assisted living. As of January 1, 2011, all programs shall have a minimum of one delegating nurse who has completed the training described in this subrule. 69.29(7) The program will notify the department in writing within ten business days of a change in the program’s manager. 69.29(8) The program must develop and implement policy and procedure for addressing sexual relationships between tenants and staff and between tenants with dementia greater than Stage 5 on the GDS. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.30(231C) Dementia-specific education for program personnel. 69.30(1) All personnel employed by or contracting with a dementia-specific program shall receive a minimum of eight hours of dementia-specific education and training within 30 days of either employment or the beginning date of the contract, as applicable. 69.30(2) The dementia-specific education or training shall include: a. An explanation of dementia and related disorders; b. The program’s specialized dementia care philosophy and program; c. Skills for communicating with persons with dementia; d. Skills for communicating with family and friends of persons with dementia; e. An explanation of family issues such as role reversal, grief and loss, guilt, relinquishing the care-giving role, and family dynamics; f. The importance of planned and spontaneous activities; g. Skills in assistance with instrumental activities of daily living; h. The importance of the service plan and social history information; i. Skills in working with challenging tenants; j. Techniques for simplifying, cueing, and redirecting; k. Staff support and stress reduction; l. Medication management and nonpharmacological interventions. 69.30(3) Dementia-specific continuing education. Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.11 a. Except as otherwise provided in this subrule, all personnel employed by or contracting with a dementia-specific program shall receive a minimum of two hours of dementia-specific continuing education annually. b. 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 continuing education annually. c. Contracted personnel who have no contact with tenants (e.g., persons providing lawn maintenance or snow removal) are not required to receive the two hours of training required in paragraph 69.30(3)“a.” d. The contracting agency may provide the program with documentation of dementia-specific continuing education that meets the requirements of this subrule. 69.30(4) An employee or contractor who provides documentation of completion of a dementia- specific education or training program within the past 12 months will be exempt from the education and training requirement of subrule 69.30(1). 69.30(5) Dementia-specific training will include hands-on training and any of the following: classroom instruction, web-based training, and case studies of tenants in the program. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.31(231C) Managed risk policy and managed risk consensus agreements. The program shall have a managed risk policy that will be provided to the tenant along with the occupancy agreement and include: 69.31(1) An 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 could result in poor outcomes for the tenant or others; 69.31(2) A consensus-based process to address specific risk situations. Program staff and the tenant will participate in the process. The result of the consensus-based process may be a managed risk consensus agreement that will include the signature of the tenant and all others who participated in the process and be included in the tenant’s file. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.32(231C) Life safety—emergency policies and procedures and structural safety requirements. 69.32(1) The program shall submit to the department and follow written emergency policies and procedures, including: a. An emergency plan with procedures for natural disasters that is located for easy reference; b. Fire safety procedures; c. Other general or personal emergency procedures, including head injury protocols; d. Provisions for amending or revising the emergency plan; e. Provisions for periodic training of all employees; f. Procedures for fire drills; g. Regulations regarding smoking; h. Monitoring and testing of smoke-control systems; i. Tenant evacuation procedures; j. Procedures for reporting and documentation; k. Extraordinary lifesaving measures, such as cardiopulmonary resuscitation (CPR). 69.32(2) An operating alarm system shall be connected to each exit door in a dementia-specific program. 69.32(3) The program shall obtain approval from the fire safety bureau of the department before the installation of any specialized door locking systems. 69.32(4) A program serving a person(s) with cognitive disorder or dementia shall have written procedures regarding: a. Alarm systems, if an alarm system is in place. b. Appropriate staff response when a tenant’s service plan indicates a risk of elopement or when a tenant exhibits wandering behavior. Inspections, Appeals, and Licensing[481]Ch 69, p.12 IAC 9/30/26 c. Appropriate staff response if a tenant with cognitive disorder or dementia is missing. 69.32(5) The program’s structure and procedures and the facility in which a program is located shall meet the requirements adopted for assisted living programs in administrative rules promulgated by the building code and fire safety bureaus. Approval of both bureaus indicating that the building complies with these requirements is necessary for certification of a program. 69.32(6) The program shall have the means to control the maximum temperature of water at sources accessible by a tenant to prevent scalding and control the maximum water temperature for tenants with cognitive impairment or dementia or at a tenant’s request. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.33(231C) Transportation. When transportation services are provided directly or under contract with the program, the following shall apply: 69.33(1) The vehicle will be accessible and appropriate to the tenants who use it, with consideration for any physical disabilities and impairments. 69.33(2) Every tenant transported will have a seat in the vehicle, except for a tenant who remains in a wheelchair during transport. 69.33(3) Vehicles will have adequate seat belts and securing devices for ambulatory and wheelchair- using passengers. 69.33(4) Wheelchairs will be secured when the vehicle is in motion. 69.33(5) During loading and unloading of a tenant, the driver will be in the proximate area of the tenants in a vehicle. 69.33(6) The driver will have a valid and appropriate Iowa driver’s license or commercial driver’s license as required by law for the vehicle being utilized for transport, or be so licensed in another state. The driver will meet any state or federal requirements for licensure or certification for the vehicle operated. 69.33(7) Each vehicle will have a first-aid kit, fire extinguisher, safety triangles and a device for two-way communication. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.34(231C) Activities. The program shall have a policy related to activities, including the following: 69.34(1) The program will provide appropriate activities for each tenant reflecting individual differences in age, health status, sensory deficits, lifestyle, ethnic and cultural beliefs, religious beliefs, values, experiences, needs, interests, abilities and skills by providing opportunities for a variety of types and levels of involvement. 69.34(2) Activities will be planned to support the tenant’s service plan consistent with occupancy policies. 69.34(3) A written schedule of activities will be developed at least monthly and made available to tenants and their legal representatives. 69.34(4) Tenants will be given the opportunity to choose their levels of participation in all activities offered in the program. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.35(231C) Structural requirements. 69.35(1) General requirements. a. The structure of the program will be designed and operated to meet the needs of the tenants. b. The buildings and grounds will be well-maintained, clean, safe and sanitary. c. Programs will have private dwelling units with a single-action, lockable entrance door. d. A program serving persons with cognitive impairment or dementia, whether in a general or dementia-specific setting, will have the means to disable or remove the lock on an entrance door and disable or remove the lock if its presence presents a danger to the health and safety of the tenant. e. The structure in which a program is housed shall comply with the administrative rules promulgated by the building code and fire safety bureaus. Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.13 f. Programs may have individual cooking facilities within the private dwelling units. Any program serving persons with cognitive impairment or dementia, whether in a general or dementia-specific setting, will have the means to disable or easily remove appliances and disable or remove them if their presence presents a danger to the health and safety of the tenant or others. 69.35(2) Programs certified prior to July 4, 2001. Facilities for programs certified prior to July 4, 2001, shall meet the following requirements: a. Each dwelling unit will have at least one room that will have not less than 120 square feet of floor area. Other habitable rooms will have an area of not less than 70 square feet. b. Each dwelling unit will have not less than 190 square feet of floor area, excluding bathrooms. c. A dwelling unit used for double occupancy will have not less than 290 square feet of floor area, excluding bathrooms. d. The program will have a minimum of 15 square feet of common area per tenant. 69.35(3) New construction built on or after July 4, 2001. Programs operated in new construction built on or after July 4, 2001, shall meet the following requirements: a. Each dwelling unit will have at least one room that will have not less than 120 square feet of floor area. Other habitable rooms will have an area of not less than 70 square feet. b. Each dwelling unit used for single occupancy will have a total square footage of not less than 240 square feet of floor area, excluding bathrooms and door swing. c. A dwelling unit used for double occupancy will have a total square footage of not less than 340 square feet of floor area, excluding bathrooms and door swing. d. Each dwelling unit will contain a bathroom, including a toilet, sink and bathing facilities. A program serving persons with cognitive impairment or dementia, whether in a general or dementia-specific setting, will have the means to disable or remove the sink or bathing facility water control and will disable or remove the water control if its presence presents a danger to the health and safety of the tenant. e. Self-closing doors are not required for individual dwelling units, whether in a general or dementia- specific setting, unless the authority with jurisdiction determines that the level of hazard has increased to require the installation of closure hardware (for example, presence of a stove, range or oven). 69.35(4) Structure being converted to or remodeled for use by a program on or after July 4, 2001. A program operating in a structure that was converted or remodeled for use for a program on or after July 4, 2001, shall meet the following requirements: a. Each dwelling unit will have at least one room that has not less than 120 square feet of floor area. Other habitable rooms will have an area of not less than 70 square feet. b. Each dwelling unit used for single occupancy will have a total square footage of not less than 190 square feet of floor area, excluding bathrooms and door swing. c. A dwelling unit used for double occupancy will have a total square footage of not less than 290 square feet of floor area, excluding bathrooms and door swing. d. Each dwelling unit will have a bathroom, including a toilet, sink and bathing facility. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.36(231C) Dwelling units in dementia-specific programs. Dementia-specific programs are exempt from the requirements in subrules 69.35(2) through 69.35(4) as follows: 69.36(1) For a program built in a family or neighborhood design: a. Each dwelling unit used for single occupancy will have a total square footage of not less than 150 square feet of floor area, excluding a bathroom; and b. Each dwelling unit used for double occupancy will have a total square footage of not less than 250 square feet of floor area, excluding a bathroom. 69.36(2) Dementia-specific programs may choose not to provide bathing facilities in the dwelling units. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.37 Reserved. Inspections, Appeals, and Licensing[481]Ch 69, p.14 IAC 9/30/26 481—69.38(83GA,SF203) Identification of veteran’s benefit eligibility. 69.38(1) Within 30 days of a tenant’s admission to an assisted living program that receives reimbursement through the medical assistance program under Iowa Code chapter 249A, the program shall ask the tenant or the tenant’s personal representative whether the tenant is a veteran or whether the tenant is the spouse, widow, or dependent of a veteran and document the response. 69.38(2) If the tenant may be a veteran or the spouse, widow, or dependent of a veteran, the program shall report the tenant’s name along with the name of the veteran, if applicable, as well as the name of the contact person for this information, to the department of veterans affairs. The program may report such information to the department of health and human services. 69.38(3) If a tenant is eligible for benefits through the U.S. Department of Veterans Affairs or other third-party payor, the program first shall seek reimbursement from the identified payor source before seeking reimbursement from the medical assistance program established under Iowa Code chapter 249A. [ARC 0065D, IAB 2/4/26, effective 3/11/26] 481—69.39(231C) Respite care services. “Respite care services” means an organized program of temporary supportive care provided for 24 hours or more to a person in order to relieve the usual caregiver of the person from providing continual care to the person, or on request of the tenant as a trial of the program. An assisted living program that chooses to provide respite care services must meet the following requirements related to respite care services and be certified as an assisted living program. 69.39(1) Length of stay. Respite care services will be provided for no more than 30 consecutive days and for a total of no more than 60 days in a consecutive 12-month period beginning on the first day the individual stays in the program. 69.39(2) No separate certificate. An assisted living program that chooses to provide respite care services is not required to obtain a separate certificate or pay a certification fee. 69.39(3) Assessment. The program nurse will assess the individual prior to the individual’s stay and will document: a. Safety and supervision needs; b. Medical needs; c. Dietary needs; d. Bowel and bladder function. 69.39(4) Written direction to staff. The program nurse will document the care needs of the individual based on the assessment conducted pursuant to subrule 69.39(3) and provide the documentation to staff. 69.39(5) Involuntary termination of respite care services. The program may terminate the respite care services for the individual. Rule 481—69.24(231C) will not apply. The program will make proper arrangements for the welfare of the individual prior to involuntary termination of respite care services, including notification of the individual’s family or legal representative. 69.39(6) Contract. The program will have a contract with each individual, including: a. The time period during which the individual will be considered to be receiving respite care services, not to exceed 30 consecutive days. b. A description of all fees, charges, and rates for respite care services, and any additional and optional services and their related costs. c. A statement that respite care services may be involuntarily terminated. Rule 481—69.24(231C) will not apply. d. Identification of the party responsible for payment of fees and identification of the respite care individual’s legal representative, if any. e. Identification of emergency contacts, including but not limited to the individual’s family member(s) and physician. f. A statement that all individual information will be maintained in a confidential manner to the extent required under state and federal law. g. The refund policy, if applicable. h. A statement regarding billing and payment procedures. 69.39(7) Admission to program. a. Individuals receiving respite care will not be considered an admission to the program. Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.15 b. Individuals receiving respite care will be included in the program’s census. c. The program will not enter into multiple 30-day contracts with an individual receiving respite care in order to lengthen the individual’s stay in the program. d. If an individual receiving respite care remains in the program beyond 30 consecutive days and is eligible for admission, the department will consider the individual a tenant in the program. The program will follow all requirements for admission to the program. 69.39(8) Level of care criteria. Individuals receiving respite care must meet the criteria found in subrule 69.23(1) for admission and retention of tenants. Respite care services will not be provided by an assisted living program to persons requiring a level of care that is higher than the level of care the program is certified to provide. 69.39(9) Accessibility by the department. The department shall have the same access to respite care services records as provided in 481—subrule 67.10(2). [ARC 0065D, IAB 2/4/26, effective 3/11/26] These rules are intended to implement Iowa Code chapter 231C. Inspections, Appeals, and Licensing[481]Ch 69, p.16 IAC 9/30/26 Table A [Filed ARC 8176B (Notice ARC 7878B, IAB 6/17/09), IAB 9/23/09, effective 1/1/10] [Filed ARC 1376C (Notice ARC 1291C, IAB 1/22/14), IAB 3/19/14, effective 4/23/14] [Filed ARC 1667C (Notice ARC 1511C, IAB 6/25/14), IAB 10/15/14, effective 11/19/14] [Filed ARC 1927C (Notice ARC 1860C, IAB 2/4/15), IAB 4/1/15, effective 5/6/15] [Filed ARC 2463C (Notice ARC 2200C, IAB 10/14/15), IAB 3/16/16, effective 4/20/16] [Filed ARC 4976C (Notice ARC 4867C, IAB 1/15/20), IAB 3/11/20, effective 4/15/20] [Filed ARC 6054C (Notice ARC 5920C, IAB 9/22/21), IAB 11/17/21, effective 12/22/21] [Filed ARC 0065D (Notice ARC 9783C, IAB 12/10/25), IAB 2/4/26, effective 3/11/26] Inspections, Appeals, and Licensing[481]IAC 9/30/26 Ch 69, p.17 [Editorial change: IAC Supplement 6/10/26] Inspections, Appeals, and Licensing[481]Ch 69, p.18 IAC 9/30/26