Licensure Terms

Assisted Living Program and Residential Care Facility

General Approach

The Department of Inspections and Appeals, Health Facilities Division, licenses assisted living programs (ALPs) and residential care facilities (RCFs). ALPs serve a primarily elderly population and RCFs serve a younger adult population, including persons with physical and/or intellectual disabilities, persons with mental illness, as well as older persons.

ALPs may be certified as a dementia care unit if they meet additional requirements. RCFs may provide memory care services in a designated unit or a stand- alone facility. The Department approves the memory care program after reviewing the facility’s policies, staffing plan, admission and discharge criteria, safety procedures, and service plan.

Adult Foster Care. Elder group homes are licensed as a single-family residence operated to provide room, board, and personal care and health-related services for 3-5 elderly residents who are not related to the person providing the service. Homes must be staffed by an on-site manager 24 hours per day, 7 days per week. Regulatory provisions for elder group homes are not included in this profile but a link to the provisions can found at the end.

This profile includes summaries of selected regulatory provisions for ALPs and RCFs. The complete regulations are online at the links provided at the end.

Definitions

Assisted living programs provide housing with services to three or more residents in a physical structure that offers a home-like environment. ALPs encourage family involvement and resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, shared risk, and independence.

ALPs certified as dementia-specific may serve between 5 and 55 residents who have dementia between Stages 4 and 7 on the Global Deterioration Scale; or 55 or more residents of whom 10 percent or more have Stage 4-7 dementia based on the Global Deterioration Scale; or offer specialized care for persons with dementia, such as Alzheimer’s disease, in a dedicated setting.

Residential care facilities provide personal assistance and other essential daily living activities to individuals who are unable to sufficiently or properly care for themselves because of illness, disease, or physical or mental impairment.

Resident Agreements

Assisted Living Programs. The resident agreement includes the costs of services and terms of payment, as well as refunds and third-party provider agreements; occupancy and transfer criteria; grievance policies; emergency response policy; staffing policies, including whether or not staff are available 24 hours a day; staff delegation policies; and how staffing will be adjusted to meet changing needs.

Dementia-specific ALPs must, in addition, describe the services and programming for social activities that will be provided to meet residents’ life skill needs.

Residential Care Facilities. The resident agreement must include the costs of services, payment terms, and refund policies; bed hold policies; discharge criteria; and facility-specific policies.

Disclosure Provisions

No provisions identified for either facility type.

Admission and Retention Policy

Assisted Living Programs. Programs may not admit or retain residents who require total assistance with four or more activities of daily living (ADLs) for more than 21 days; are bedbound; require two-person assistance with standing, transfer, or evacuation; pose a danger to self or others; are in an acute stage of alcoholism, drug addiction, or uncontrolled mental illness; have unmanageable incontinence on a routine basis; require more than part-time or intermittent health-related care (21 days); or meet the program’s discharge criteria.

Part-time or intermittent nursing care includes licensed nursing care for unstable conditions; daily medication injections (except for stable diabetes); daily assessment or treatment of conditions, such as an open wound or a pressure ulcer; total care for unmanageable incontinence; or routine two-person assistance with standing, transfer, or evacuation.

Programs may request exceptions to the part-time or intermittent health care limit for residents who need hospice care or who temporarily need more than part-time or intermittent health care for more than 21 days. The Department may give approval for limited time periods if the resident makes an informed choice to remain, the program has the staff to meet the extended needs, and the health and welfare of other residents is not jeopardized.

Residential Care Facilities. Individuals may be admitted only on a written order signed by a physician certifying that the individual being admitted requires no more than personal care and supervision and does not require nursing care.

Services

Assisted living programs must provide assistance with personal care (ADLs) and health-related services. Health-related services mean less than daily skilled nursing services and professional therapies for temporary but not indefinite periods of time of up to 21 days a month. Programs must also provide resident access to a 24-hour personal emergency response system.

Residential care facilities must provide personal care services, including assistance with ADLs; social and recreational activities; and medication services.

Service Planning

Assisted living programs must assess residents’ functional, cognitive, and health status at specified intervals and upon a significant change in condition, and develop individualized service plans. A multidisciplinary team (including a health professional and human services professional) must be involved in service planning when residents require personal care or health-related services.

As needed, a managed risk agreement may be negotiated between the resident and facility. The agreement includes the resident’s or responsible person’s signed acknowledgment of the shared responsibility for identifying and meeting needs and the process for managing risk and upholding resident autonomy when resident’s decisions may result in poor outcomes for the resident or others.

Service plans for residents with dementia must include planned and spontaneous activities based on the resident’s abilities and personal interests.

Residential Care Facilities. Before admission, applicants must be examined by a physician to provide information about the individual’s medical status and diagnoses. Staff must develop a written, individualized, and integrated program of ongoing services for the resident that addresses the resident’s priorities, goals, and assessed needs.

Third-Party Providers

Assisted Living Programs. A program may contract with third-party providers of personal care and health-related services; however, the program is accountable for meeting all minimum standards. If the resident contracts with a third-party provider, the resident assumes the responsibility and risk for the employment or contractual relationship. All contracted services must be specified in the service plan and health- related services must be documented in the medication record.

Residential Care Facilities. No provisions identified.

Medication Provisions

Assisted Living Programs. Residents may self-administer medications or have medications administered by facility staff. The Iowa Nurse Practice Act allows nurses to delegate medication administration to unlicensed staff. Medication administration includes medication “setup,” described as routine prompting, cueing, and reminding; opening containers or packaging at the resident’s direction; reading instructions or other label information; and/or transferring medications from the original container into suitable medication dispensing containers.

A program that administers medications or provides health care professional- directed or health-related care must provide for a registered nurse (RN) to monitor each resident who receives program-administered medications for adverse reactions and ensure that the medication orders are current and properly administered. Monitoring must occur at least every 90 days or after a significant change in condition.

Residential Care Facilities. Residents may self-administer medications or have medications administered by facility staff. The following personnel may administer medications:

  • A licensed nurse or physician or an individual who has completed a Department- approved medication aide course.
  • Injectable medications must be administered by a qualified nurse, physician, pharmacist, or physician
  • Freestanding facilities licensed for 15 or fewer beds may permit a person who has completed a state-approved medication manager course to administer medications.

Food Service and Dietary Provisions

Assisted Living Programs. Facilities must provide hot meals at least once a day or coordinate with other community providers to make arrangements for the availability of meals. All meals must follow recommendations of the National Academy of Science’s Food and Nutrition Board. If therapeutic diets are provided, a health care provider must prescribe the diet and a licensed dietitian must be available to write and approve the therapeutic menu and review food preparation and service procedures.

Residential Care Facilities. Three daily meals must be served that meet recommended daily dietary allowances of the National Academy of Science’s Food and Nutrition Board.

Staffing Requirements

Assisted Living Program

Type of Staff. A program manager is required to oversee daily operations and staffing. Programs administering medications or providing health-related services must provide for a registered nurse to monitor medications, delegate medication administration, ensure that physician orders are current, and assess and monitor health status. Personnel are required to assist residents with daily activities.

Staff Ratios. No minimum ratios. A sufficient number and type of staff must be available 24 hours a day to meet residents’ scheduled and unscheduled needs.

Residential Care Facility

Type of Staff. Facilities must have a full-time administrator who is responsible for daily operations and staffing; staff to provide personal care; an activity coordinator to organize and monitor the activities program; and either a licensed nurse, physician, or certified medication aide to administer medications.

Staff Ratios. Minimum staff-to-resident ratios are 1:25 during the day; 1:35 during the evening; and 1:45 during the night. The Department may require additional staffing based on residents’ needs. Staff must be awake when on duty in facilities with 15 or more residents

Training Requirements

Assisted Living Programs. Program managers and/or delegating nurses hired after January 1, 2010, must complete an assisted living management or nursing course within 6 months of hire. All personnel must be trained on the program’s accident, fire safety, and emergency procedures. 

Residential Care Facilities. The administrator must provide monthly in-service training for staff.

Provisions for Apartments and Private Units

Assisted Living Programs. Private apartments are not required. Resident rooms may be single-occupancy or double-occupancy and must have a bathroom, including a toilet, sink, and bath or shower. Kitchens are optional.

Residential Care Facilities. No more than four residents may share a room. Bathrooms and bathing facilities may be shared, with at least one bathtub or shower for every 15 residents and one sink and toilet for every ten residents.

Provisions for Serving Persons with Dementia

Dementia Care Staff

Assisted living programs and residential care facilities must have at least one staff person on duty and awake 24 hours a day in the dementia care unit.

Dementia Staff Training

Assisted Living Programs. All personnel employed by or contracting with a dementia-specific program must receive a minimum of 8 hours of dementia-specific education and training within 30 days of employment. Direct care staff must receive at least 8 hours of annual continuing education and all other personnel at least 2 hours of dementia-specific continuing education. Specific topics include explanation of dementia; the service philosophy and program; communication skills; family issues; planned and spontaneous activities; ADL assistance; service planning and social history; working with challenging residents; cuing and redirecting; and staff support and stress reduction.

Residential Care Facilities. Staff must have at least 6 hours of special training appropriate to their job descriptions within 30 days of hire and 6 hours of annual training on the same topics described above.

Dementia Facility Requirements

Assisted Living Programs. An operating alarm system must be connected to each exit door in a dementia-specific program. Staff must have the means to disable or remove the lock on an entrance door and do so if the presence of the lock presents a danger to residents’ health and safety. If kitchens are provided in apartments, the program must be able to disable or remove appliances if needed to protect the resident and others.

Residential Care Facilities. No provisions identified.

Background Checks

Assisted Living Programs and Residential Care Facilities. Before hiring an individual, the manager must request a criminal history check by the Department of Public Safety and a child and dependent adult abuse record check by the Department of Human Services (DHS). If the applicant has a record, DHS determines whether the crime warrants prohibiting the individual’s employment.

Inspection and Monitoring

Assisted Living Programs. Facilities receive a conditional certification and are inspected by the Department within 3 months. Pending a successful inspection, facilities receive a 2-year license and are then inspected every other year unless there is a complaint.

Residential Care Facilities. Facilities receive a conditional certification and are inspected by the Department within 3 months to receive license. Inspections must be conducted at least every 30 months.

Public Financing

Services in both assisted living and RCFs are covered through a Medicaid 1915(c) Elderly Waiver program administered by DHS.

Room and Board Policy

Iowa provides an optional state supplement (OSS) for eligible RCF residents but not for ALP residents. The amount of the OSS is based on the allowable costs of residential care, plus a personal needs allowance (PNA) that is retained by the resident, minus the federal Supplemental Security Income payment. In 2015, the maximum monthly OSS is $299.55. In 2011, the PNA was $93 a month.1

Family supplementation is permitted.

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1 Social Security Administration. State Assistance Programs for SSI Recipients, January 2011. http://www.socialsecurity.gov/policy/docs/progdesc/ssi_st_asst/2011/ia.html. Current information about the PNA was not available online or from other sources.

Location of Licensing, Certification, or Other Requirements

Iowa Administrative Code, Title 481, Chapter 69: Assisted Living Programs. [January 1, 2010] https://www.legis.iowa.gov/docs/ACO/IAC/LINC/09-23-2009.Chapter.481.69.pdf

Iowa Code, Chapter 231C: Assisted Living Programs. [2011] http://www.state.ia.us/government/dia/231C_2011Code.pdf

Iowa Administrative Code, Title 481, Chapter 57: Residential Care Facilities. [December 10, 2014]

https://www.legis.iowa.gov/law/administrativeRules/rules?agency=481&chapter=57&pubDate=0 7-24-2013

Iowa Finance Authority website: Affordable Assisted Living Operator Toolkit, includes information for providers and links to regulations and resources. http://www.iowafinanceauthority1.com/AALOperatorsToolkit.asp

Information Sources

Cindy Baddeloo Deputy Director
Iowa Health Care Association
and
Iowa Center for Assisted Living