Original Notice.

     Preproposal statement of inquiry was filed as WSR 04-09-089 and 04-01-087.

     Title of Rule and Other Identifying Information: Chapter 388-72A WAC, Comprehensive assessment reporting and evaluation (CARE) tool.

     Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA, on September 7, 2004, at 10:00 a.m.

     Date of Intended Adoption: Not earlier than September 8, 2004.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, 4500 10th Avenue S.E., Lacey, WA, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., September 7, 2004.

     Assistance for Persons with Disabilities: Contact Fred Swenson, DSHS Rules Consultant, by September 3, 2004, TTY (360) 664-6178 or (360) 664-6097.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Amending and adding new sections to chapter 388-72A WAC, Comprehensive assessment and reporting evaluation (CARE) tool, to update program rules, update references, incorporate the CARE algorithm in rule, and incorporate CARE assessment criteria for children receiving state plan Medicaid personal care (MPC) services.

     The CR-102 filed as WSR 04-11-086 has been withdrawn, and language from that proposed rule pertaining to children receiving state plan MPC (Medicaid personal care) services has been incorporated in these proposed rules.

     Reasons Supporting Proposal: See above.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.39A.095.

     Statute Being Implemented: RCW 74.08.090, 74.09.520, 74.39A.090, 74.39A.095.

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

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

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Brooke Buckingham, P.O. Box 45600, Olympia, WA 98504-5600, (425) 670-6485.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the rules and determined that no new costs will be imposed on businesses.

     A cost-benefit analysis is not required under RCW 34.05.328. The proposed rule is exempt by RCW 34.05.328 (5)(b)(vii), rules relating to client medical eligibility. The CARE tool and algorithm in the proposed rule are used to determine clients' eligibility for medical long-term care services in home and community-based settings.

July 1, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0010, filed 2/19/03, effective 3/22/03.]

     (1) Activities of daily living consist of the following care tasks that are directly related to your disabling condition:

     (a) Bathing((,)): How you take a full-body bath/shower, sponge bath, and transfer in/out of tub/shower;

     (b) Bed mobility((,)): How you move to and from a lying position, turn side to side, and position your body while in bed;

     (c) Body care((,)): How you perform with passive range of motion, applications of dressings and ointments or lotions to the body and pedicure to trim toenails and apply lotion to feet. In adult family homes or in ((licensed boarding homes contracting with DSHS to provide)) contracted assisted living ((services)) facilities, dressing changes using clean technique and topical ointments ((must be delegated by a registered nurse)) require nurse delegation in accordance with chapter 246-840 WAC. Body care excludes:

     (i) Foot care for clients who are diabetic or have poor circulation; or

     (ii) Changing bandages or dressings when sterile procedures are required.

     (d) Dressing((,)): How you put on, fasten, and take off all items of clothing, including donning/removing prosthesis;

     (e) Eating((,)): How you eat and drink, regardless of skill. Eating includes any method of receiving nutrition, e.g., by mouth, tube or through a vein;

     (f) Locomotion in room and immediate living environment((,)): How you move between locations in your room and immediate living environment. If you are in a wheelchair, locomotion includes how self-sufficient you are once in your wheelchair;

     (g) Locomotion outside of immediate living environment including outdoors((,)): How you move to and return from more distant areas. If you are living in a boarding home or nursing facility (NF), this includes areas set aside for dining, activities, etc. If you are living in your own home or in an adult family home, locomotion outside immediate living environment including outdoors, includes how you move to and return from a patio or porch, backyard, to the mailbox, to see the next-door neighbor, etc;

     (h) Walk in room, hallway and rest of immediate living environment((,)): How you walk between locations in your room and immediate living environment;

     (i) Medication management((,)): Describes the amount of assistance, if any, required to receive medications, over the counter preparations or herbal supplements;

     (j) Toilet use((,)): How you use the toilet room, commode, bedpan, or urinal, transfer on/off toilet, cleanse, change pad, manage ostomy or catheter, and adjust clothes;

     (k) Transfer((,)): How you move between surfaces, i.e., to/from bed, chair, wheelchair, standing position. Transfer does not include how you move to/from the bath ((or)), toilet, or vehicle; and

     (l) Personal hygiene((,)): How you maintain personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, hands (includes nail care), menses care, and perineum. This does not include personal hygiene in baths and showers.

     (2) Instrumental activities of daily living (IADL) consist of the following routine activities performed around the home or in the community.

     (a) Meal preparation((,)): How meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food, utensils, and cleaning up after meals). NOTE: This task may not be authorized to just plan meals or clean up after meals. You must need assistance with actual meal preparation;

     (b) Ordinary housework((,)): How ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry);

     (c) Essential shopping((,)): How shopping is completed to meet your health and nutritional needs (e.g., selecting items). Shopping is limited to brief, occasional trips in the local area to shop for food, medical necessities and household items required specifically for your health, maintenance or well-being. This includes shopping with or for you;

     (d) Wood supply((,)): How wood is supplied (e.g., splitting, stacking, or carrying wood) when you use wood as the sole source of fuel for heating and/or cooking;

     (e) Travel to medical services((,)): How you travel by vehicle to a physician's office or clinic in the local area to obtain medical diagnosis or treatment-includes driving vehicle yourself, traveling as a passenger in a car, bus, or taxi;

     (f) Managing finances((,)): How bills are paid, checkbook is balanced, household expenses are managed. The department cannot pay for any assistance with managing finances; and

     (g) Telephone use((,)): How telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed).

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0035, filed 2/19/03, effective 3/22/03.]

     (1) Self-performance, what you actually did in the last seven days before the assessment, not what you might be capable of doing. Coding is based on the level of performance that occurred three or more times in the seven-day period.

     (2) Support provided, which means the highest level of support provided by others in the last seven days before the assessment, even if that level of support occurred only once.

     (3) Status, which identifies whether a need is met, unmet, partially met, or declined.

     (4) Assistance available.

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     (a) Independent if you received no help or oversight, or if you needed help or oversight only once or twice;

     (b) Supervision if you received oversight (monitoring or standby), encouragement, or cueing three or more times;

     (c) Limited assistance if you were highly involved in the activity and given physical help in guided maneuvering of limbs or other nonweight bearing assistance on three or more occasions;

     (d) Extensive assistance if you performed part of the activity, but on three or more occasions, you needed weight bearing support or you received full performance of the activity during part, but not all, of the activity;

     (e) Total dependence if you received full caregiver performance of the activity and all subtasks during the entire seven-day period from others. Total dependence means complete nonparticipation by you in all aspects of the ADL; or

     (f) Activity did not occur if you or others do not perform an ADL over the last seven days before your assessment. The activity may not have occurred because:

     (i) You were not able (e.g., walking, if paralyzed); or

     (ii) No provider was available to assist; or

     (iii) You declined assistance with the task.

     (2) The assessor also determines the level of support provided. Your support provided is scored as:

     (a) No set-up or physical help provided by others;

     (b) Set-up help only provided, which is the type of help characterized by providing you with articles, devices, or preparation necessary for greater self-performance of the activity (such as giving or holding out an item that you take from others);

     (c) One-person physical assist provided;

     (d) Two- or more person physical assist provided; or

     (e) Activity did not occur during entire seven-day period.

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     (a) Limited assistance with bathing if physical help is limited to transfer only; or

     (b) Extensive assistance with bathing if you needed physical help with part of the activity (other than transfer).

     (2) The activity of body care is assessed to determine whether you need assistance. You are scored as needing assistance if you require:

     (a) Application of ointment or lotions;

     (b) Trimming of toenails;

     (c) Dry bandage changes; or

     (d) Passive range of motion treatment.

     (3) The activity of medication management is assessed to determine whether you need assistance managing your medications. This assistance is scored as:

     (a) Independent if you remember to take medications as prescribed and manage your medications without assistance;

     (b) Assistance required if you need assistance from a nonlicensed provider to facilitate your self-administration of a prescribed, over the counter, or herbal medication, you are assessed as needing assistance with medication management. Assistance required includes reminding or coaching you, handing you the medication container, opening the container, using an enabler to assist you in getting the medication into your mouth, and placing the medication in your hand. This does not include assistance with intravenous or injectable medications. You must be aware that you are taking medications;

     (c) Self-directed medication assistance/administration if you are a person with a functional disability who is capable of and who chooses to self-direct your medication assistance/administration. In licensed boarding homes, this may include situations in which you cannot physically self-administer medications but can accurately direct others, per WAC 388-78A-0300; or

     (d) Must be administered if you must have medications placed in your mouth or applied or instilled to your skin or mucus membrane. Administration must either be performed by a licensed professional or delegated by a registered nurse to a qualified caregiver (per chapter 246-840 WAC). Intravenous or injectable medications may never be delegated. Administration may also be performed by a family member or unpaid caregiver if facility licensing regulations allow.

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     (a) Independent if you received no help, set-up help, or supervision;

     (b) Supervision if you received set-up help or arrangements only;

     (c) Limited assistance if you sometimes performed the activity yourself and other times needed assistance;

     (d) Extensive assistance if you were involved in performing the activity, but required cueing/supervision or partial assistance at all times;

     (e) Total dependence if you needed the activity fully performed by others; or

     (f) Activity did not occur if you or others did not perform the activity in the last seven days before the assessment.

     (2) For each IADL, the assessor determines how difficult it is or would be for you to perform the activity. This is scored as:

     (a) No difficulty in performing the activity;

     (b) Some difficulty in performing the activity (e.g., you need some help, are very slow, or fatigue easily); or

     (c) Great difficulty in performing the activity (e.g., little or no involvement in the activity is possible).

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     (a) Met, which means the ADL or IADL will be fully provided by an informal support;

     (b) Unmet, which means an informal support will not be available to provide assistance with the identified ADL or IADL;

     (c) Partially met, which means an informal support will be available to provide some assistance, but not all, with the identified ADL or IADL; or

     (d) Client declines, which means you do not want assistance with the task.

     (2) If partially met is selected, then the amount of the assistance available is determined using one of four categories:

     (a) Less than one-fourth of the time;

     (b) One-fourth to one-half of the time;

     (c) Over one-half of the time to three-fourths of the time; or

     (d) Over three-fourths of the time.

     Note: For children seventeen years and younger living with their legally responsible natural/step/adoptive parents, the status and assistance available will be met or partially met over three fourths of the time.

     The following table is used to determine the percentages outlined in subsection (2)(a) through (d) of this section.

Place illustration here.

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NOTE: If the activity did not occur, the assessor codes self performance as total and status as met.

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     (1) You are age:

     (a) Eighteen or older and blind or disabled, as defined in WAC 388-511-1105; or

     (b) Sixty-five or older.

     (2) You meet financial eligibility requirements. This means the department will assess your finances and determine if your income and resources fall within the limits set in WAC 388-515-1505, Community options program entry system (COPES);

     (3) You:

     (a) Are not eligible for Medicaid personal care services (MPC); or

     (b) Are eligible for MPC services, but the department determines that the amount, duration, or scope of your needs is beyond what MPC can provide.

     (4) Your ((comprehensive)) CARE assessment shows you need the level of care provided in a nursing facility (or will likely need the level of care within thirty days unless COPES services are provided) which means one of the following applies((.)):

     (a) You require care provided by or under the supervision of a registered nurse or a licensed practical nurse on a daily basis, or:

     (b) You have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) with at least three or more of the following((, as defined in WAC 388-72A-0040)):

     (i) Setup in eating (e.g., cutting meat and opening containers at meals; giving one food category at a time);

     (ii) Supervision in toileting;

     (iii) Supervision in bathing;

     (iv) Supervision plus setup in transfer;

     (v) Supervision plus setup in bed mobility;

     (vi) Supervision plus set up help in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (vii) Assistance required in medication management; or

     (c) You have an unmet or partially met need with at least two or more of the following((, as defined in WAC 388-72A-0040)):

     (i) Extensive assistance plus one person physical assistance in toileting;

     (ii) Extensive assistance plus one person physical assistance in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (iii) Extensive assistance plus one person physical assistance in transfer;

     (iv) Limited assistance plus one person physical assistance in bed mobility and need turning/repositioning;

     (v) Physical help limited to transfer plus one person physical assist in bathing;

     (vi) Supervision plus one person physical assist in eating; or

     (vii) Daily assistance required in medication management; or

     (d) You have a cognitive impairment and require supervision due to one or more of the following: Disorientation, memory impairment, impaired decision making, or wandering and have an unmet or partially met need with at least one or more of the following((, as defined in WAC 388-72A-0040)):

     (i) Extensive assistance plus one person physical assistance in toileting;

     (ii) Extensive assistance plus one person physical assistance in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (iii) Extensive assistance plus one person physical assistance in transfer;

     (iv) Limited assistance plus one person physical assistance in bed mobility;

     (v) Physical help limited to transfer plus one person physical assist in bathing;

     (vi) Supervision plus one person physical assist in eating; or

     (vii) Daily assistance required in medication management.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0055, filed 2/19/03, effective 3/22/03.]

     (1) You are certified as ((Title XIX)) categorically needy, as defined in WAC 388-500-0005. Categorically needy medical institutional programs described in chapter 388-513 WAC do not meet this criteria.

     (2) You are functionally eligible which means you:

     (a) Have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) in at least three or more of the following((, as defined in WAC 388-72A-0040)):

     (((a))) (i) Help/oversight one or two times during the last seven days plus setup in eating;

     (((b))) (ii) Supervision in toileting;

     (((c))) (iii) Supervision in bathing;

     (((d))) (iv) Supervision in dressing;

     (((e))) (v) Supervision plus setup in transfer;

     (((f))) (vi) Supervision plus setup in bed mobility;

     (((g))) (vii) Supervision plus set up help in one of the following three tasks:

     (((i))) (A) Walk in room, hallway and rest of immediate living environment;

     (((ii))) (B) Locomotion in room and immediate living environment((;

     (iii))); or

     (C) Locomotion outside of immediate living environment including outdoors.

     (((h))) (viii) Assistance required in medication management;

     (((i))) (ix) Supervision in personal hygiene;

     (((j))) (x) Assistance with body care, which means you need:

     (((i))) (A) Application of ointment or lotions;

     (((ii))) (B) Your toenails trimmed;

     (((iii))) (C) Dry bandage changes; or

     (((iv))) (D) Passive range of motion treatment.

     (((3))) (b) You have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) with at least one or more of the following((, as defined in WAC 388-72A-0040)):

     (((a))) (i) Extensive assistance plus one person physical assistance in toileting;

     (((b))) (ii) Extensive assistance plus one person physical assistance in one of the following three tasks:

     (((i))) (A) Walk in room, hallway and rest of immediate living environment((;

     (ii))); or

     (B) Locomotion in room and immediate living environment((;

     (iii))); or

     (C) Locomotion outside of immediate living environment including outdoors.

     (((c))) (iii) Extensive assistance plus one person physical assistance in transfer;

     (((d))) (iv) Limited assistance plus one person physical assistance in bed mobility and need turning/repositioning;

     (((e))) (v) Physical help limited to transfer plus one person physical assist in bathing;

     (((f))) (vi) Supervision plus one person physical assist in eating; ((or

     (g))) (vii) Daily assistance required in medication management; ((or

     (h))) (viii) Assistance with body care, which means you need:

     (((i))) (A) Application of ointment or lotions;

     (((ii))) (B) Your toenails trimmed;

     (((iii))) (C) Dry bandage changes; or

     (((iv))) (D) Passive range of motion treatment.

     (((i))) (ix) Extensive assistance plus one person physical assistance in dressing((.

     (j))); or

     (x) Extensive assistance plus one person physical assistance in personal hygiene.

[Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.04.200, 74.09.520, 74.39.020, 74.39A.090, 2003 1st sp.s. c 25, 2003 c 140. 03-24-001, § 388-72A-0060, filed 11/19/03, effective 12/20/03. Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0060, filed 2/19/03, effective 3/22/03.]

     (1) Be eighteen years of age or older;

     (2) Have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) in at least one or more of the following((, as defined in WAC 388-72A-0040)):

     (a) Help/oversight one or two times during the last seven days plus setup in eating;

     (b) Supervision in toileting;

     (c) Supervision in bathing;

     (d) Supervision in dressing;

     (e) Supervision plus setup in transfer;

     (f) Supervision plus setup in bed mobility;

     (g) Supervision plus set up help in one of the following three tasks:

     (i) Walk in room, hallway and rest of immediate living environment;

     (ii) Locomotion in room and immediate living environment; or

     (iii) Locomotion outside of immediate living environment including outdoors.

     (h) Assistance required in medication management;

     (i) Supervision in personal hygiene;

     (j) Assistance with body care, which means you need:

     (i) Application of ointment or lotions;

     (ii) Your toenails trimmed; or

     (iii) Dry bandage changes; or

     (iv) Passive range of motion treatment.

     (3) Currently be on the Chore program and not be eligible for MPC or COPES, Medicare home health or other programs if these programs can meet your needs;

     (4) Have net household income (as described in WAC 388-450-0005((, 388-450-0020,)) and 388-450-0040((, and 388-511-1130))) not exceeding:

     (a) The sum of the cost of your Chore services; and

     (b) One-hundred percent of the Federal Poverty Level (FPL) adjusted for family size.

     (5) Have resources, as described in chapter 388-470 WAC, which does not exceed ten thousand dollars for a one-person family or fifteen thousand dollars for a two-person family. (Note: One thousand dollars for each additional family member may be added to these limits.)

     (6) Not transfer assets on or after November 1, 1995 for less than fair market value as described in WAC 388-513-1365.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0065, filed 2/19/03, effective 3/22/03.]

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[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0070, filed 2/19/03, effective 3/22/03.]

     (1) Cognitive performance

     (((a) Short term memory;

     (b) Self-performance in eating;

     (c) Ability to make self understood;

     (d) Ability to make decisions regarding ADLs; and

     (e) Comatose or in a persistent vegetative state)), as defined in WAC 388-72A-0081, by using the cognitive performance scale (CPS) and assigning a score from zero to six.

     (2) Clinical complexity

     (((a) Diagnoses requiring more than average care time and/or special care;

     (b) Skin problems receiving treatment;

     (c) Unstable clinical conditions; and

     (d) Skilled nursing needs)), as defined in WAC 388-72A-0082.

     (3) Mood/behaviors ((the assessment data evaluated may include, but is not limited to the following:

     (a) Assaulting care givers;

     (b) Resisting care;

     (c) Wandering; and

     (d) Depression)) symptoms, as defined in WAC 388-72A-0083

     (4) ((Activities of daily living ())ADLs((),)) by scoring the amount of assistance ((the client needs)) received to perform ((ADLs)) ADL in the past seven days, as defined in WAC 388-72A-0084.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0080, filed 2/19/03, effective 3/22/03.]

     (1) Is the client comatose?

     (a) No,

     (b) Yes.

     (2) What is the client's ability to make everyday decisions about tasks or activities of daily living in the seven days prior to the assessment?

     (a) Independent -- Decisions about the client's daily routine are consistent and organized; reflecting the client's lifestyle, choices, culture, and values.

     (b) Modified Independence/difficulty in new situations -- The client has an organized daily routine, was able to make decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations.

     (c) Moderately impaired/poor decisions; unaware of consequences -- Decisions are poor and the client requires reminders, cues and supervision in planning, organizing and correcting daily routines. Client attempts to make decisions, although poorly.

     (d) Severely impaired/no or few decisions or preferences regarding ADLs -- Decision making severely impaired, never/rarely makes decisions.

     (3) How is the client able to make himself/herself understood (to those closest to him/her), to express or communicate requests, needs, opinions, urgent problems and social conversations, whether in speech, writing, sign language, symbols, or a combination of these including use of a communication board or keyboard?

     (a) Understood -- The client expresses ideas clearly;

     (b) Usually understood -- The client has difficulty finding the right words or finishing thoughts, resulting in delayed responses; or requires some prompting to make self understood.

     (c) Sometimes understood -- The client has limited ability, but is able;

     (d) Rarely/never understood.

     (4) Does the client have short-term memory problem, which is defined as client's capacity to remember recent events; or does the client have delayed recall?

     (5) Does the client have total dependence for self performance in eating, as defined in WAC 388-72A-0037?

Place illustration here.

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Condition	AND an ADL Score of
ALS (Lou Gehrig's disease)	>14
Aphasia (expressive and/or receptive)	>=2
Cerebral Palsy	>14
Diabetes Mellitus (insulin dependent)	>14
Diabetes Mellitus (noninsulin dependent)	>14
Emphysema & (SOB (at rest or exertion) or dizziness/vertigo)	>10
COPD & (SOB (at rest or exertion) or dizziness/vertigo)	>10
Explicit terminal prognosis	>14
Hemiplegia	>14
Multiple sclerosis	>14
Parkinson disease	>14
Pathological bone fracture	>14
Pressure ulcers, areas of persistent skin redness     OR Pressure ulcers, partial loss of skin layers     OR Pressure ulcers, a full thickness lost     OR Skin problem, skin desensitized to pain/pressure     OR Skin problem, open lesions     OR Skin problem, stasis ulcers	>=2
AND
Receives ulcer care     OR (Received) or (needs and received) or (need met) pressure relieving device     OR (Receive) or (needs and received) or (need met) turning/reposition program     OR Receives application of dressing     OR Receives wound/skin care
Quadriplegia	>14
Rheumatoid Arthritis	>14
Skin problem, burns AND Receives application of dressings     OR Receives wound/skin care	>=2
Frequently incontinent, bladder     OR Incontinent all or most of the time, bladder     OR Frequently incontinent, bowel     OR Incontinent all or most of the time, bowel AND Uses, has leakage, needs assistance     OR Does not use, has leakage OR Any scheduled toileting plan	>10
Current swallowing problem and not independent in eating	>10
Edema	>14
Pain daily	>14
Bowel program receives and needs	>10
Dialysis, needs	>10
IV nutritional support, needs     OR Tube feedings, needs AND Total calories received per IV or tube was greater than 50%     OR Total calories per IV or tube was 25-50% AND Fluid intake greater than 2 cups	>=2
Hospice care, needs	>14
Injections, needs	>14
Intravenous medications, needs	>10
Management of IV lines, needs	>10
Ostomy care, needs	>=2
Oxygen therapy, needs	>10
Radiation, needs	>10
Range of motion, passive, receives and needs	>10
Walking, training, receives and needs	>10
Suction, needs	>=2
Tracheostomy care, needs	>10
Ventilator/respirator, needs	>10

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     (2) Each documented behavior within CARE is described as:

     (a) Current, which means it occurred within seven days of the assessment date, including the day of the assessment. Behaviors that are indicated as current must also include information about:

     (i) Whether the behavior is easily altered or not easily altered; and

     (ii) The frequency of the behavior.

     (b) Past, which means it occurred between eight days and five years of the assessment date. For behaviors indicated as past, the assessor determines whether the behavior is addressed with current interventions or whether no interventions are in place.

     (3) CARE places you in the Mood and behavior classification group only if you have one or more of the following behavior/moods that meets the corresponding description in the status, frequency, and alterability column. No other moods or behaviors documented in CARE are pertinent to this group.

Behavior/Mood	AND Status, Frequency & Alterability
Assaultive	Current
Combative during personal care	Current
Combative during personal care	In past and addressed with current interventions
Crying tearfulness	Current, frequency 4 or more days per week
Delusions	In past, addressed with current interventions
Depression score >=14	N/A
Disrobes in public	Current and not easily altered
Easily irritable/agitated	Current and not easily altered
Eats nonedible substances	Current
Eats nonedible substances	In past, addressed with current interventions
Hallucinations	Current
Hiding items	In past, addressed with current interventions
Hoarding/collecting	In past, addressed with current interventions
Mental health therapy/program	Need
Repetitive complaints/questions	Current, daily
Repetitive complaints/questions	In past, addressed with current interventions
Repetitive movement/pacing	Current, daily
Resistive to care	Current
Resistive to care	In past, addressed with current interventions
Sexual acting out	Current
Sexual acting out	In past, addressed with current interventions
Spitting	Current and not easily altered
Spitting	In past, addressed with current interventions
Breaks/throws items	Current
Unsafe smoking	Current and not easily altered
Up at night and requires intervention	Current
Wanders exit seeking	Current
Wanders exit seeking	In past, addressed with current interventions
Wanders not exit seeking	Current
Wanders not exit seeking	In past, addressed with current interventions
Yelling/screaming	Current, frequency 4 or more days per week

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     (a) Personal hygiene;

     (b) Bed mobility;

     (c) Transfers;

     (d) Eating;

     (e) Toilet use;

     (f) Dressing;

     (g) Locomotion in room;

     (h) Locomotion outside room; and

     (i) Walk in room.

     (2) CARE assigns a points value as described in the chart below. Only one score is used for the locomotion in room, locomotion outside of room and walk in room. The highest score of the three is used in determining the overall ADL score.

ADL Scoring Chart
If Self Performance is:	Score Equals
Independent	0
Supervision	1
Limited assistance	2
Extensive assistance	3
Total dependence	4
Did not occur/no provider	4
Did not occur/client not able	4
Did not occur/client declined	0

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     (4) ADLs by scoring the assistance needed to perform ADLs.)) Exceptional care classification groups for the in-home setting occur only when the following criteria are met in either of the diagrams below:

Diagram 1 of Condition
One of the following diagnoses: Quadriplegia Paraplegia ALS (Amyotrophic Lateral Sclerosis) Parkinson's Disease Multiple Sclerosis Comatose Muscular Dystrophy Cerebral Palsy Post Polio Syndrome TBI (traumatic brain injury)	AND
ADL score of greater than or equal to 22	AND
(Needs) or (needs and received) or (need met) Turning/repositioning program	AND
External catheter or Intermittent catheter or Indwelling catheter care or Bowel program or Ostomy care	AND
Needs active range of motion (AROM) or Needs passive range of motion (PROM) performed by one of the following providers: Individual provider or agency provider; Self-directed care (individual provider only); or Private duty nurse.

Diagram 2 of Condition
ADL score greater than or equal to 22	AND
(Needs) or (needs and received) or (need met) Turning/repositioning program	AND
Need for AROM or need for PROM and Performed by one of the following providers: Individual provider or agency provider; Self-directed care (individual provider only); or Private duty nurse.	AND
IV nutrition support or tube feeding and Total calories received per IV or tube was greater than 50% and Fluid intake greater than 2 cups	AND
Needs dialysis (performed by individual provider or agency provider); Self-directed care (individual provider only); or Private duty nurse. or Needs ventilator/respirator (performed by individual provider or agency provider); Self-directed care (individual provider only); or Private duty nurse.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0085, filed 2/19/03, effective 3/22/03.]

Classification		ADL Score		Group
Group D Cognitive performance score = 4-6 and Clinically complex = yes and Mood/behavior = yes or no		ADL Score 18-28		D High (12)
		ADL Score 13-17		D Med (11)
		ADL Score 2-12		D Low (10)
Group C Cognitive performance score = 0-3 and Clinically complex = yes and Mood/behavior = yes or no		ADL Score 18-28		C High (9)
		ADL Score 9-17		C Med (8)
		ADL Score 2-8		C Low (7)
Group B Mood & behavior = Yes and Clinically complex = no and Cognitive performance score = 0-6		ADL Score 15-28		B High (6)
		ADL Score 5-14		B Med (5)
		ADL Score 0-4		B Low (4)
Group A Mood & behavior = No and Clinically complex = No and Cognitive performance score = 0-6		ADL Score 10-28		A High (3)
		ADL Score 5-9		A Med (2)
		ADL Score 0-4		A Low (1)

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Classification		ADL Score		Group	Base Hours of Group
Group E Exceptional care = yes and Mood and behavior = yes or no and Cognitive performance score = 0-6		ADL Score 26-28		E High (14)	420
		ADL Score 22-25		E Med (13)	350
Group D Cognitive performance score = 4-6 and Clinically complex = yes and Mood and behavior = yes or no OR Cognitive performance score = 5-6 and Clinically complex = no and Mood and behavior = yes or no		ADL Score 18-28		D High (12)	240
		ADL Score 13-17		D Med (11)	190
		ADL Score 2-12		D Low (10)	145
Group C Cognitive performance score = 0-3 and Clinically complex = yes and Mood and behavior = yes or no		ADL Score 18-28		C High (9)	180
		ADL Score 9-17		C Med (8)	140
		ADL Score 2-8		C Low (7)	83
Group B Mood and behavior = yes and Clinically complex = no and Cognitive performance score = 0-4		ADL Score 15-28		B High (6)	155
		ADL Score 5-14		B Med (5)	90
		ADL Score 0-4		B Low (4)	52
Group A Mood and behavior = no and Clinically complex = no and Cognitive performance score = 0-4		ADL Score 10-28		A High (3)	78
		ADL Score 5-9		A Med (2)	62
		ADL Score 0-4		A Low (1)	29

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[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0090, filed 2/19/03, effective 3/22/03.]

     (2) In accordance with WAC 388-72A-0095 and 388-71-0460, the base hours are adjusted to account for informal support, paid by individual(s) or group(s) other than the department and support shared living circumstances.

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     (a) ((Assistance available to meet your needs. This is defined as:

     (i) Met;

     (ii) Unmet;

     (iii) Partially met.

     NOTE: Home and community programs (HCP) services may not replace other available resources the department identified when completing CARE. The hours will be adjusted to account for tasks that are either fully or partially met by other available resources. These resources may be unpaid or paid for by other state or community sources.

     (b) Environment, such as whether you:

     (i) Have laundry facilities out of home; and/or

     (ii) Use wood as a primary source of heat and/or;

     (iii) The time it takes to access essential shopping services.

     (c) Living arrangement. The department will adjust payments to a personal care provider who is doing household tasks at the same time (e.g., essential shopping, meal preparation, laundry, and wood supply) if:

     (i) There is more than one client living in the same household; or

     (ii) You and your paid provider live in the same household.

     (2))) The amount of informal supports available to fully or partially meet your needs as described in WAC 388-72A-0041.

     (i) As shown in the following table, CARE determines the adjustment by placing a numeric value on the amount of assistance available to meet your needs and reduces the base hours assigned to the classification group using the values listed below for each ADL and IADL.

Meds	Self Performance	Status	Assistance Available	Value Percentage
Self administration of medications	Rules for all codes apply except independent is not counted	Unmet	N/A	1
		Met	N/A	0
		Decline	N/A	0
		Partially met	<1/4 time	.9
			1/4 to 1/2 time	.7
			1/2 to 3/4 time	.5
			> 3/4 time	.3
Unscheduled ADLs	Self Performance	Status	Assistance Available	Value Percentage
Bed mobility, transfer, walk in room, eating, toilet use	Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider = 1; Did not occur/client declined and independent are not counted.	Unmet	N/A	1
		Met	N/A	0
		Decline	N/A	0
		Partially met	<1/4 time	.9
			1/4 to 1/2 time	.7
			1/2 to 3/4 time	.5
			>3/4 time	.3
Scheduled ADLs	Self Performance	Status	Assistance Available	Value Percentage
Dressing personal hygiene bathing	Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider = 1; Did not occur/client declined and independent are not counted .	Unmet	N/A	1
		Met	N/A	0
		Decline	N/A	0
		Partially met	<1/4 time	.75
			1/4 to 1/2 time	.55
			1/2 to 3/4 time	.35
			> 3/4 time	.15
IADLs	Self Performance	Status	Assistance Available	Value Percentage
Meal preparation Ordinary housework Essential shopping	Rules for all codes apply except independent is not counted.	Unmet	N/A	1
		Met	N/A	0
		Decline	N/A	0
		Partially met	< 1/4 time	.3
			1/4 to 1/2 time	.2
			1/2 to 3/4 time	.1
			> 3/4 time	.05
IADLs	Self Performance	Status	Assistance Available	Value Percentage
Travel to medical	Rules for all codes apply except independent is not counted.	Unmet	N/A	1
		Met	N/A	0
		Decline	N/A	0
		Partially met	< 1/4 time	.9
			1/4 to 1/2 time	.7
			1/2 to 3/4 time	.5
			> 3/4 time	.3

     (ii) The value percentage assigned to each specified ADL/IADL is summed and carried two decimal places. The resulting number is then divided by the number of qualifying ADL and IADL needs. If self-performance is coded as independent or did not occur/client declined then they are not qualifying ADLs and IADLs. The result is value A. Value A is then subtracted from one. This is value B. Value B is divided by three. This is value C. Value A and value C are summed. This is value D. Value D is multiplied by the "base hours" assigned to the client's classification group in WAC 388-72A-0087.

     (b) Your environment, as described in the diagrams below.

Condition	Status	Assistance Available	Add On Hours
Offsite laundry facilities, which means the client does not have facilities in own home and the caregiver is not available to perform any other personal or household tasks while laundry is done.	N/A	N/A	8
Client is > 45 minutes from essential services (which means he/she lives more than 45 minutes one-way from a full-service market).	Unmet	N/A	5
	Met	N/A	0
	Partially met	<1/4 time	5
		between 1/4 to 1/2 time	4
		between 1/2 to 3/4 time	2
		>3/4 time	2
Wood supply used as sole source of heat.	Unmet	N/A	8
	Met	N/A	0
	Declines	N/A	0
	Partially met	< 1/4 time	8
		between 1/4 to 1/2 time	6
		between 1/2 to 3/4 time	4
		> 3/4 time	2

     (c) Your living arrangement.

     (i) If there is more than one client living in the same household, the status cannot be unmet for the following IADLs:

     (A) Meal preparation,

     (B) Housekeeping,

     (C) Shopping,

     (D) Wood supply.

     (ii) If you and your paid provider live in the same household, the status must be met for the following IADLs:

     (A) Meal preparation,

     (B) Housekeeping,

     (C) Shopping,

     (D) Wood supply.

     (iii) When there is more than one client living in the same household and your paid provider lives in your household, the status must be met for the following IADLs:

     (A) Meal preparation,

     (B) Housekeeping,

     (C) Shopping, and

     (D) Wood supply.

     (2) The ((CARE tool will provide a)) hours identified in WAC 388-72A-0095 (1)(b) are added to the resulting hours in WAC 388-72A-0095 (1)(a). The result is the maximum number of hours that can be used to develop your care plan. The assessor must take into account cost effectiveness, client health and safety, and program limits in determining how hours can be used to meet identified client needs.

     (3) Within the limits of subsection (2) of this section, you and your case manager will work to determine what services you choose to receive if you are eligible. The hours may be used to authorize:

     (a) Personal care services (per WAC 388-72A-0055, 388-72A-0060, ((or)) 388-72A-0065, or 388-845-1300);

     (b) Home delivered meals (per WAC ((388-72A-0055)) 388-71-0415);

     (c) Adult day care (per WAC ((388-72A-055 or 388-15-652)) 388-71-0708);

     (d) ((Adult day health (per WAC 388-72A-055 or 388-15-653);

     (c))) A home health aide (per WAC ((388-72A-0055)) 388-71-0415).

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, § 388-72A-0095, filed 2/19/03, effective 3/22/03.]

     Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
NEW SECTION
WAC 388-72A-0115   When the department adjusts an algorithm, when does the adjustment become effective?   When the department adjusts an algorithm used to evaluate the information gathered by the CARE tool, the effective date of any change generated by the adjustment(s) to the client's CARE level or hours shall be:

     (1) Immediate for applicants;

     (2) ((The first of the month following the month in which the adjustment was made when the adjustment may reduce the care level or hours; or

     (3))) At the time of the ((client's yearly review when the adjustment may increase the care level or hours)) recipient's next assessment.

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     Reviser's note: The unnecessary underscoring and strike through 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 388-72A-0120   When a client requests a fair hearing to have the client's CARE tool assessment results reviewed and there is (are) a more recent CARE assessment(s), which CARE tool assessment does the administrative law judge review in the fair hearing?   The administrative law judge must review the most recent CARE tool assessment.

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     The following sections of the Washington Administrative Code are repealed:

WAC 388-72A-0040	What information does the assessor gather?
WAC 388-72A-0075	What does the CARE computerized assessment tool do with the client information entered by department staff?

© Washington State Code Reviser's Office