Iowa Admin. Code r. 441-81.16 - [Effective 7/1/2025] Outpatient services
Medicaid outpatient services provided by certified skilled nursing facilities are defined in the same way as the Medicare program.
This rule is intended to implement Iowa Code section 249A.4 and 1991 Iowa Acts, chapter 267, section 132(1)"i."
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) Deemed meeting of requirements. A nurse aide is deemed to satisfy the requirement of completing a nurse aide training and competency evaluation approved by the department of inspections and appeals if:
a. The nurse aide successfully completed a nurse aide training and competency evaluation program before July 1, 1989, and
(1) At least 60 clock hours were substituted for 75 clock hours, and the person has made up at least the difference in the number of clock hours in the program the person completed and 75 clock hours in supervised practical nurse aide training or in regular in-service nurse aide education, or
(2) The person was found to be competent (whether or not by the state) after completion of a nurse aide training of at least 100 clock hours' duration, or
(3) The person can demonstrate that the person served as a nurse aide at one or more facilities of the same employer in Iowa for at least 24 consecutive months before December 19, 1989, or
(4) The person completed, before July 1, 1989, a nurse aide training and competency evaluation program that the department of inspections and appeals determines would have met the requirements for approval at the time it was offered; or
b. The person is a veteran, an active duty service member, or a member of the reserve forces, who has:
(1) Successfully completed a U.S. military training program that includes a curriculum comparable to the nurse aide training program required by this rule and has documented successful completion of that program with either a diploma, certifications, or Form DD 214 showing completion of hospital corpsman or medical service specialist or equivalent training, and
(2) Provided documentation showing that the person has 75 clock hours of practical experience in a nurse aide role, which may include classroom instruction, prior equivalent experience, or a combination of the two, and
(3) Successfully completed the nurse aide training and competency examination.
(2) State review and approval of nurse aide training and competency evaluation programs or competency evaluation programs.
a. The department of inspections and appeals shall, in the course of all surveys, determine whether the nurse aide training and evaluation requirements of 81.13(19)"e" and 81.16(1) are met.
b. Requirements for approval of programs.
(1) Before the department of inspections and appeals approves a nurse aide training and competency evaluation program or competency evaluation program, the department of inspections and appeals shall determine whether:
1. A nurse aide training and competency evaluation program meets the course requirements of 81.16(3).
2. A nurse aide competency evaluation program meets the requirements of 81.16(4).
(2) Except as provided by paragraph 81.16(2)"f," the department of inspections and appeals shall not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in a facility which, in the previous two years:
1. Has operated under a nurse staffing waiver for a period in excess of 48 hours per week; or
2. Has been subject to an extended or partial extended survey; or
3. Has been assessed a civil money penalty of not less than $5,000; or
4. Has operated under temporary management appointed to oversee the operation of the facility and to ensure the health and safety of the facility 's residents; or
5. Pursuant to state action, was closed or had its residents transferred; or
6. Has been terminated from participation in the Medicaid or Medicare program; or
7. Has been denied payment under subrule 81.40(1) or 81.40(2).
c. Application process. Applications shall be submitted to the department of inspections and appeals before a new program begins and every two years thereafter on Form 427-0517, Application for Nurse Aide Training. The department of inspections and appeals shall, within 90 days of the date of a request or receipt of additional information from the requester:
(1) Advise the requester whether or not the program has been approved; or
(2) Request additional information from the requesting entity.
d. Duration of approval. The department of inspections and appeals shall not grant approval of a nurse aide training and competency evaluation program for a period longer than two years. A program shall notify the department of inspections and appeals and the department of inspections and appeals shall review that program when there are substantive changes made to that program within the two-year period.
e. Withdrawal of approval.
(1) The department of inspections and appeals shall withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program offered by or in a facility described in 81.16(2)"b" (2).
(2) The department of inspections and appeals may withdraw approval of a nurse aide training and competency evaluation program or nurse aide competency evaluation program if the department of inspections and appeals determines that any of the applicable requirements for approval or registry, as set out in subrule 81.16(3) or 81.16(4), are not met.
(3) The department of inspections and appeals shall withdraw approval of a nurse aide training and competency evaluation program or a nurse aide competency evaluation program if the entity providing the program refuses to permit unannounced visits by the department of inspections and appeals.
(4) If the department of inspections and appeals withdraws approval of a nurse aide training and competency evaluation program or competency evaluation program, the department of inspections and appeals shall notify the program in writing, indicating the reasons for withdrawal of approval of the program. Students who have started a training and competency evaluation program from which approval has been withdrawn shall be allowed to complete the course.
f. An exception to subparagraph 81.16(2)"b" (2) may be granted by the department of inspections and appeals (DIA) for 75-hour nurse aide training courses offered in (but not by) a facility under the following conditions:
(1) The facility has submitted Form 470-3494, Nurse Aide Education Program Waiver Request, to the DIA to request a waiver for each 75-hour nurse aide training course to be offered in (but not by) the facility .
(2) The 75-hour nurse aide training is offered in a facility by an approved nurse aide training and competency evaluation program (NATCEP).
(3) No other NATCEP program is offered within 30 minutes' travel from the facility , unless the facility can demonstrate the distance or program would create a hardship for program participants.
(4) The facility is in substantial compliance with the federal requirements related to nursing care and services.
(5) The facility is not a poor performing facility .
(6) Employees of the facility do not function as instructors for the program unless specifically approved by DIA.
(7) The NATCEP sponsoring the 75-hour nursing aide training course is responsible for program administration and for ensuring that program requirements are met.
(8) The NATCEP has submitted an evaluation to the DIA indicating that an adequate teaching and learning environment exists for conducting the course.
(9) The NATCEP has developed policies for communicating and resolving problems encountered during the course, including notice by the facility to the program instructor and students on how to contact the DIA to register any concerns encountered during the course.
(10) The NATCEP shall require the program instructor and students to complete an evaluation of the course. The instructor shall return the completed evaluations to the NATCEP which shall return the evaluations to DIA.
(3) Requirements for approval of a nurse aide training and competency evaluation program. The department has designated the department of inspections and appeals to approve required nurse aide training and competency evaluation programs. Policies and procedures governing approval of the programs are set forth in these rules.
a. For a nurse aide training and competency evaluation program to be approved, such program shall, at a minimum:
(1) Consist of no less than 75 clock hours of training, and
(2) Include at least the subjects specified in 81.16(3)"b," and
(3) Include at least 30 hours of didactic theory instruction, which may be provided in a classroom setting or through online course curricula, and
(4) Include at least 16 hours of laboratory experience provided in a face-to-face environment that complements the didactic theory curricula, and
(5) Include 30 hours of supervised clinical training in a face-to-face environment and supervised by a department of inspections and appeals-approved instructor in a manner not inconsistent with the licensing requirements of the Iowa board of nursing. In extenuating circumstances, a laboratory setting may be utilized in place of face-to-face clinical training subject to the department 's approval, and
(6) Ensure that students do not independently perform any services for which they have not been trained and found proficient by the department of inspections and appeals-approved instructor, and
(7) Meet the following requirements for department of inspections and appeals-approved instructors who train nurse aides:
1. The training of nurse aides shall be performed by or under the general supervision of a registered nurse who possesses a minimum of two years of nursing experience, at least one year of which shall be in the provision of long-term care facility services.
2. Instructors shall be registered nurses and shall have completed a course in teaching adults or have experience teaching adults or supervising nurse aides.
3. In a facility -based program, when the director of nursing is a registered nurse, the training of nurse aides may be performed by registered nurses under the general supervision of the director of nursing for the facility . The director of nursing is prohibited from performing the actual training.
4. Other personnel from the health professions as set forth in 42 CFR 483.152(5) may supplement the instructor. Supplemental personnel shall have at least one year of experience in their fields.
5. The ratio of department of inspections and appeals-approved instructors to students shall not exceed one registered nurse, or licensed practical nurse functioning as an assistant to a registered nurse, who is in the proximate area in the clinical setting, for every 15 students in the clinical setting, and
(8) Contain information regarding competency evaluation through written or oral examination and skills demonstration.
b. The curriculum of the nurse aide training program shall include:
(1) At least a total of 16 hours of training in the following areas prior to any direct contact with a resident:
1. Communication and interpersonal skills.
2. Infection control.
3. Safety and emergency procedures including the Heimlich maneuver.
4. Promoting residents' independence.
5. Respecting residents' rights.
(2) Basic nursing skills:
1. Taking and recording vital signs.
2. Measuring and recording height and weight.
3. Caring for the residents' environment.
4. Recognizing abnormal changes in body functioning and the importance of reporting these changes to a supervisor.
5. Caring for residents when death is imminent.
(3) Personal care skills, including, but not limited to:
1. Bathing.
2. Grooming, including mouth care.
3. Dressing.
4. Toileting.
5. Assisting with eating and hydration.
6. Proper feeding techniques.
7. Skin care.
8. Transfers, positioning, and turning.
(4) Mental health and social service needs:
1. Modifying aide's behavior in response to residents' behavior.
2. Awareness of developmental tasks associated with the aging process.
3. How to respond to resident behavior.
4. Allowing the resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity.
5. Using the resident's family as a source of emotional support.
(5) Care of cognitively impaired residents:
1. Techniques for addressing the unique needs and behaviors of persons with dementia (Alzheimer's and others).
2. Communicating with cognitively impaired residents.
3. Understanding the behavior of cognitively impaired residents.
4. Appropriate responses to the behavior of cognitively impaired residents.
5. Methods of reducing the effects of cognitive impairments.
(6) Basic restorative services:
1. Training the resident in self-care according to the resident's ability.
2. Use of assistive devices in transferring, ambulation, eating and dressing.
3. Maintenance of range of motion.
4. Proper turning and positioning in bed and chair.
5. Bowel and bladder training.
6. Care and use of prosthetic and orthotic devices.
(7) Residents' rights:
1. Providing privacy and maintenance of confidentiality.
2. Promoting the residents' rights to make personal choices to accommodate their needs.
3. Giving assistance in resolving grievances and disputes.
4. Providing needed assistance in getting to and participating in resident and family groups and other activities.
5. Maintaining care and security of residents' personal possessions.
6. Promoting the residents' rights to be free from abuse , mistreatment , and neglect and the need to report any instances of this type of treatment to appropriate facility staff.
7. Avoiding the need for restraints in accordance with current professional standards.
c. Prohibition of charges.
(1) A nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program or competency evaluation program may not be charged for any portion of the program including any fees for textbooks, course materials, or nurse aide competency evaluations.
(2) If a person who is not employed, or does not have an offer to be employed, as a nurse aide becomes employed by, or receives an offer of employment from, a facility no later than 12 months after completing a nurse aide training and competency evaluation program or competency evaluation program, the facility shall reimburse the nurse aide for costs incurred in completing the program or competency evaluation on a pro rata basis during the period in which the person is employed as a nurse aide . The formula for paying the nurse aides on a pro rata basis shall be as follows:
1. Add all costs incurred by the nurse aide for the course, books, and competency evaluations.
2. Divide the total arrived at in paragraph "1" above by 12 to prorate the costs over a one-year period and establish a monthly rate.
3. The nurse aide shall be reimbursed the monthly rate each month the nurse aide works at the facility until one year from the time the nurse aide completed the course.
d. Setting and equipment. The classroom shall have appropriate equipment, be of adequate size, and not interfere with resident activities.
e. Records and reports. Nurse aide education programs approved by the department of inspections and appeals shall:
(1) Notify the department of inspections and appeals:
1. Of dates of classroom and clinical sessions as well as location of classrooms and clinical practice sites before each course begins and if the course is canceled.
2. When a facility or other training entity will no longer be offering nurse aide training courses.
3. Whenever the person coordinating the training program is hired or terminates employment.
(2) Keep a list of faculty members and their qualifications available for department review.
(3) Provide each nurse aide a record of skills for which the nurse aide has been found competent during the course and which may be performed before completion of the competency evaluation.
(4) Complete a lesson plan for each unit which includes behavioral objectives, a topic outline and student activities and experiences.
(5) Provide the student, within 30 days of the last class period, evidence of having successfully completed the course.
(4) Nurse aide competency evaluation. A competency evaluation program shall contain a written or oral portion and a skills demonstration portion.
a. Notification to person. The department of inspections and appeals shall advise in advance any person who takes the competency evaluation that a record of the successful completion of the evaluation will be included in the state's nurse aide registry .
b. Content of the competency evaluation program.
(1) Written or oral examinations. The competency evaluation shall:
1. Allow an aide to choose between a written and oral examination.
2. Address each of the course requirements listed in 81.16(3)"b."
3. Be developed from a pool of test questions, only a portion of which is used in any one examination.
4. Use a system that prevents disclosure of both the pool of questions and the individual competency evaluations.
5. If oral, be read from a prepared text in a neutral manner.
6. Be tested for reliability and validity using a nationally recognized standard as determined by the department of education.
7. Be in English, unless the prevailing language used in the facility where a nurse aide will be working is other than English.
(2) Demonstration of skills. The skills demonstration evaluation shall consist of a demonstration of randomly selected items drawn from a pool consisting of tasks generally performed by nurse aides. This pool of skills shall include all of the personal care skills listed in 81.16(3)"b"(3).
c. Administration of the competency evaluation.
(1) The competency examination shall be administered and evaluated only by an entity approved by the department of inspections and appeals, which is neither a skilled nursing facility that participates in Medicare nor a nursing facility that participates in Medicaid.
(2) Charging nurse aides for competency testing is prohibited in accordance with 81.16(3)"c."
(3) The skills demonstration part of the evaluation shall be performed in a facility or laboratory setting comparable to the setting in which the person will function as a nurse aide and shall be administered and evaluated by a registered nurse with at least one year's experience in providing care for the elderly or the chronically ill of any age.
d. Facility proctoring of the competency evaluation.
(1) The competency evaluation may, at the nurse aide 's option, be conducted at the facility in which the nurse aide is or will be employed unless the facility is prohibited from being a competency evaluation site.
(2) The department of inspections and appeals may permit the competency evaluation to be proctored by facility personnel if the department of inspections and appeals finds that the procedure adopted by the facility ensures that the competency evaluation program:
1. Is secure from tampering.
2. Is standardized and scored by a testing, educational, or other organization approved by the department of inspections and appeals.
3. Requires no scoring by facility personnel.
(3) The department of inspections and appeals shall retract the right to proctor nurse aide competency evaluations from facilities in which the department of inspections and appeals finds any evidence of impropriety, including evidence of tampering by facility staff.
e. Successful completion of the competency evaluation program.
(1) A score of 70 percent or above is passing for both the written or oral and skills demonstration parts of the test.
(2) A record of successful completion of the competency evaluation shall be included in the nurse aide registry within 30 days of the date the person is found to be competent.
(3) The competency testing entity shall inform the nurse aide of the test score within 30 calendar days of the completion of the test and shall inform the nurse aide registry of the nurse aide 's scores within 20 calendar days after the test is administered.
f. Unsuccessful completion of the competency evaluation program.
(1) If the person does not complete the evaluation satisfactorily, the person shall be advised in writing within ten working days after the test is scored:
1. Of the areas which the person did not pass.
2. That the person has three opportunities to take the evaluation.
(2) Each person shall have three opportunities to pass each part of the test. If one part of the test is failed, only that part need be taken a second or third time. If either part of the test is failed three times, the 75-hour course shall be taken or retaken before the test can be taken again.
g. Storage of evaluation instrument. The person responsible for administering a competency evaluation shall provide secure storage of the evaluation instruments when they are not being administered or processed.
h. Application process. Entities wishing to secure approval for a competency evaluation program shall submit a copy of the evaluation plan and procedures to the department of inspections and appeals. The department of inspections and appeals shall notify the applicant of its decision within 90 days of receipt of the application. The notification shall include the reason for not giving approval if approval is denied and the applicable rule citation.
(5) Registry of nurse aides.
a. Establishment of registry. The department of inspections and appeals shall establish and maintain a registry of nurse aides that meets the following requirements. The registry:
(1) Shall include, at a minimum, the information required in 81.16(5)"c."
(2) Shall be sufficiently accessible to meet the needs of the public and health care providers promptly.
(3) Shall provide that any response to an inquiry that includes a finding of abuse , neglect, mistreatment of a resident or misappropriation of property also include any statement made by the nurse aide which disputes the finding.
b. Registry operation.
(1) Only the department of inspections and appeals may place on the registry findings of abuse , neglect, mistreatment of a resident or misappropriation of property.
(2) The department of inspections and appeals shall determine which persons:
1. Have successfully completed a nurse aide training and competency evaluation program or nurse aide competency evaluation program.
2. Have been deemed as meeting these requirements.
3. Do not qualify to remain on the registry because they have performed no nursing or nursing-related services for monetary compensation during a period of 24 consecutive months.
(3) The department of inspections and appeals shall not impose any charges related to registration on persons listed in the registry.
(4) The department of inspections and appeals shall provide information on the registry promptly.
c. Registry content.
(1) The registry shall contain at least the following information on each person who has successfully completed a nurse aide training and competency evaluation program or competency evaluation program which was approved by the department of inspections and appeals or who may function as a nurse aide because of having been deemed competent:
1. The person's full name.
2. Information necessary to identify each person.
3. The date the person became eligible for placement in the registry through successfully completing a nurse aide training and competency evaluation program or competency evaluation or by being deemed competent.
4. The following information on any finding by the department of inspections and appeals of abuse , neglect, mistreatment of residents or misappropriation of property by the person: documentation of the department of inspections and appeals' investigation, including the nature of the allegation and the evidence that led the department of inspections and appeals to conclude that the allegation was valid; the date of the hearing, if the person chose to have one, and its outcome; and a statement by the person disputing the allegation, if the person chooses to make one. This information must be included in the registry within ten working days of the finding and shall remain in the registry permanently, unless the finding was made in error, the person was found not guilty in a court of law, or the department of inspections and appeals is notified of the person's death.
5. A record of known convictions by a court of law of a person convicted of abuse , neglect, mistreatment or misappropriation of resident property.
(2) The registry shall remove entries for persons who have performed no nursing or nursing-related services for monetary compensation for a period of 24 consecutive months unless the person's registry entry includes documented findings or convictions by a court of law of abuse , neglect, mistreatment or misappropriation of property.
d. Disclosure of information. The department of inspections and appeals shall:
(1) Disclose all of the information listed in 81.16(5)"c"(1), (3), and (4) to all requesters and may disclose additional information it deems necessary.
(2) Promptly provide persons with all information contained in the registry about them when adverse findings are placed on the registry and upon request. Persons on the registry shall have sufficient opportunity to correct any misstatements or inaccuracies contained in the registry.
e. Placement of names on nurse aide registry . The facility shall ensure that the name of each person employed as a nurse aide in a Medicare- or Medicaid-certified nursing facility in Iowa is submitted to the registry. The telephone number of the registry is (515)281-4963. The address is Nurse Aide Registry , Lucas State Office Building, Des Moines, Iowa 50319-0083.
(1) Persons employed as nurse aides shall complete Form 427-0496, Nurse Aide Registry Application, within the first 30 days of employment. This form shall be submitted to the department of inspections and appeals. Form 427-0496 may be obtained by calling or writing the nurse aide registry .
(2) A nurse aide who is not employed may apply for inclusion on the registry by submitting a copy of completed Form 427-0496 to the nurse aide registry .
(3) When the registry has received a signed application and entered the required training and testing information on the registry, a letter will be sent to the nurse aide that includes all the information the registry has on the nurse aide . A nurse aide may obtain a copy of the information on the registry by writing the nurse aide registry and requesting the information. The letter requesting the information must include the nurse aide 's social security number, current or last facility of employment, date of birth and current mailing address and must be signed by the nurse aide .
(6) Hearing. When there is an allegation of abuse against a nurse aide , the department of inspections and appeals shall investigate that allegation. When the investigation by the department of inspections and appeals makes a finding of an act of abuse , the nurse aide named will be notified of this finding and the right to a hearing. The nurse aide shall have 30 days to request a hearing. The request shall be in writing and shall be sent to the department of inspections and appeals. The hearing shall be held pursuant to department of inspections and appeals rules 481-Chapter 10. After 30 days, if the nurse aide fails to appeal, or when all appeals are exhausted, the nurse aide registry will include a notation that the nurse aide has a founded abuse report on record if the final decision indicates the nurse aide performed an abusive act.
(7) Appeals. Adverse decisions made by the department of inspections and appeals in administering these rules may be appealed pursuant to department of inspections and appeals rules 481-Chapter 10.
This rule is intended to implement Iowa Code section 249A.4.