Purpose: This order corrects only the following sections of chapter 388-110 WAC, Contracted residential care services, filed as WSR 04-16-063 on July 30, 2004: WAC 388-110-020, 388-110-140, and 388-110-220.

     All other sections filed as WSR 04-16-063 are not affected by this correction. Those sections will take effect as filed.

     WSR 04-16-063 explained changes intended to be made to these three sections from the proposed to the permanent rule. However, the rule text filed with WSR 04-16-063 omitted the changes noted to the sections listed above. This corrected filing is needed to clarify the rule and to assure that changes to the rule made by the department in response to public comments are accurately reflected in the permanent rules. See below for the text changes to these permanent rules as compared to the rules proposed as WSR 04-13-021.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-110-020, 388-110-140, and 388-110-220.

     Statutory Authority for Adoption: RCW 74.39A.010, 74.39A.020, 74.39A.060, and 74.39A.070.

     Other Authority: Chapter 74.39A RCW.

      Adopted under notice filed as WSR 04-13-021 on June 7, 2004.

     Changes Other than Editing from Proposed to Adopted Version: The following changes have been made to the proposed rule based upon suggestions and comments received, as well as technical and editing changes noted during the process.

     WAC 388-110-020 Definitions, the definition of "personal care services" has been revised to clarify that "instrumental activities of daily living" are not included in the definition.

     WAC 388-110-140 Assisted living services facility structural requirements, subsection (1) has been revised to clarify the definition of "type 'B' dwelling unit" defined by the International Code Council has been adopted into rule by the Washington State Building Code Council.

     WAC 388-110-220 Enhanced adult residential care service standards, subsection (3)(a) deleted "re-assessment" and replaced with "assessment."

     A final cost-benefit analysis is available by contacting Denny McKee, Program Manager, P.O. Box 45600, Olympia, WA 98504-5600, phone (360) 725-2590, e-mail McKeeDD@dshs.wa.gov, fax (360) 438-7903.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.

     Date Adopted: August 19, 2004.

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (("Aging in place" means being in a care environment that can accommodate a resident's progressive disability or changing needs without relocating. For aging in place to occur, needed services are adjusted to meet the changing needs of the resident.))

     "Applicant" means the individual, partnership, corporation or other entity which has applied for a contract with the department to provide assisted living services, enhanced adult residential care, enhanced adult residential care-specialized dementia care services, or adult residential care to state funded residents in a licensed boarding home.

     "Assisted living services" is a package of services((, including)) provided by a boarding home that has a contract with the department under RCW 74.39A.010 to provide personal care ((and limited)) services, intermittent nursing services, and medication administration services ((that the department contracts with a licensed boarding home to provide)) in accordance with Parts I and II of this chapter. Assisted living services include housing for the resident in a private apartment-like unit.

     "Boarding home" means the same as the definition found in RCW 18.20.020(((2))), or a boarding home located within the boundaries of a federally recognized Indian reservation and licensed by the tribe.

     (("Caregiver" means any person responsible for providing direct personal care services to a resident and may include but is not limited to the contractor, employee, volunteer, or student.))

     "Case manager" means the department staff person or designee assigned to negotiate, monitor, and facilitate a service plan for residents receiving services fully or partially paid for by the department.

     "Contractor" means the individual, partnership, corporation, or other entity which is licensed by the department or tribe to operate the boarding home and contracts with the department to provide assisted living services, enhanced adult residential care, enhanced adult residential care-specialized dementia care services, or adult residential care to state funded residents in a licensed boarding home.

     "Department" means the Washington state department of social and health services (DSHS).

     "Dignity" means the quality or condition of being esteemed and respected in such a way as to validate the self-worth of the resident.

     "Enhanced adult residential care" is a package of services((, including)) provided by a boarding home that is licensed under chapter 18.20 RCW and that has a contract with the department to provide personal care ((and limited)) services, intermittent nursing services, and medication administration services ((that the department contracts with a licensed boarding home to provide)) in accordance with Parts I and III of this chapter.

     (("Frail elder or vulnerable adult" means the same as the definition found in RCW 74.34.020 or 43.43.830.))

     "Enhanced adult residential care-specialized dementia care services" is a package of service, including specialized dementia care assessment and care planning, personal care services, intermittent nursing services, medication administration services, specialized environmental features and accommodations, and activity programming. Enhanced adult residential care-specialized dementia care services are delivered only within:

     (1) Contracted boarding homes that are dedicated solely to the care of individuals with dementia, including Alzheimer's disease, and that meet the requirements of parts I and III of this chapter; or

     (2) Designated, separate units located within contracted boarding homes that are dedicated solely to the care of individuals with dementia, including Alzheimer's disease, and that meet the requirements of parts I and III of this chapter.

     "Homelike" means an environment having the qualities of a home, including privacy, comfortable surroundings, and the opportunity to ((modify)) decorate one's living area and arrange furnishings to suit one's individual preferences. A homelike environment provides residents with an opportunity for self-expression, and encourages interaction with the community, family and friends.

     "Independence" means free from the control of others and being able to assert one's own will, personality and preferences.

     "Individuality" means the quality of being unique; the aggregate of qualities and characteristics that distinguishes one from others. Individuality is supported by modifying services to suit the needs or wishes of a specific individual.

     (("Limited nursing services" means the same as the definition found in WAC 246-316-265.))

     "Medication administration" means the direct application of a prescribed medication, whether by injection, inhalation, ingestion, or any other means, to the body of a resident by a person legally authorized to do so.

     "Personal care services" means ((both physical assistance and/or prompting and supervising the performance of direct personal care tasks as determined by the resident's needs as defined in WAC 388-71-202.)) the same as physical or verbal assistance with activities of daily living included under "personal care services" described in WAC 388-72A-0035(1). Personal care services do not include assistance with instrumental activities of daily living described in WAC 388-72A-0035(2), nor assistance with tasks that must be performed by a licensed health professional.

     "Resident" means a person residing in a boarding home for whom services are paid for, in whole or in part, by the department under a contract for assisted living services, enhanced adult residential care, enhanced adult residential care-specialized dementia care services, or adult residential care. "Resident" includes former residents when examining complaints about admissions, re-admissions, transfers or discharges. For decision-making purposes, the term "resident" includes the resident's surrogate decision maker in accordance with state law or at the resident's request.

[Statutory Authority: RCW 74.08.090, 74.09.520, and 74.39A.090. 02-21-098, § 388-110-020, filed 10/21/02, effective 11/21/02. Statutory Authority: RCW 74.39A.010, 74.39A.020, 74.39A.060, 74.39A.080, 74.39A.170, 18.88A.210-[18.88A.]240 and 70.129.040. 96-11-045 (Order 3979), § 388-110-020, filed 5/8/96, effective 6/8/96.]

     (a) ((In an existing facility, an individual unit with)) A minimum area of one hundred eighty square feet ((including counters, closets and built-ins, and excluding the bathroom. In a new facility, an individual unit with a minimum of)) in an existing boarding home, and two hundred twenty square feet ((including)) in a new boarding home. The minimum area may include counters, closets and built-ins, ((and excluding)) but must exclude the bathroom;

     (b) A separate private bathroom, which includes a sink, toilet, and a shower or bathtub. In a new ((facility, a minimum of fifty percent of resident bathrooms shall be wheelchair accessible and have a roll-in shower)) boarding home, the contractor must provide a minimum of one wheelchair accessible bathroom with a roll-in shower that is at least forty-eight inches by thirty inches for every two residents whose care is partially or fully funded by the department through the assisted living contract;

     (c) A lockable entry door;

     (d) A kitchen area equipped((, at a minimum,)) with a refrigerator, a microwave oven or stovetop, and a counter or table for food preparation. In a new ((facility, a)) boarding home, the kitchen area must also be equipped with a ((sink and counter area, and)) storage space for utensils and supplies, and a counter surface, a minimum of thirty inches wide by twenty-four inches in depth, a maximum height of thirty-four inches, and a knee space beneath at least twenty-seven inches in height; and

     (e) A living area wired for telephone and, where available in the geographic location, wired for television service.

     (2)(a) For purposes of this section, a new boarding home is:

     (i) A new building to be used as a boarding home or part of a boarding home, for which plans are submitted to the department of health for construction review on or after June 8, 1996; or

     (ii) An addition, modification, or alteration to an existing licensed boarding home, for which plans are submitted to the department of health for construction review on or after June 8, 1996.

     (A) The department may, in consultation with the office of construction review services in the department of health, exempt from selected new boarding home contract construction requirements, a limited addition, modification, or alteration to an existing licensed boarding home that will improve the quality of life for residents, if compliance with all new boarding home contract construction requirements would otherwise make the limited addition, modification, or alteration cost prohibitive. A limited addition, modification, or alteration means any physical change to an existing licensed boarding home that does not affect the structural integrity of the building, does not affect fire and life safety, and does not increase the boarding home's maximum facility capacity as defined in WAC 388-78A-2020.

     (B) A major addition, modification, or alteration to an existing licensed boarding home must meet new boarding home contract construction requirements for applicable portions of the building. A major addition, modification, or alteration means any physical change within a room or area in an existing licensed boarding home that results in reconstruction to structural or other building systems.

     (b) All boarding homes that are not new boarding homes under subsection (2)(a) of this section, are existing boarding homes. An existing building, or portion thereof, that is converted to boarding home use must be considered an existing boarding home unless there is an addition, modification or alteration to the existing building.

     (3) If a boarding home submitted plans to the department of health for construction review on or after June 8, 1996, and the boarding home had an assisted living contract as of September 1, 2004, then the boarding home is "grandfathered" under the contracting rules for structural requirements that were in effect at the time of contracting and is considered to meet the assisted living structural requirements of subsection (1) of this section. However, if the same boarding home submits plans to the department of health for construction review for an addition, modification or alteration of the boarding home after September 1, 2004, then the boarding home must meet the current new boarding home requirements of subsection (1) for the applicable portions of the building.

     (4) Married couples may share an apartment-like unit under an assisted living contract if:

     (a) Both residents understand they are each entitled to live in a separate private unit; and

     (b) Both residents mutually request to share a single apartment-like unit.

     (5) In a new ((facility)) boarding home, the contractor ((shall)) must provide a private accessible mailbox in which the resident may receive mail.

     (((3))) (6) The contractor ((shall)) must provide homelike smoke-free common areas with sufficient space for socialization designed to meet resident needs. Common areas ((shall)) must be available for resident use at any time provided such use does not disturb the health or safety of other residents. ((When possible,)) The contractor must make access to outdoor areas ((shall be made)) available to all residents.

     (((4))) (7) The contractor ((shall)) must provide a space for residents to meet with family and friends outside the resident's living unit.

     (((5)(a) For purposes of this section, a new facility is:

     (i) A new building to be used as a boarding home or part of a boarding home, for which plans are submitted to the department of health for construction review, as required by WAC 246-316-070, on or after the effective date of this chapter; or

     (ii) An addition, modification, or alteration to an existing building, for which plans are submitted to the department of health for construction review, as required by WAC 246-316-070, on or after the effective date of this chapter.

     (b) All facilities that are not new facilities under subsection (5)(a) of this section, are existing facilities. An existing building, or portion thereof, that is converted to boarding home use shall be considered an existing facility unless there is an addition, modification or alteration to the existing building))

     (8) The department may grant an exemption to the requirements of this section as they apply to a specified resident when it is in the best interest of the specific resident.

[Statutory Authority: RCW 74.39A.010, 74.39A.020, 74.39A.060, 74.39A.080, 74.39A.170, 18.88A.210-[18.88A.]240 and 70.129.040. 96-11-045 (Order 3979), § 388-110-140, filed 5/8/96, effective 6/8/96.]

     (7) The contractor shall allow a maximum of two residents per room)) In a boarding home with an enhanced adult residential care contract, the contractor must meet the requirements of parts I and III of this chapter, and for residents served under the enhanced adult residential care contract:

     (a) Develop for each resident a negotiated service agreement that supports the principles of dignity, privacy, choice in decision making, individuality, and independence.

     (b) Provide or arrange for, at no additional cost to the resident and consistent with the resident's negotiated service agreement and chapter 388-78A WAC:

     (i) Intermittent nursing services;

     (ii) Medication administration;

     (iii) Personal care services; and

     (iv) Supportive services that promote independence and self-sufficiency; and

     (c) Not allow more than two residents per room.

     (2) An enhanced adult residential care-specialized dementia care services contract is a distinct contract, separate from an enhanced adult residential care contract. In a boarding home with an enhanced adult residential care-specialized dementia care services contract, the contractor must:

     (a) Meet the requirements of parts I and III of this chapter,

     (b) Meet the requirements of subsection (1) of this section, and

     (c) Maintain an enhanced adult residential care services contract or an assisted living services contract in addition to the enhanced adult residential care-specialized dementia care services contract.

     (3) In a boarding home with an enhanced adult residential care-specialized dementia care services contract, for residents served under that contract, the contractor must:

     (a) Complete a full assessment of residents as specified in chapter 388-78A WAC, at a minimum, on a semi-annual basis;

     (b) Maintain awake staff twenty-four hours per day. The contractor must provide staffing that is adequate to respond to the assessed sleeping and waking patterns and needs of residents;

     (c) Develop and implement policies and procedures:

     (i) To manage residents who may wander;

     (ii) To outline actions to be taken in case a resident elopes; and

     (iii) To obtain consultative resources to address behavioral issues for residents. The contractor must include a plan that identifies the professional (i.e., clinical psychologist, psychiatrist, psychiatric nurse practitioner, or other behavioral specialist familiar with care of persons with dementia with complex or severe problems) who will provide the consultation, and when and how the consultation will be utilized.

     (d) Ensure that each staff who works directly with residents has at least six hours of continuing education per year related to dementia, including Alzheimer's disease. This six hours of continuing education may be part of the ten hours of continuing education required by WAC 388-112-0205. Appropriate topics include, but are not limited to:

     (i) Aggressive behaviors and catastrophic reactions;

     (ii) Agitation: Caregiving strategies;

     (iii) Delusions and hallucinations;

     (iv) Dementia problem-solving strategies;

     (v) Depression and dementia;

     (vi) Fall prevention for dementia;

     (vii) Personal care as meaningful activity;

     (viii) Promoting pleasant and purposeful activity; and

     (ix) Resistance to care: Caregiving strategies.

     (e) Provide all necessary physical assistance with bathing and toilet use for residents who require caregivers to perform these activities and subtasks of these activities, and required oversight and supervision, encouragement and cuing. For the purposes of this subsection:

     (i) "Bathing" has the same meaning as described in WAC 388-72A-0035; and

     (ii) "Toilet use" has the same meaning as described in WAC 388-72A-0035.

     (f) Provide extensive assistance with eating as necessary, including required oversight and supervision, encouragement and cuing. The contractor must also provide all necessary physical assistance with eating on an occasional basis for residents who require total feeding assistance. However, the contractor is not required to provide tube feedings or intravenous nutrition nor provide total feeding assistance for an extended or indefinite period.

     (i) "Eating" has the same meaning as described in WAC 388-72A-0035, except that the contractor is not required to provide tube feedings or intravenous nutrition;

     (ii) "Extensive assistance" has the same meaning as described in WAC 388-72A-0040.

     (g) Provide daily activities consistent with the functional abilities, interests, habits and preferences of the individual residents. The contractor must support the participation of residents and the resident council, if there is one, in the development of recreational and activity programs that reflect the needs and choices of residents. On a daily basis, the contractor must provide residents access to:

     (i) Opportunities for independent, self-directed, activities.

     (ii) Individual activities, in which a staff person or volunteer engages the resident in a planned and/or spontaneous activity of interest. Activities may include personal care activities that provide opportunities for purposeful and positive interactions; and

     (iii) Group activities.

     (h) Offer opportunities for activities that accommodate variations in a resident's mood, energy and preferences. The contractor must make appropriate activities available based upon the resident's individual schedule and interests. For example, individuals up at night must have access to staff support, food and appropriate activities;

     (i) Make available multiple common areas, at least one of which is outdoors, that vary by size and arrangement such as: various size furniture groupings that encourage social interaction; areas with environmental cues that may stimulate activity, such as a resident kitchen or workshop; areas with activity supplies and props to stimulate conversation; a garden area; and paths and walkways that encourage exploration and walking. These areas must accommodate and offer opportunities for individual or group activity;

     (j) Ensure that the outdoor area for residents:

     (i) Is accessible to residents without staff assistance;

     (ii) Is surrounded by walls or fences at least seventy-two inches high;

     (iii) Has areas protected from direct sunshine and rain throughout the day;

     (iv) Has walking surfaces that are firm, stable, slip-resistant and free from abrupt changes, and are suitable for individuals using wheelchairs and walkers;

     (v) Has suitable outdoor furniture;

     (vi) Has plants that are not poisonous or toxic to humans; and

     (vii) Has areas for appropriate outdoor activities of interest to residents, such as walking paths, raised garden or flower beds, bird feeders, etc.

     (k) Ensure that areas used by residents have a residential atmosphere, and residents have opportunities for privacy, socialization, and wandering behaviors;

     (l) Ensure any public address system in the area of specialized dementia care services is used only for emergencies;

     (m) Encourage residents' individualized spaces to be furnished and or decorated with personal items based on resident needs and preferences;

     (n) Ensure residents have access to their own rooms at all times without staff assistance; and

     (o) Make available and offer at no additional cost to the resident generic personal care items needed by the resident such as soap, shampoo, toilet paper, toothbrush, toothpaste, deodorant, sanitary napkins, and disposable razors. This does not include items covered by medical coupons or preclude residents from choosing to purchase their own personal care items.

[Statutory Authority: RCW 74.39A.010, 74.39A.020, 74.39A.060, 74.39A.080, 74.39A.170, 18.88A.210-[18.88A.]240 and 70.129.040. 96-11-045 (Order 3979), § 388-110-220, filed 5/8/96, effective 6/8/96.]

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