WSR 98-22-101

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Aging and Adult Services Administration)

[Filed November 4, 1998, 10:42 a.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 97-03-124.

Title of Rule: WAC 388-15-650 through 388-15-662, adult day health services; WAC 388-15-650 Purpose, 388-15-651 Definitions, 388-15-652 Adult day care (COPES level I), 388-15-653 Adult day health (level II), 388-15-654 Plan of care, 388-15-655 Title XIX adult day health certification and monitoring, 388-15-656 Administration and organization, 388-15-657 Staffing, 388-15-658 Personnel requirements, 388-15-659 Facility, 388-15-660 Nonduplication of services, 388-15-661 Clients in residential care or nursing facilities care settings, and 388-15-662 Expenditures not to exceed.

Purpose: Establishes client eligibility, care levels, payment rates, and criteria for provider eligibility.

Statutory Authority for Adoption: RCW 74.39A.007 and 74.08.090.

Statute Being Implemented: RCW 74.39A.007.

Summary: These rules will establish eligibility, care levels and payment rates that will ensure appropriate health and social services for the clients receiving Medicaid services.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Cheryl Allen, Aging and Adult Services Administration, 600 Woodland Square Loop S.E., Lacey, WA 98504, (360) 478-4772.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: These rules will implement the goals and objectives outlined in RCW 74.39A.007 and 74.39A.030 by offering a balanced array of health, social, and supportive services. Adult day health will promote individual choice, dignity, and the highest practicable level of independence while ensuring services that are the most cost-effective.

Proposal does not change existing rules.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

Small Business Economic Impact Statement

Are large and small business involved? The majority of the adult day health providers impacted by these rules would be classified as nonprofit small businesses. The definition of a small business found in RCW 19.85.020 is: "Any business entity, including a sole proprietorship, corporation, partnership, or other legal entity, that is owned and operated independently from all other businesses, that has the purpose of making a profit, and that has fifty or fewer employees."

What is the impact on business? There is no significant impact since each provider receives an adequate rate depending on the metropolitan area or county in which they are located, and the level of care that is authorized for each participant. The ability to generate revenue does not go away. The average provider can receive an average daily rate per participant of $40.43 for level II services and an average of $30.82 per participant for level I services (for as many days per week they are operating).

Are there disproportionate impacts to large and small business? There would be no disproportionate impacts as all providers receive the same level of reimbursement.

How did the department mitigate these costs? There is no disproportionate impact, therefore no costs to mitigate.

A copy of the statement may be obtained by writing to Aging and Adult Services Administration, Adult Day Health Program Manager, P.O. Box 45600, Olympia, WA 98504-5600, phone (360) 493-2545, fax (360) 438-8633.

RCW 34.05.328 applies to this rule adoption. These rules do meet the definition of significant rules and a cost benefit analysis has been prepared. To obtain a copy of the cost benefit analysis please contact the address above.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on December 22, 1998, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by December 11, 1998, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by December 22, 1998.

Date of Intended Adoption: January 15, 1999.

November 3, 1998

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

SHS-2475.3

NEW SECTION

WAC 388-15-650  Purpose. To assist individuals to remain in the community in the least restrictive environment while enabling families and other caregivers to continue providing needed support. WAC 388-15-650 through 388-15-662 is to regulate adult day health facilities that receive Medicaid or state general funding for client care. Adult day health programs that do not receive any Medicaid or state general funds are exempt from these requirements.

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NEW SECTION

WAC 388-15-651  Definitions. "Adult day care" (level I). Adult day care provides supervised daytime programs where frail and disabled adults can participate in social, educational, and recreational activities. Services at this level are the basic "core services" that must be provided in all adult day care and adult day health programs. Level I is appropriate for clients who have chronic medical conditions that do not require the services of a skilled health professional on a routine basis. A registered nurse and social worker provide consultation regarding the individual's participation in the program and assessment of the client's overall well-being and need for additional services. Level I offers respite to caregivers by providing a safe alternative to home care.

"Adult day health" (level II). Adult day health is a structured program that provides licensed rehabilitative and skilled nursing services in an environment that also offers social work services and socialization for frail and disabled adults. Level II services provide rehabilitative, nursing, and professional level of psychological/counseling services with a focus on prevention, teaching, and health monitoring. Each participant has a specialized plan of care designed to structure his or her participation and to address particular needs.

"Certification." The process by which an area agency on aging as authorized by the department certifies an adult day health center to be eligible for Medicaid reimbursement for direct services provided to eligible individuals. The center must directly provide the services and meet requirements set by the department including fiscal requirements for contracting with the department. Adult day health centers that do not accept Medicaid or state-funded clients are not certified through this process.

"Core services." A common set of services that is provided by all programs that must include: client screening, individual assessment, and plan of care; basic health monitoring with consultation from a registered nurse; social services, therapeutic activities, at least one nutritional meal per day, including modified diet if needed; coordination and/or provision of transportation; emergency care for participants.

"Intake evaluation." The screening process conducted by the Adult Day Health center must be completed in order to gain an initial assessment of the appropriateness of the adult day health program for the client. During the intake process, clients for whom the program is not appropriate, are referred to other community agencies.

"Plan of care." The written plan that is developed with the participation of the client, and/or the client's authorized representative, is monitored by the individual responsible from the multidisciplinary team for each participant's plan. The plan of care details the services to be provided through identifying services needed with goals, objectives, and duration of the services.

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NEW SECTION

WAC 388-15-652  Adult day care (COPES level I). (1) Determining eligibility for COPES level I adult day care.

(a) Home and community services staff (HCS) or area agency on aging (AAA) case managers determine eligibility, by determining the need of the client cannot be appropriately met in a less structured setting and in accordance with the criteria listed in subsection (2) of this section.

(b) The need for services must be documented in the plan of care, assessed, and re-authorized at regular, specified intervals.

(c) A physician does not need to authorize adult day care services as is required for level II adult day health.

(2) A person who is eligible for COPES and needing supervision or activities of daily living who can benefit from level I services to remain in their own home may receive level I services if it is an approved part of the clients service plan developed by HCS staff, AAA staff or authorized subcontractors. Eligibility criteria for adult day care COPES level I. Clients are eligible when they are:

(a) Eligible for COPES as defined in WAC 388-15-620; and

(b) Ineligible for, and/or are eligible for, but do not have access to, level II adult day health; and

(c) Determined to be in need of one or more of the following services:

(i) Provision of personal care as defined in WAC 388-15-202(38);

(ii) Basic health monitoring with consultation from a registered nurse;

(iii) Therapeutic activities; or

(iv) Supervision or protection.

(3) Identifying providers. The AAA directly designates adult day care level I providers through a COPES contract.

(4) Rates and sources of payment for adult day care level I.

(a) Transportation is not reimbursed under this rate. Arrangements for transportation for eligible Medicaid recipients are made with the local Medicaid transportation brokers or with individual client COPES funds.

(b) Services are reimbursed on an hourly basis up to four hours per day. Any service provided over four hours per day shall be reimbursed at the daily rate. Effective July 1, 1997 the rates are as follows:

(c) Service plan for adult day care level I. The level I service is a part of the COPES service plan for the client. This plan is developed by HCS, AAA (or authorized subcontractor) staff. A client/participant may receive both level I and level II services on different days. If, according to an adult day health center plan of care, a client/participant may need a level II service three days per week, but only wishes and would benefit from socialization or activities of daily living (ADL) assistance two additional days, both services may be authorized to complement the week.

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NEW SECTION

WAC 388-15-653  Adult day health (level II). (1) Determining eligibility for level II.

(a) Certified providers assess the prospective client's need for day health. The assessment must include all services that the client has been authorized to receive. A state-approved assessment tool must be used. The two approved tools are:

(i) The OARS multidimensional functional assessment; and

(ii) The comprehensive assessment (CA) provided by AASA. The CA must not contain the AASA/DSHS logo.

(b) The adult day health provider must document the client's need for skilled nursing care or rehabilitative therapy and the frequency of the planned care provision.

(c) Day health providers must verify each client's Medicaid and COPES eligibility.

(d) The provider must obtain a current medical report from the client's physician. The report must have been completed and dated by the client's physician within the last three months. The facility must inform the physician that he or she is documenting the need for skilled nursing or professional rehabilitative therapy services. The facility staff must obtain, from the attending physician, the following additional medical information:

(i) Frequency with which the client must be seen by the physician (client must agree to visits as ordered by the physician);

(ii) Orders for physical, speech, and hearing or other rehabilitative therapy; and

(iii) The physician's signature shall indicate that the client has a medical need for adult day health services and orders the development of a plan of care, and the provision of adult day health services.

(e) The multidisciplinary team, in preparing the plan of care, shall include input from the attending physician of any client funded by Medicaid.

(f) The plan of care shall be forwarded to the attending physician within one week of completion.

(g) Medicaid clients shall have their plan of care reassessed at least once every three months by the multidisciplinary team, which is to include the clients attending physician.

(h) Progress notes on Medicaid clients must be recorded weekly.

(i) Changes in the Medicaid clients plan of care are to be filed in their case record and a copy forwarded to the clients physician.

(2) Eligibility criteria for adult day health level II.

(a) Applicants are considered eligible for level II when they are:

(i) Active Title XIX recipients in the following categories:

or

(ii) Enrolled COPES clients receiving at least one COPES service (not including level II day health).

(b) In addition to subsection (1)(a) of this section, eligible clients must also be in need of one or more of the following and not have access to:

(i) Skilled nursing services: Skilled nursing services are services provided by a registered nurse (RN), or a licensed practical nurse (LPN). Reminding or coaching a client is not a skilled service. Skilled nursing services may include, but is not limited to, one or more of the following:

(A) Observation and assessment: This service may be medically necessary for a client who is in an unstable condition.

(B) Teaching and training activities: Teaching and training activities enable the client to become independent. Examples of teaching a client are:

(I) Self-administration of an injection,

(II) Prefill insulin syringes,

(III) Irrigate a catheter,

(IV) Care for a colostomy or ileostomy,

(V) Dressing changes and aseptic techniques,

(VI) Management of activities of daily living,

(VII) Understand an illness, medications, its symptoms and how to cope.

(C) Intervention: Services provided directly by the licensed nurse may include, but are not limited to:

(I) Inset or irrigate a catheter,

(II) Administer medications or medical gases,

(III) The administration and management of infusion therapy services.

(ii) Rehabilitative therapies: Therapy services must be medically necessary for preventing further deterioration or restoring a function affected by the client's illness, disability, or injury. These services must be provided by or under the supervision of the therapist.

(A) Physical therapy: Physical therapy must be provided according to applicable state practice laws and regulations. Physical therapy may include but not be limited:

(I) Assessing the participant's mobility level, strength, range of motion endurance, balance, ability to transfer.

(II) Provide treatment to relieve pain and/or develop restore, or maintain functioning.

(III) Establish a maintenance program and provide written and verbal instructions to program staff and the family/caregiver to assist the participant with implementation.

(B) Occupational therapy: Occupational therapy services must be provided according to applicable state practice laws and regulations. Occupational therapy may include, but are not limited to:

(I) Administer basic evaluation to determine baseline level of functioning, ability to transfer, range of motion, balance, strength and coordination, activities of daily living and cognitive-perceptual functioning.

(II) Teach and train participant and/or staff in the use of therapeutic, creative, and self-care activities to improve or maintain the participant's capacity for self-care and independence, and increase the range of motion, strength and coordination.

(C) Speech pathology and audiology: Speech pathology and audiology services must be provided according to applicable state practice laws and regulations. Services may include, but are not limited to:

(I) Establish a treatment program to improve communication ability and correct disorders.

(II) Provide speech therapy procedures that include auditory comprehension tasks visual and/or reading comprehensive tasks, language intelligibility tasks, training involving the use of alternative communication devices.

(III) Swallowing assessment and treatment.

(c) The client must receive services from one of the licensed professionals listed above. If, at the time of reassessment, it is determined that the participant requires fewer or more days of attendance, based on documentation of care delivered, the plan of care will be adjusted.

(3) Identifying providers. Level II providers for billing purposes are designated through a contract with the DSHS medical assistance administration (MAA). In order to be eligible to contract with MAA, they must be certified by the AAA. The AAA is required to conduct an annual review for continuing certification for each provider.

(4) Rates for level II and sources of payment.

(a) Transportation is not reimbursed under level II adult day health rate. Arrangements for transportation are made with the local Medicaid transportation brokers.

(b) Effective July 1, 1997 the rates are as follows:

(c) There is a one time only intake evaluation that is reimbursed at eighty-two dollars and ninety cents.

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Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

NEW SECTION

WAC 388-15-654  Plan of care. The plan of care:

(1) Is developed by the multidisciplinary team of the adult day health center. In determining days of attendance for each participant, the center will assess the individual for the frequency of need for any of the above listed services. In addition, the plan should determine the frequency for active psycho-social therapy, which includes assessment for and treatment of mental illness, which must be provided by an appropriate therapist as defined in RCW or state regulations.

(2) For level II determine the frequency of attendance based on frequency of need for skilled nursing or rehabilitation therapy.

(3) Must be authorized by the participant's physician. The physician must be informed that he or she is documenting the participant's need for services described in the plan of care.

(4) Must include at a minimum the following:

(a) Identified needs in each service area;

(b) Time-limited measurable goals and objective of the care for the person served;

(c) Type and scope of interventions to be provided in order to reach predicted outcomes;

(d) Discharge/transition plan for the person, including specific criteria for discharge/transition.

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NEW SECTION

WAC 388-15-655  Title XIX adult day health certification and monitoring. (1) Administration.

(a) Role of the AAA.

(i) The AAA, as authorized by the department, is responsible for the administration of the certification process for determining eligibility of an adult day health center to receive Medicaid funds. The AAA will make the initial certification and annual review (recertification) of applicants. A letter of certification will be given to applicants meeting all requirements, administrative and fiscal for contracting with the department. The AAA shall notify the department in writing of all certifications.

(ii) When an applicant applying for initial certification does not meet all the certification requirements, certification will be denied. A notice from the AAA setting forth the reason for denial will be mailed to the applicant within thirty days after completion of the site visit.

(iii) The department may take action such as, but not limited to, stop placement, corrective action or revocation of certification at any time the adult day health center is found not to be in compliance with client eligibility requirements, or not meeting the administrative or fiscal requirements. The AAA shall notify the facility in writing of the reasons for revocation. Revocation will become effective sixty days after notice is mailed to the facility. Revocation may be suspended if the facility submits an approved corrective action plan within thirty days after the mailing date of the revocation notice. The AAA will determine the date by which the corrective action must be completed.

(2) Minimum requirements for certification.

(a) Mission statement, articles of incorporation and bylaws. (b) Names and addresses of the board of directors (including minutes of the last three meetings) if the applicant is a nonprofit organization. Names and addresses of all owners if the applicant is a proprietary.

(c) Organizational chart.

(d) Total program operating budget including all revenue sources and client fees generated.

(e) Program policies and operating procedures manual (all centers must operate at least three days a week and provide a structured program for participants for at least four hours a day.

(f) Personnel policies and job descriptions of each paid staff position and volunteer positions.

(g) Definitions, policies and procedures around suspected abuse, neglect, or exploitation and mandatory reporting to adult protective services.

(h) Financial statement or the latest audit report of the organization by a certified public accountant (CPA).

(i) A floor plan of the facility indicating usage of space with interior measurements.

(j) Building inspection report, fire department inspection report, local health department inspection report, and food handler permit if food is prepared in the facility.

(k) Updated TB test for each staff member.

(l) All forms used in client's case records/files.

(m) Program/activities calendar for the month prior to application.

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NEW SECTION

WAC 388-15-656  Administration and organization. (1) Governing board.

(a) Unless the program is independently owned or functions through a governmental unit, a formal governing body shall have full legal authority and fiduciary responsibility for the operation of the program, adopting bylaws, and rules that address:

(i) Purposes of the program;

(ii) Governing body's composition and size, and members' and committee chairs' terms of office;

(iii) Frequency of meetings.

(b) The organization shall develop a written plan, reviewed on a regular basis, that addresses:

(i) The core values and mission of the organization, that promote seeing the persons served as the focus of the adult day health program;

(ii) That supports leadership that identifies and demonstrates ethical behavior in business, marketing, communication, and the provision of services; and

(iii) Information dissemination from a variety of sources to plan and improve performance and to educate, inform and demonstrate to all stakeholders the value of adult day health services.

(2) The advisory committee.

(a) Every adult day health program shall have a body that serves as an advisory committee. When an adult day health program is a subdivision or subunit of a multifunction organization, a committee or subcommittee of the governing body of the multifunction organization may serve as the advisory committee of the program.

(b) For a single purpose agency the governing body may fulfill the functions of the advisory committee.

(c) The advisory committee shall meet at least twice a year, but preferably quarterly, and shall have an opportunity, at least annually, to review and make recommendations on program policies. The advisory committee should be representative of the community and include family members of current or part participants and nonvoting staff representatives.

(3) A written plan of operation.

The administrator shall be responsible for the development of a current, written plan of operation with approval of the governing body. The plan of operation shall be reviewed, and if necessary, revised annually. The plan may include:

(a) Short- and long-range program goals;

(b) Definition of the target population, including number, age and needs of participants;

(c) Geographical definition of the service area;

(d) Hours and days of operation;

(e) Description of basic services and any optional services;

(f) Policies and procedures for service delivery;

(g) Policies and procedures for admission and discharge;

(h) Policies and procedures for assessment and reassessment, and the development of a plan of care with participants and/or family/caregiver by an interdisciplinary team;

(i) Staffing pattern;

(j) A plan for utilizing community resources;

(k) Policies and procedures for recruitment, orientation, training, evaluation, and professional development of staff and volunteers;

(l) General record policies;

(m) Statement of participant rights;

(n) Mandated reporting procedures;

(o) Marketing plan;

(p) Strategic planning;

(q) Accident, illness, and emergency procedures;

(r) Grievance procedures;

(s) Procedures for reporting suspected abuse;

(t) Payment mechanisms, funding sources and rates; or

(u) Operational budget.

(4) A written emergency plan. A written plan for handling emergencies shall be developed, and posted at each program site and on all program owned vehicles. Staff shall be trained to ensure smooth implementation of the emergency plan. If a single participant is present, at least one staff member on site shall be trained in cardiopulmonary resuscitation (CPR) and first aid.

(5) Lines of supervision and responsibility.

(a) To ensure continuity of direction and supervision, there shall be a clear division of responsibility between the governing body and the adult day health program administrator.

(b) An administrator shall be appointed and given full authority and responsibility to plan, staff, direct, and implement the program. The administrator shall also have the responsibility for establishing collaborative relations with other community organizations to ensure necessary support services to participants and their families/caregivers.

(c) The administrator or the individual(s) designated by the administrator shall be on site to manage the program's day-to-day operations during hours of operation. If the administrator is responsible for more than one site, or has duties not related to adult day health administration or provision of services, a program director shall be designated for each additional site and shall report to the administrator.

(d) An organizational chart shall be developed to illustrate the lines of authority and communication channels, and shall be provided to all staff.

(6) Administrative policies and procedures.

(a) Every adult day health program shall demonstrate fiscal responsibility by utilizing generally accepted principles of accounting in all its financial transactions. Fiscal policies, procedures, and records shall be developed to enable the administrator to meet the fiscal reporting needs of the governing body.

(b) Every adult day health program shall develop a plan to address the future financial needs of the program. The plan shall include projected program growth, capital purchases, projected revenue, projected expenses, and plans for fund raising.

(7) Quality improvement.

(a) Every adult day health program shall develop a quality improvement plan, with specific measurable objectives, designed to meet requirements of any licensing, funding sources, and professional standards.

(b) Policies and procedures for monitoring program quality and determining further action shall be developed by the administrator with the advice of the multidisciplinary staff team and the advisory committee with the approval of the governing body.

(8) Personnel policies and practices.

(a) There shall be a written job description for each staff position that specifies:

(i) Qualifications for the job;

(ii) Delineation of tasks; and

(iii) Lines of supervision and authority.

(b) Each employee shall receive, review, and sign a copy of the job description at the time of employment. Volunteers who function as staff also shall be provided written descriptions of responsibilities.

(c) Provision shall be made for orientation of new employees and volunteers. All staff and volunteers shall receive regular in-service training and staff development that meet their individual training needs. This shall be documented.

(d) Probationary evaluations and annual performance evaluations, in accordance with job descriptions, shall be conducted and shall conform to the policy of the funding or parent organization. Staff members shall review the written evaluation, which shall be signed by both the employee and supervisor. Copies shall be kept in locked personnel files.

(e) Each employee shall receive and/or review a copy of the program's personnel policies at the time of employment.

(f) Each employee shall have an individual file containing: Employee's qualifications, verification of training completed, signed job description and all performance evaluations. In addition, personnel files shall contain a copy of a current license or certificate, if applicable to the staff position, and certification of CPR and first aid training, if applicable.

(g) Whenever volunteers function in the capacity of staff, all applicable personnel policies pertain.

(h) The program shall conform to federal and state labor laws, must be in compliance with equal opportunity guidelines, and must adhere to federal and state employment regulations.

(9) Participant policies. Policies shall define the target population, admission criteria, discharge criteria, medication policy, participant rights, fee schedule, confidentiality, grievance procedures, and staff/participant ratios. Policies shall conform to the following:

(a) Nondiscrimination policy. No individual shall be excluded from participation in or be denied the benefits of or be otherwise subjected to discrimination in the adult day health program on the grounds of age, race, color, sex, religion, or national origin, creed, marital status, Vietnam era or disabled veteran's status, sensory, physical, or mental handicap.

(b) Bill of rights. A participant bill of rights shall be developed, posted, distributed to, and explained to participants, families, staff, and volunteers in the language understood by the individual.

(c) Illness/injury procedure. There shall be written procedures to be followed in case a participant becomes ill or is injured. The procedures shall be posted in at least one visible location at all program sites and shall be thoroughly explained, to staff, volunteers and participants. The procedures shall describe arrangements for hospital inpatient and emergency room service and include directions on how to secure ambulance transportation.

(d) Medications. Participants who need to take medications while at the program, and who are sufficiently mentally alert, shall be encouraged and expected to bring, keep and take their own medications as prescribed. Some participants may need assistance with their medications, and a few may need to have their medications administered by program staff. In order for program staff to administer any prescribed medication, there must be a written authorization from the participant's physician stating that the medication is to be administered at the program site and identifying the licensed person responsible for administration.

(e) The program shall develop written mediation procedures who are explained to all staff and anyone else who has responsibility in this area. At a minimum, these procedures shall describe the following:

(i) How medications will be stored;

(ii) Under what conditions licensed program staff will administer medications;

(iii) How medications brought to the program by a participant must be labeled;

(iv) How general medications such as aspirin or laxatives are to be used;

(v) How the use of medications will be entered in participants' case records.

(10) General record.

The adult day health program shall maintain a secure participant record system to ensure confidentiality. The record system shall include, but is not limited to:

(a) A permanent registry of all participants with dates of admission and discharge;

(b) A written policy on confidentiality and the protection of records that defines procedures governing their use and removal, and conditions for release of information contained in the records;

(c) A written policy on conditions that require authorization in writing by the participant or the legally responsible party for release of appropriate information not otherwise authorized by law;

(d) A written policy providing for the retention and storage of records for at least five years (or in accordance with state or local requirement) from the date of the last service to the participant;

(e) A written policy on the retention and storage of such records in the event the program discontinues operation, depending on the requirements of funding sources;

(f) A policy and procedure manual governing the record system and procedures for all agency staff;

(g) Maintenance of records on the agency's premises in secure storage area;

(h) Notes and reports in the participant's record that are typewritten or legibly written in ink, dated, and signed by the recording person with his/her title.

(11) Participant records. The following shall maintain a record for each participant. This shall include, but is not limited to, the following:

(a) Application and enrollment forms;

(b) Medical history and functional assessment (initial and ongoing);

(c) Plan of care (initial and reviews) and revisions;

(d) Fee determination form;

(e) Service contract;

(f) Signed authorizations for releases of medical information and photos, as appropriate;

(g) Signed authorizations for participant to receive emergency medical care if necessary;

(h) Correspondence;

(i) Attendance and service records;

(j) Transportation plans;

(k) Where appropriate:

(i) Medical information form;

(ii) Documentation of physicians' orders;

(iii) Physical examinations;

(iv) Treatment, therapy, and medication notes;

(l) Progress notes, chronological and timely;

(m) Where appropriate, discharge plan and summary;

(n) Current photograph of client;

(o) Emergency contacts;

(p) Signed statement that participant or legal representative has read the policies of the program with respect to the Patient Self-Determination Act of 1990.

(12) Administrative records. Administrative records shall include the following:

(a) Personnel records (including personnel training);

(b) Fiscal records;

(c) Statistical records;

(d) Government-related records (funding sources/regulatory);

(e) Contracts;

(f) Organizational records;

(g) Results of quality improvement plan which could include annual evaluation, utilization review, or care plan audit;

(h) Board and advisory group meeting minutes;

(i) Certificates of fire and health inspections;

(j) Incident reports;

(k) Emergency plan;

(l) Criteria for participant termination.

(13) Community relations. Adult day health programs shall provide information on adult day health to target populations and the general public. Participants and their families shall be made aware of community agencies for financial, social, recreational, educational and medical services. In addition, the program staff shall establish linkages with other community agencies and institutions to coordinate services and form service networks.

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NEW SECTION

WAC 388-15-657  Staffing. (1) Staff selection is dependent on participant needs, program design, and regulatory requirements. The program must have the proper balance of professionals and paraprofessionals or nonprofessionals to adequately meet the needs of participants. Services must be delivered by those with adequate professional training. One staff person can have multiple functions; for example, an administrator who is also responsible for providing nursing services or social services.

(2) All core services shall have an administrator/program director and an activity coordinator on staff. Health care and social services personnel may be on staff or consulting. Personnel delivering level II services may be on staff or on contract.

(3) Staffing levels in all adult day health program will vary based upon the number of participants and the care provided. The staffing level shall be sufficient to:

(a) Serve the number and functioning levels of adult day health program participants;

(b) Meet program objectives;

(c) Provide access to other community resources.

(4) The staff-participant ratio shall be a minimum of one to six. Persons counted in the staff-participant ratio are those who provide direct service with participants. When there is more than one participant present there shall be at least two staff members on the premises, one of whom is directly supervising the participants.

(5) As the number of participants with functional impairments increases, the staff-participant ratio shall be adjusted accordingly. Programs serving a high percentage of participants who are severely impaired shall have a staff-participant ratio of one to four. All programs shall have a written policy regarding staff-participant ratios.

(6) To ensure adequate care and safety of participants, there shall be provision for qualified substitute staff.

(7) Volunteers shall be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualification standards of the organization, and have designated responsibilities.

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NEW SECTION

WAC 388-15-658  Personnel requirements. (1) Administrator. The administrator:

(a) Is responsible for the development, coordination, supervision, and fiscal control and evaluation of services provided through the adult day health program.

(b) Shall have a master's degree and one year supervisory experience in health or social services (full-time or equivalent) or bachelor's degree and two years supervisory experience in a social or health service setting.

(2) Program director.

(a) The program director shall have a bachelor's degree in health, social services or a related field, with one year supervisory experience (full-time or equivalent) in a social or health service setting, or a high school diploma and four years of experience in a health or social services field of which two years must be supervision.

(b) For level II services, minimum requirements for the program director shall be a bachelor's degree in health, social services or a related field, with one year supervisory experience (full-time or equivalent) in a social or health service setting.

(3) Social worker.

(a) The social worker shall have a master's degree in social work or counseling and at least one year of professional work experience (full-time or the equivalent), or a bachelor's degree in social work or counseling and two years of experience in a human service field.

(b) Depending on the setting and licensing requirements, social work functions may be performed by other human service professionals, such as rehabilitation counselors, gerontologists, or mental health workers (although they may not call themselves social workers without appropriate credentials).

(4) Registered nurse (RN). The nurse shall be a registered nurse (RN) with valid state credentials and a minimum of one year applicable experience (full-time equivalent).

(5) Licensed practical nurse (LPN). The licensed practical nurse (LPN) shall have valid state credentials and a minimum of one year applicable experience (full-time equivalent).

(6) Activities coordinator. The activities coordinator shall have a bachelor's degree in recreational therapy or a related field and one year of experience (full-time equivalent) in social or health services or an associate degree in recreational therapy or a related field plus two years of appropriate experience.

(7) Certified occupational therapy assistant (COTA) or physical therapy assistant. The COTA or physical therapy assistant shall be certified with valid state credentials and a minimum of one year applicable experience (full-time equivalent).

(8) Nursing assistant/certified (NAC). The nursing assistant shall be certified with valid state credentials and a minimum of one year applicable experience (full-time equivalent).

(9) Program assistant/aide/personal care aide. The program assistant or aide shall have one or more years of experience in working with adults in a health care or social service setting.

(10) Therapists. Physical therapists, occupational therapist, speech therapists, recreation therapists, mental health therapists, or any other therapists, utilized shall have valid state credentials and one year of experience in a social or health setting.

(11) Consultants. Consultants shall be available to provide services as needed in order to supplement professional staff and enhance the program's quality.

(12) Secretary/bookkeeper. The secretary/bookkeeper shall have at least a high school diploma or equivalent and skills and training to carry out the duties of the position.

(13) Driver. The driver shall have a valid and appropriate state driver's license, a safe driving record, and training in first aid and CPR. The driver shall meet any state requirements for licensure or certification.

(14) Volunteers. The volunteers shall be individuals or groups who desire to work with adult day health participants and shall take part in program orientation and training. The duties of volunteers shall be mutually determined by volunteers and staff. Duties, to be performed under the supervision of a staff member, shall either supplement staff in established activities or provide additional services for which the volunteer has special talents.

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NEW SECTION

WAC 388-15-659  Facility. (1) Location.

(a) Selection of a location for a program facility shall be based on information about potential participants in its service area and be made in consultation with other agencies, organizations, and institutions serving older individuals and those with functional impairments, as well as considering the availability of a suitable location.

(b) Space.

(i) The facility shall comply with applicable state and local building regulations, zoning, fire, and health codes or ordinances. When possible, the facility shall be located on the street level. If the facility is not located at street level, it is essential to have a ramp and/or elevators. An evacuation plan for relocation of participants shall also be in place in the event of an emergency.

(ii) Each adult day health program, when it is co-located in a facility housing other services, shall have its own separate identifiable space for main activity areas during operational hours. Certain space can be shared, such as the kitchen and therapy rooms.

(iii) The facility shall have sufficient space to accommodate the full range of program activities and services. The facility shall provide at least sixty square feet of program space for multi-purpose use for each day health participant. In determining adequate square footage, only those activity areas commonly used by participants are to be included. Dining and kitchen areas are to be included only if these areas are used by participants for activities other than meals. Reception areas, storage area, offices, restrooms, passage ways, treatment rooms, service areas, or specialized spaces used only for therapies are not to be included when calculating square footage.

(iv) The facility shall be adaptable to accommodate variations of activities (group and/or individual) and services. The program shall provide and maintain essential space necessary to provide services and to protect the privacy of the participants receiving services. There shall be sufficient private space to permit staff to work effectively and without interruption. There shall be sufficient space available for private discussions.

(v) There shall be adequate storage space for program and operating supplies.

(vi) The facility's restrooms shall be located as near the activity area as possible, preferably no more than forty feet away. The facility shall include at least one toilet for each ten participants. Programs that have a large number of participants that require more scheduled toileting or assistance with toileting shall have at least one toilet for each eight participants. The toilet shall be equipped for use by mobility-limited persons, easily accessible from all program areas, and one or two of the toilet areas should be designed to allow assistance from one or two staff.

(vii) Each bathroom shall contain an adequate supply of soap, toilet tissues and paper towels.

(ix) In addition to space for program activities, the facility shall have a rest area and designated areas to permit privacy and to isolate participants who become ill or disruptive, or may require rest. It shall be located away from activity areas and near a restroom and the nurse's office. There shall be at least one bed, couch or recliner for each ten participants which can be used for resting or the isolation of a participant who is ill or suspected of coming down with a communicable disease. If beds are used, the mattresses shall be protected and linen changed after each use by different participants.

(x) A loading zone with sufficient space for getting on and off a vehicle shall be available for the safe arrival and departure of participants. There should be sufficient parking available to accommodate family caregivers, visitors, and staff. Adequate lighting should be provided.

(2) Atmosphere and design.

(a) The design shall facilitate the participants' movement throughout the facility and encourage involvement in activities and services. The environment shall reinforce orientation and awareness of the surroundings by providing cues and information about specific rooms, locations, and functions that help the participant to get his/her orientation to time and space.

(b) A facility shall be architecturally designed in conformance with the requirements of sections 504 of the Rehabilitation Act of 1973 to accommodate individuals with a disability and meet any state and local barrier-free requirements and/or the Americans with Disabilities Act.

(c) Illumination levels in all areas shall be adequate, and careful attention shall be given to avoiding glare. Attention shall be paid to lighting in transitional areas such as outside to inside and different areas of the facility.

(d) Sound transmission shall be controlled. Excessive noise, such as fan noise, shall be avoided.

(e) Comfortable conditions shall be maintained within a comfortable temperature range. Excessive drafts shall be avoided uniformly throughout the facility.

(f) Sufficient furniture shall be available for the entire participant population present. Furnishings shall accommodate the needs of participants and be attractive, comfortable, sturdy and safe. Straight-backed chairs with arms shall be used during activities and meals.

(g) An adult day health facility shall be visible and recognizable as a part of the community. The entrance to the facility shall be clearly identified. It shall also be appealing and protective to participants and others.

(h) When necessary, arrangements shall be made with local authorities to provide safety zones for those arriving by motor vehicle and adequate traffic signals for people entering and exiting the facility.

(i) A telephone shall be available for participant use.

(3) Safety and sanitation.

(a) The facility and grounds shall be safe, clean, and accessible to all participants. It shall be designed, constructed, and maintained in compliance with all applicable local, state, and federal health and safety regulations.

(b) There shall be an area for labeled medication, secured and stored apart from participant activity areas. If medications need to be refrigerated, they should be in a locked box - if not in their own refrigerator.

(c) Safe and sanitary handling, storing, preparation, and serving of food shall be assured. If meals are prepared on the premises, kitchen appliances, food preparation area, and equipment must meet state and local requirements.

(d) Toxic substances, whether for activities or cleaning, shall be stored in an area not accessible to participants. They must be clearly marked, the contents identified, and stored in original containers.

(e) At least two well-identified exits shall be available. Nonslip surfaces or bacteria-resistant carpets shall be provided on stairs, ramps, and interior floors.

(f) Alarm/warning systems are necessary to ensure the safety of the participants in the facility in order to alert staff to potentially dangerous situations. It is recommended that call bells shall be installed or placed in the rest areas, restroom stalls, and showers.

(g) An evacuation plan shall be strategically posted in each facility.

(h) The facility shall be free of hazards, such as high steps, steep grades, and exposed electrical cords. Steps and curbs shall be painted and the edges of stairs marked appropriately to highlight them. All stairs, curb cuts, ramps, and bathrooms accessible to those with disabilities shall be equipped with properly anchored handrails.

(i) Procedures for fire safety as approved by the local fire authority shall be adopted and posted, including provisions for fire drills, inspection and maintenance of fire extinguishers, periodic inspection, and training by fire department personnel. The program shall conduct and document quarterly fire drills and keep reports of drills on fire. Improvements shall be made based on the fire drill evaluation. Smoke detectors shall also be used.

(j) Emergency first-aid kits shall be visible and accessible to staff. Contents of the kits shall be replenished after use and reviewed as needed. A nurse or personnel trained in first aid and CPR shall be on hand whenever participants are present. Infection control procedures shall be followed by all staff. All staff shall be trained in and use Universal Precautions.

(k) There shall be sufficient maintenance and housekeeping personnel to assure that the facility is clean, sanitary, and safe at all times. Maintenance and housekeeping shall be carried out on a regular schedule and in conformity with generally accepted sanitation standards, without interfering with the program.

(l) If smoking is permitted, an adequately ventilated special area away from the main program area shall be provided and supervised.

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NEW SECTION

WAC 388-15-660  Nonduplication of services. The need for coordination of care shall be considered for each participant. If the person is a client of another agency and/or receiving services from the department, the plan of care shall be developed in conjunction with the services provided by the other agencies or the department.

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NEW SECTION

WAC 388-15-661  Clients in residential care or nursing facility care settings. Residential clients may receive adult day health level II services when the service is an approved part of the service plan developed by AASA staff. AASA staff will prorate the amount paid to the residential setting for the hours in which the resident/participant was attending adult day health. Clients receiving nursing facility care shall not be authorized adult day health services. Clients who reside in adult residential care, assisted living or adult family homes shall not be authorized COPES funded adult day care.

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NEW SECTION

WAC 388-15-662  Expenditures not to exceed. If program expenditures exceed the budget appropriations, the department shall have the authority to limit services by setting forth alternative ways of determining eligibility such as:

(1) Authorizing service to only those clients with the greatest care needs.

(2) Department staff shall assess and authorize all adult day health services.

(3) Limit the number of days a client may receive services.

(4) The department shall comply with established rules and procedures for client notification should action in this section become necessary.

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