DEPARTMENT OF HEALTH

The words and phrases in this chapter have the following meanings unless the context clearly indicates otherwise.

(1) "Consumer" means:

(a) An individual receiving health care or services from a health care facility or health care professional;

(b) A person pursuant to RCW 7.70.065 authorized to provide informed consent to health care on behalf of (a) of this subsection who is not competent to consent.

(2) "Department" means the Washington state department of health.

(3) "Employee" means an individual employed by a health care facility or health care professional at the time the:

(a) Alleged improper quality of care occurred; or

(b) Alleged improper quality of care is discovered.

(4) "Good faith" means an honest and reasonable belief in the truth of the allegation.

(5) "Health care" means any care, service, or procedure provided by a health care facility or a health care provider:

(a) To diagnose, treat, or maintain a patient’s physical or mental condition; or

(b) That affects the structure or function of the human body.

(6) "Health care facility" includes the following:

(a) Adult residential rehabilitation centers regulated pursuant to chapter 71.12 RCW;

(b) Alcoholism treatment facilities regulated pursuant to chapter 71.12 RCW;

(c) Alcoholism hospitals regulated pursuant to chapter 71.12 RCW;

(d) Ambulance and aid services regulated pursuant to chapter 18.73 RCW;

(e) ((Boarding homes)) Assisted living facilities regulated pursuant to chapter 18.20 RCW;

(f) Childbirth centers regulated pursuant to chapter 18.46 RCW;

(g) Home care agencies regulated pursuant to chapter 70.127 RCW;

(h) Home health agencies regulated pursuant to chapter 70.127 RCW;

(i) Hospice agencies regulated pursuant to chapter 70.127 RCW;

(j) Hospitals regulated pursuant to chapter 70.41 RCW;

(k) Pharmacies regulated pursuant to chapter 18.64 RCW;

(l) Private psychiatric hospitals regulated pursuant to chapter 71.12 RCW;

(m) Residential treatment facilities for psychiatrically impaired children and youth regulated pursuant to chapter 71.12 RCW;

(n) Rural health care facilities regulated pursuant to chapter 70.175 RCW.

(7) "Health care provider," "health care professional," "professional" or "provider" mean a person who is licensed, certified, registered or otherwise authorized by the law of this state to provide health care in the ordinary course of business or practice of a profession.

(8) "Improper quality of care," as defined in RCW 43.70.075, means any practice, procedure, action, or failure to act that violates any state law or rule of the applicable state health licensing authority under Title 18 RCW or chapters 70.41, 70.96A, 70.127, 70.175, 71.05, 71.12, and 71.24 RCW, and enforced by the department of health. Improper quality of care shall not include good faith personnel actions related to employee performance or actions taken according to established terms and conditions of employment. Good faith personnel action will not prevent investigations of alleged improper quality of care.

(9) "Whistleblower" means a consumer, employee, or health care professional who in good faith reports alleged quality of care concerns to the department of health.

The words and phrases in this chapter have the following meanings unless the context clearly indicates otherwise.

(1) "Alternative program" means a coordinated quality improvement program determined by the department to be substantially equivalent to RCW 70.41.200(1).

(2) "Department" means the Washington state department of health.

(3) "Governing body" means:

(a) The person, persons or board responsible for the health care entity; or

(b) In the case of a provider group where no person, persons or board is in charge of all providers; the person, persons or group identified by the provider group is responsible for the coordinated quality improvement program.

(4) "Health care entity" means a health care institution, medical facility, provider group, professional society or organization, health care service contractors, health maintenance organizations, health carriers approved under chapter 48.43 RCW, and any other person or entity providing health care coverage under chapter 48.42 RCW that is subject to the jurisdiction of any state agency or any subdivision thereof, authorized by RCW 43.70.510 to have a department-approved coordinated quality improvement program.

(5) "Health care institution" or "medical facility" includes the following:

(a) Adult residential rehabilitation centers regulated under chapter 71.12 RCW;

(b) Alcohol and drug treatment facilities and hospitals regulated under chapter 70.96A RCW;

(c) Emergency medical care and transportation services regulated under chapter 18.73 RCW;

(d) ((Boarding homes)) Assisted living facilities regulated under chapter 18.20 RCW;

(e) Childbirth centers regulated under chapter 18.46 RCW;

(f) Community mental health centers regulated under chapter 71.05 or 71.24 RCW;

(g) Home health agencies, home care agencies, hospice care centers, and hospice agencies regulated under chapter 70.127 RCW;

(h) Medical test sites regulated under chapter 70.42 RCW;

(i) Nursing homes regulated under chapter 18.51 RCW;

(j) Pharmacies regulated under chapter 18.64 RCW;

(k) Private psychiatric hospitals and residential treatment facilities for psychiatrically impaired children and youth regulated under chapter 71.12 RCW;

(l) Rural health care facilities regulated under chapter 70.175 RCW;

(m) Organizations that provide designated trauma care services individually or jointly under chapter 70.168 RCW;

(n) Facilities owned and operated by a political subdivision or instrumentality of the state, including, but not limited to:

(i) Public health departments;

(ii) Fire districts and departments;

(iii) Soldiers' and veterans' homes;

(iv) State mental health institutions;

(v) Health clinics operated by educational institutions;

(vi) Department of corrections health care facilities;

(vii) County jail health clinics;

(viii) County drug and alcohol treatment facilities; and

(ix) Public hospital districts;

(o) Facilities required by federal law and implementing regulations, including, but not limited to:

(i) Native American health facilities; and

(ii) Veterans' affairs health services; and

(p) Other facilities that the department determines meet the definition of "health care facility" in RCW 48.43.005.

(6) "Health care provider" or "provider" means:

(a) A person regulated under Title 18 RCW to practice health or health related services or otherwise practicing health care services in this state consistent with state law; or

(b) An employee or agent of a person described in (a) of this subsection, acting in the course and scope of the employee's or agent's employment performing health care or auxiliary services.

(7) "Health care provider group" or "provider group" means an organized body or consortium of five or more providers in total.

(8) "Negative health care outcome" means a patient death or impairment of bodily function other than those related to the natural course of illness, disease or proper treatment in accordance with generally accepted health care standards.

(9) "Professional society or organization" means a group of health care professionals, including, but not limited to, state or local health care professional associations.

(10) "Program" means coordinated quality improvement program under RCW 43.70.510.

The following definitions shall apply in the interpretation and enforcement of chapter 246-100 WAC:

(1) "Acquired immunodeficiency syndrome (AIDS)" means illness, disease, or conditions defined and described by the Centers for Disease Control, U.S. Public Health Service, Morbidity and Mortality Weekly Report (MMWR), December 18, 1992, Volume 41, Number RR-17. A copy of this publication is available for review at the department and at each local health department.

(2) "AIDS counseling" means counseling directed toward:

(a) Increasing the individual's understanding of acquired immunodeficiency syndrome; and

(b) Assessing the individual's risk of HIV acquisition and transmission; and

(c) Affecting the individual's behavior in ways to reduce the risk of acquiring and transmitting HIV infection.

(3) "Anonymous HIV testing" means that the name or identity of the individual tested for HIV will not be recorded or linked to the HIV test result. However, once the individual testing positive receives HIV health care or treatment services, reporting of the identity of the individual to the state or local public health officer is required.

(4) "Board" means the Washington state board of health.

(5) "Case" means a person, alive or dead, having been diagnosed to have a particular disease or condition by a health care provider with diagnosis based on clinical or laboratory criteria or both.

(6) "Child day care facility" means an agency regularly providing care for a group of children for less than twenty-four hours a day and subject to licensing under chapter 74.15 RCW.

(7) "Communicable disease" means an illness caused by an infectious agent which can be transmitted from one person, animal, or object to another person by direct or indirect means including transmission via an intermediate host or vector, food, water, or air.

(8) "Confidential HIV testing" means that the name or identity of the individual tested for HIV will be recorded and linked to the HIV test result, and that the name of the individual testing positive for HIV will be reported to the state or local health officer in a private manner.

(9) "Contaminated" or "contamination" means containing or having contact with infectious agents or chemical or radiological materials that pose an immediate threat to present or future public health.

(([(10)])) (10) "Contamination control measures" means the management of persons, animals, goods, and facilities that are contaminated, or suspected to be contaminated, in a manner to avoid human exposure to the contaminant, prevent the contaminant from spreading, and/or effect decontamination.

(11) "Department" means the Washington state department of health.

(12) "Detention" or "detainment" means physical restriction of activities of an individual by confinement for the purpose of controlling or preventing a serious and imminent threat to public health and may include physical plant, facilities, equipment, and/or personnel to physically restrict activities of the individual to accomplish such purposes.

(13) "Disease control measures" means the management of persons, animals, goods, and facilities that are infected with, suspected to be infected with, exposed to, or suspected to be exposed to an infectious agent in a manner to prevent transmission of the infectious agent to humans.

(14) "Health care facility" means:

(a) Any facility or institution licensed under chapter 18.20 RCW, ((boarding home)) assisted living facilities, chapter 18.46 RCW, birthing centers, chapter 18.51 RCW, nursing homes, chapter 70.41 RCW, hospitals, or chapter 71.12 RCW, private establishments, clinics, or other settings where one or more health care providers practice; and

(b) In reference to a sexually transmitted disease, other settings as defined in chapter 70.24 RCW.

(15) "Health care provider" means any person having direct or supervisory responsibility for the delivery of health care who is:

(a) Licensed or certified in this state under Title 18 RCW; or

(b) Is military personnel providing health care within the state regardless of licensure.

(16) "HIV testing" means conducting a laboratory test or sequence of tests to detect the human immunodeficiency virus (HIV) or antibodies to HIV performed in accordance with requirements to WAC 246-100-207. To assure that the protection, including but not limited to, pre- and post-test counseling, consent, and confidentiality afforded to HIV testing as described in chapter 246-100 WAC also applies to the enumeration of CD4 + (T4) lymphocyte counts (CD4 + counts) and CD4 + (T4) percents of total lymphocytes (CD4 + percents) when used to diagnose HIV infection, CD4 + counts and CD4 + percents will be presumed HIV testing except when shown by clear and convincing evidence to be for use in the following circumstances:

(a) Monitoring previously diagnosed infection with HIV;

(b) Monitoring organ or bone marrow transplants;

(c) Monitoring chemotherapy;

(d) Medical research; or

(e) Diagnosis or monitoring of congenital immunodeficiency states or autoimmune states not related to HIV.

The burden of proving the existence of one or more of the circumstances identified in (a) through (e) of this subsection shall be on the person asserting such existence.

(17) "Infectious agent" means an organism such as a virus, rickettsia, bacteria, fungus, protozoan, or helminth that is capable of producing infection or infectious disease.

(18) "Isolation" means the separation, for the period of communicability or contamination, of infected or contaminated persons or animals from others in such places and under such conditions as to prevent or limit the direct or indirect transmission of the infectious agent or contaminant from those infected or contaminated to those who are susceptible or who may spread the agent or contaminant to others.

(19) "Local health department" means the city, town, county, or district agency providing public health services to persons within the area, as provided in chapter 70.05 RCW and chapter 70.08 RCW.

(20) "Local health officer" means the individual having been appointed under chapter 70.05 RCW as the health officer for the local health department, or having been appointed under chapter 70.08 RCW as the director of public health of a combined city-county health department, or his or her delegee appointed by the local board of health.

(21) "Nosocomial infection" means an infection acquired in a hospital or other health care facility.

(22) "Outbreak" means the occurrence of cases of a disease or condition in any area over a given period of time in excess of the expected number of cases.

(23) "Post-test counseling" means counseling after the HIV test when results are provided and directed toward:

(a) Increasing the individual's understanding of human immunodeficiency virus (HIV) infection;

(b) Affecting the individual's behavior in ways to reduce the risk of acquiring and transmitting HIV infection;

(c) Encouraging the individual testing positive to notify persons with whom there has been contact capable of spreading HIV;

(d) Assessing emotional impact of HIV test results; and

(e) Appropriate referral for other community support services.

(24) "Pretest counseling" means counseling provided prior to HIV testing and aimed at:

(a) Helping an individual to understand:

(i) Ways to reduce the risk of human immunodeficiency virus (HIV) transmission;

(ii) The nature, purpose, and potential ramifications of HIV testing;

(iii) The significance of the results of HIV testing; and

(iv) The dangers of HIV infection; and

(b) Assessing the individual's ability to cope with the results of HIV testing.

(25) "Principal health care provider" means the attending physician or other health care provider recognized as primarily responsible for diagnosis and treatment of a patient or, in the absence of such, the health care provider initiating diagnostic testing or therapy for a patient.

(26) "Quarantine" means the limitation of freedom of movement of such well persons or domestic animals as have been exposed to, or are suspected to have been exposed to, an infectious agent, for a period of time not longer than the longest usual incubation period of the infectious agent, in such manner as to prevent effective contact with those not so exposed.

(27) "School" means a facility for programs of education as defined in RCW 28A.210.070 (preschool and kindergarten through grade twelve).

(28) "Sexually transmitted disease (STD)" means a bacterial, viral, fungal, or parasitic disease or condition which is usually transmitted through sexual contact, including:

(a) Acute pelvic inflammatory disease;

(b) Chancroid;

(c) Chlamydia trachomatis infection;

(d) Genital and neonatal herpes simplex;

(e) Genital human papilloma virus infection;

(f) Gonorrhea;

(g) Granuloma inguinale;

(h) Hepatitis B infection;

(i) Human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS);

(j) Lymphogranuloma venereum;

(k) Nongonococcal urethritis (NGU); and

(l) Syphilis.

(29) "Spouse" means any individual who is the marriage partner of an HIV-infected individual, or who has been the marriage partner of the HIV-infected individual within the ten-year period prior to the diagnosis of HIV-infection, and evidence exists of possible exposure to HIV.

(30) "State health officer" means the person designated by the secretary of the department to serve as statewide health officer, or, in the absence of such designation, the person having primary responsibility for public health matters in the state.

(31) "Suspected case" or "suspected to be infected" means the local health officer, in his or her professional judgment, reasonably believes that infection with a particular infectious agent is likely based on signs and symptoms, laboratory evidence, or contact with an infected individual, animal, or contaminated environment.

(32) "Veterinarian" means an individual licensed under provisions of chapter 18.92 RCW, veterinary medicine, surgery, and dentistry and practicing animal health care.

(1) A state or local health officer within his or her jurisdiction may, in accordance with RCW 70.24.024, issue orders for medical examination, testing, and/or counseling, as well as orders to cease and desist specific activities, when he or she knows or has reason to believe that a person has a sexually transmitted disease and is engaging in conduct endangering the public health.

(a) For purposes of this section, "reason to believe" means a health officer's belief that is based on:

(i) Laboratory test results confirming or suggestive of a STD; or

(ii) A health care provider's direct observation of clinical signs confirming an individual has or is likely to have a STD; or

(iii) Information obtained directly from an individual infected with a STD about the identity of his or her sexual or needle-sharing contacts when:

(A) Contact with the infected individual occurred during a period when the disease may have been infectious; and

(B) The contact was sufficient to transmit the disease; and

(C) The infected individual is, in the health officer's judgment, credible and believable.

(b) "Conduct endangering the public health" for the purposes of RCW 70.24.024 and this section, means:

(i) Anal, oral, or vaginal intercourse for all sexually transmitted diseases;

(ii) For HIV and Hepatitis B:

(A) Anal, oral, or vaginal intercourse; and/or

(B) Sharing of injection equipment; and/or

(C) Donating or selling blood, blood products, body tissues, or semen; and

(iii) Activities described in (b)(i) and (ii) of this subsection resulting in introduction of blood, semen, and/or vaginal fluids to:

(A) Mucous membranes;

(B) Eyes;

(C) Open cuts, wounds, lesions; or

(D) Interruption of epidermis.

(c) State and local health officers and their authorized representatives shall have authority to issue written orders for medical examination, testing, and/or counseling under chapter 70.24 RCW, only after:

(i) All other efforts to protect public health have failed, including reasonable efforts to obtain the voluntary cooperation of the person to be affected by the order; and

(ii) They have sufficient evidence to "reasonably believe" the individual to be affected by the order:

(A) Has a sexually transmitted disease; and

(B) Is engaging in "conduct endangering public health"; and

(iii) They have investigated and confirmed the existence of "conduct endangering the public health" by:

(A) Interviewing sources to assess their credibility and accuracy; and

(B) Interviewing the person to be affected by the order; and

(iv) They have incorporated all information required in RCW 70.24.024 in a written order.

(d) State and local health officers and their authorized representatives shall have authority to issue written orders for treatment under RCW 70.24.022 only after laboratory test results or direct observation of clinical signs or assessment of clinical data by a physician confirm the individual has, or is likely to have, a sexually transmitted disease.

(e) State and local health officers and their authorized representatives shall have authority to issue written orders to cease and desist from specified activities under RCW 70.24.024 only after:

(i) They have determined the person to be affected by the order is engaging in "conduct endangering public health"; and

(ii) Laboratory test results, or direct observation of clinical signs or assessment of clinical data by a physician, confirm the individual has, or is likely to have, a sexually transmitted disease; and

(iii) They have exhausted procedures described in subsection (8)(a) of this section; and

(iv) They have enlisted, if appropriate, court enforcement of the orders described in (c) and (d) of this subsection.

(f) Written orders to cease and desist from specified activities shall be for an initial period of time not to exceed three months, and may be renewed by the health officer for periods of time not to exceed three months provided all requirements of RCW 70.24.024 regarding notification, confidentiality, right to a judicial hearing, and right to counsel are met again at the time of renewal.

(2) A state or local health officer within his or her jurisdiction may, in accordance with RCW 70.24.034, bring action in superior court to detain a person in a designated or approved facility when he or she knows or has reason to believe that person has a sexually transmitted disease and continues to engage in behaviors that present an imminent danger to the public health.

(a) "Behaviors that present an imminent danger to public health" or "BPID" for the purposes of detention in accordance with RCW 70.24.034 and this section means the following activities, under conditions specified below, performed by an individual with a laboratory-confirmed HIV infection:

(i) Anal or vaginal intercourse without a latex condom; or

(ii) Shared use of blood-contaminated injection equipment;

(iii) Donating or selling HIV-infected blood, blood products, or semen; and

(iv) Activities described in (a)(i) and (ii) of this subsection constitute BPID only if:

(A) The infected individual received post-test counseling as described in WAC 246-100-209 prior to repeating activities; and

(B) The infected individual did not inform the persons with whom the activities occurred of his or her infectious status.

(b) State and local health officers and their authorized representatives shall have authority to seek court orders for detainment under RCW 70.24.034 only for persons infected with HIV and only after:

(i) Exhausting procedures described in subsection (1) of this section; and

(ii) Enlisting, if appropriate, court enforcement of orders to cease and desist; and

(iii) Having sufficient evidence to "reasonably believe" the person is engaging in BPID.

(c) A local health officer may notify the state health officer if he or she determines:

(i) The criteria for BPID are met by an individual; and

(ii) Such individual fails to comply with a cease and desist order affirmed or issued by a court.

(d) A local or state health officer may request the prosecuting attorney to file an action in superior court to detain an individual specified in this subsection. The requesting local or state health officer or authorized representative shall:

(i) Notify the department prior to recommending the detainment setting where the individualized counseling and education plan may be carried out consistent with subsection (9)(d), (e), and (f) of this section;

(ii) Make a recommendation to the court for placement of such individual consistent with (e), (f), and (g) of this subsection; and

(iii) Provide to the court an individualized plan for education and counseling consistent with (f) of this subsection.

(e) State board of health requirements for detainment of individuals demonstrating BPID include:

(i) Sufficient number of staff, caregivers, and/or family members to:

(A) Provide round-the-clock supervision, safety of detainee, and security; and

(B) Limit and restrict activities to prevent BPID; and

(C) Make available any medical, psychological, or nursing care when needed; and

(D) Provide access to AIDS education and counseling; and

(E) Immediately notify the local or state health officer of unauthorized absence or elopement; and

(ii) Sufficient equipment and facilities to provide:

(A) Meals and nourishment to meet nutritional needs; and

(B) A sanitary toilet and lavatory; and

(C) A bathing facility; and

(D) Bed and clean bedding appropriate to size of detainee; and

(E) A safe detention setting appropriate to chronological and developmental age of detainee; and

(F) A private sleeping room; and

(G) Prevention of sexual exploitation;

(iii) Sufficient access to services and programs directed toward cessation of BPID and providing:

(A) Linguistically, socially, culturally, and developmentally appropriate ongoing AIDS education and counseling; and

(B) Psychological and psychiatric evaluation and counseling; and

(C) Implementation of court-ordered plan for individualized counseling and education consistent with (g) of this subsection;

(iv) If required, provide access to isolation and/or restraint in accordance with restraint and seclusion rules in WAC 275-55-263 (2)(c);

(v) Maintain a safe, secure environment free from harassment, physical danger, and sexual exploitation.

(f) Washington state board of health standards for an individualized counseling and education plan for a detainee:

(i) Consideration of detainee's personal and environmental characteristics, culture, social group, developmental age, and language;

(ii) Identification of habitual and addictive behavior and relapse pattern;

(iii) Identification of unique risk factors and possible cross-addiction leading to behavior presenting imminent danger to public health;

(iv) Identification of obstacles to behavior change and determination of specific objectives for desired behavior;

(v) Provision of information about acquisition and transmission of HIV infection;

(vi) Teaching and training of individual coping skills to prevent relapse to BPID;

(vii) Specific counseling for chemical dependency, if required;

(viii) Identification of and assistance with access to community resources, including social services and self-help groups appropriate to provide ongoing support and maintenance of behavior change; and

(ix) Designation of a person primarily responsible for counseling and/or education who:

(A) Completed pretest and post-test counselor training approved by the office on AIDS; and

(B) Received training, as approved by the office on AIDS, focused on facilitating behavior change related to preventing BPID; and

(C) Has a postgraduate degree in social work, psychology, counseling, psychosocial nursing, or other allied profession; and

(D) Completed at least one year clinical experience after postgraduate education with a primary focus on individualized behavior change; and

(E) Is a certified counselor under chapter 18.19 RCW;

(x) Designation and provision of a qualified counselor under WAC 275-19-145 when the detainee is assessed to have a drug or alcohol problem.

(g) The state board of health designates the following settings appropriate for detainment provided a setting meets requirements in (e)(i), (ii), (iii), (iv), and (v) of this subsection:

(i) Homes, care facilities, or treatment institutions operated or contracted by the department;

(ii) Private homes, as recommended by the local or state health officer;

(iii) ((Boarding homes)) Assisted living facilities licensed under chapter 18.20 RCW;

(iv) Nursing homes licensed under chapter 18.51 RCW;

(v) Facilities licensed under chapter 71.12 RCW, including:

(A) Psychiatric hospitals, per chapter 246-322 WAC;

(B) Alcoholism treatment centers if certified for substance use under chapter 275-19 WAC;

(C) Adult residential rehabilitation centers, per chapter 246-325 WAC;

(D) Private adult treatment homes, per chapter 246-325 WAC;

(E) Residential treatment facilities for psychiatrically impaired children and youth, per chapter 246-323 WAC;

(vi) A hospital licensed under chapter 70.41 RCW.

As used in this chapter of the rules and regulations, the following definitions apply:

(1) "Additional food safety training" means completion of a comprehensive training program on food safety of at least four hours in length. Training may include topics such as: Proper cooking, hot-holding, cold-holding and cooling of potentially hazardous foods; cross-contamination prevention; HACCP and/or proper hand washing techniques. Approval of training programs shall be obtained from jurisdictional health departments or the department by the training provider. Approval of training programs must be obtained in advance.

(2) "Applicant" means an individual applying to obtain an initial or renewal food worker card.

(3) "Department" means the Washington state department of health.

(4) "Food service establishment" means:

(a) A place, location, operation, site, or facility where food is manufactured, prepared, processed, packaged, dispensed, distributed, sold, served, or offered to the consumer regardless of whether or not compensation for food occurs, including but not limited to:

(i) Restaurants, snack bars, cafeterias, taverns, bars;

(ii) Retail food stores, supermarkets, retail meat markets, retail fish markets, retail bakeries, delicatessens;

(iii) Institutional operations licensed by the department, the state department of social and health services or local health officer, such as schools, hospitals, jails, prisons, nursing homes, ((boarding homes)) assisted living facilities, and child care facilities;

(iv) Central preparation sites, including caterers;

(v) Satellite servicing locations;

(vi) Temporary food service establishments or mobile food units;

(vii) Bed and breakfast operations;

(viii) Remote feeding sites;

(ix) Adult family homes; and

(x) Vending machines dispensing potentially hazardous foods.

(b) This term does not include:

(i) Private homes where food is prepared or served for consumption by household members and/or their guests;

(ii) Establishments offering only commercially prepackaged nonpotentially hazardous foods;

(iii) Commercial food processing establishments, licensed and regulated by the USDA, FDA, or WSDA; and

(iv) Farmers exempt from licensure under RCW 36.71.090.

(5) "Food service worker" means an individual who works (or intends to work) with or without pay in a food service establishment and handles unwrapped or unpackaged food or who may contribute to the transmission of infectious diseases through the nature of his/her contact with food products and/or equipment and facilities. This does not include persons who simply assist residents or patients in institutional facilities with meals, or students in K-12 schools who periodically assist with school meal service.

(6) "Food worker card" means a food and beverage service workers' permit as required under chapter 69.06 RCW.

(7) "Health officer" means the county, city-county, or district health officer of a jurisdictional health department, or his/her authorized representative, or the representative of the department.

(8) "Jurisdictional health department" refers to one of the following:

(a) Local health district as defined in chapter 70.46 RCW.

(b) City-county health department as defined in chapter 70.08 RCW.

(c) County health department as defined in chapter 70.05 RCW.

(9) "Person" means any individual, partnership, corporation, association, or other legal entity or agency of state, county, or municipal government, or agency of the federal government which is subject to the jurisdiction of the state.

(10) "Secretary" means the secretary of the state department of health.

The definitions in this section apply throughout this chapter unless the context clearly indicates otherwise.

(1) "ALTI" means Advanced Lifeguard Training International.

(2) "ANSI" means American National Standards Institute.

(3) "APHA" means American Public Health association.

(4) "Approved" means the department or local health officer has stated in writing that the design plans and specifications are in accordance with this chapter.

(5) "APSP" means Association of Pool and Spa Professionals.

(6) "ARC" means American Red Cross.

(7) "Architect" means a registered architect currently licensed under chapter 18.08 RCW in Washington state.

(8) "ASA" means American Standards Association.

(9) "ASHRAE" means American Society of Heating, Refrigeration and Air Conditioning Engineers.

(10) "ASTM" means American Society for Testing and Materials.

(11) "Attendant" means a person appointed by the owner or manager meeting the training requirements of this chapter who monitors activities and conditions for the purpose of ensuring bather safety.

(12) "AWWA" means American Waterworks Association.

(13) "Bathing beach" means a bathing place, together with buildings and appurtenances, on a natural pond, lake, stream, or other body of fresh or salt water that is open to the public for bathing by express permission of the owner, operated for a fee, or openly advertised as a place for bathing by the public.

(14) "Board" means the state board of health.

(15) "Branch line" means suction piping between a junction fitting and a suction outlet.

(16) "Commercial strength ammonia" means ammonia having a strength of twenty-six degrees Baume.

(17) "Communication system" means any combination of devices permitting the passage of messages between personnel and/or personnel and bathers. Systems can include but are not limited to two-way radios, hard wired intercoms, horns, whistles, hand signals, direct voice, signs, or equivalent.

(18) "Contaminant" means any physical, chemical, or biological substance present in the WRF water which may adversely affect the health or safety of the bather or the quality of the water.

(19) "CPR" means cardiopulmonary resuscitation.

(20) "CPSC" means U.S. Consumer Product Safety Commission.

(21) "Cross-connection" means any physical arrangement connecting:

(a) Potable water system directly or indirectly, with anything other than another potable water system; or

(b) WRF pool to any water source capable of contaminating either the WRF pool, its components, or potable water source as a result of backflow.

(22) "DE" means diatomaceous earth.

(23) "Department" means the Washington state department of health.

(24) "Deep water" means water greater than five feet in depth.

(25) "Diving envelope" means the minimum dimensions of an area within the pool necessary to provide entry from a diving board, platform, or pool decking intended for users to dive.

(26) "E&A" means Ellis and Associates.

(27) "Engineer" means a registered professional engineer currently licensed under chapter 18.43 RCW.

(28) "EPA" means U.S. Environmental Protection Agency.

(29) "Equalizer line outlet" means a suction outlet located on the pool wall below the waterline and connected by pipe to the body of a skimmer to prevent air from being drawn into the pump if the water level drops below the skimmer weir.

(30) "F" means Fahrenheit.

(31) "Fall zones" mean the areas under and around play toys where a person playing on them could fall. These areas should be free of obstacles or other equipment so that there's plenty of room. Basic guidelines include the following:

(a) Fall zones should extend a minimum of six feet in all directions from the perimeter of the play toy equipment.

(b) If the height of an adjacent play toy is thirty inches or more, the minimum distance between pieces of play equipment should be at least nine feet.

(32) "FINA" means Federation Internationale de Natation Amateur.

(33) "fps" means feet per second.

(34) "General use pool" means any swimming, spa, wading, or spray pool regulated by this chapter not meeting the definition of a "limited use pool."

(35) "gpm" means gallons per minute.

(36) "Handhold" means a structure not over twelve inches above the water line around the perimeter of the pool wall, affording physical means for the bather to grasp the pool sides.

(37) "IAPMO" means International Association of Plumbing and Mechanical Officials.

(38) "Illness or injury report" means the written record of all facts regarding an injury or illness associated with the WRF.

(39) "Innovative design feature" means a design feature, equipment, device, or operative procedure not specifically covered by these rules or chapter 246-262 WAC.

(40) "Junction fitting" means a pipe fitting in the shape of a "T" or a "Y" used to connect suction outlets to a pump or a balancing tank, and provides two branch line connections and one trunk line connection.

(41) "Licensed medical practitioner" includes medical doctor, osteopath, chiropractor, naturopath, and medical therapist currently licensed in Washington state.

(42) "Lifeguard" means a person meeting the training requirements of these rules appointed by the owner or manager to maintain surveillance over the bathers on the deck or in the pool and to supervise bather safety.

(43) "Lifeguard station" means designated work station of a lifeguard.

(44) "Lifesaving equipment" means emergency equipment and barrier protection.

(45) "Lifesaving Society" means the organization in Canada that establishes training requirements and standards for lifeguard training.

(46) "Limited use pool" means:

(a) Any swimming, spa, wading, or spray pool regulated by this chapter at an apartment, ((boarding home)) assisted living facility, condominium, fraternity, home owners association, hotel, mobile home park, motel, recreational vehicle park, sorority or rental housing unit for the use of the persons living or residing at the facility and their resident's invited guests.

(b) When organized programs are provided at the facility (including, but not limited to, formal swimming or diving lessons, swim meets, or exercise classes), for users besides those specified under the limited use category, the pool facility shall be considered to be a general use pool during periods of such activity.

(47) "Local health officer" means the health officer of the city, county, or city-county department or district or a representative authorized by the local health officer.

(48) "Main drain" means a submerged suction outlet for transferring water from a swimming pool, spa pool, or wading pool.

(49) "mg/l" means milligrams per liter. When requirements in this regulation specify limits for liquid volume measurements using mg/l or ppm, either may be used depending on the type of testing equipment available.

(50) "NAUI" means National Association of Underwater Instructors.

(51) "NSF" means National Sanitation Foundation.

(52) "NSPI" means National Spa and Pool Institute.

(53) "Outlet drain" means a drain for transferring water from a spray pool.

(54) "Owner" means a person owning and responsible for a WRF or their authorized agent.

(55) "PADI" means Professional Association of Diving Instructors.

(56) "Person" means an individual, firm, partnership, copartnership, corporation, company, association, club, government entity, or organization of any kind.

(57) "Physical plant" refers to pool shell, piping, lighting, ventilation, locker rooms, chemical storage rooms, mechanical rooms, or other structural facility components that are not readily modified. It does not include pumps, filters or disinfection systems.

(58) "Play toy" is a water feature added to a pool for use by bathers that provides activity or action that enhances the overall use of the water environment. Such feature may include, but not be limited to, fixed stationary features, inflatable or floatable equipment, or other equipment with the intent to invite bathers to play on or around the feature.

(59) "Pool" means swimming pool, wading pool, spray pool, or spa pool or the like.

(60) "ppm" means parts per million. See notation under mg/l for use.

(61) "Private club" means a group or organization requiring membership enrollment.

(62) "Radius of curvature" means the radius arc denoting the curved surface from the point of departure from the springline (vertical sidewall) of the pool to the pool bottom.

(63) "Response time" means time between bather distress and initiation of rescue assistance contact by a lifeguard in facilities providing lifeguards.

(64) "Recreational water contact facility" means an artificial water associated facility with design and operational features that provide patron recreational activity which is different from that associated with a conventional swimming pool and purposefully involves immersion of the body partially or totally in the water, and that includes but is not limited to water slides, wave pools, and water lagoons. These facilities are regulated by chapter 246-262 WAC.

(65) "Secretary" means the secretary of the department.

(66) "Serious injury" means any injury:

(a) Requiring emergency service response where a person requires medical treatment as determined by the emergency medical response personnel; or

(b) Resulting in a person seeking medical attention at a medical facility, hospital emergency room or admittance to a hospital.

(67) "Shallow water" means water equal to or less than five feet in depth.

(68) "Shallow water lifeguard" means a person appointed by the owner or manager to supervise bather safety in water depths not exceeding five feet who meets the training requirements of this chapter.

(69) "Spa pool" means a pool designed for relaxation or recreational use where the user is usually sitting, reclining, or at rest and the pool is not drained, cleaned, and refilled for each user. The spa pool may include, but not be limited to, hydrojet circulation, hot water, cold water, mineral baths, air induction bubbles in any combination.

(70) "Spray pool" means a pool or artificially constructed depression for use by bathers in which water is sprayed, but is not allowed to pond in the bottom of the pool.

(71) "Springline" means the point where the pool wall breaks from vertical and begins its arc in the radius of curvature (for cove construction) to the bottom of the pool.

(72) "Suction fitting standard" means the ANSI/APSP-16 2011, Suction Fittings for Use in Swimming Pools, Wading Pools, Spas, and Hot Tubs.

(73) "Suction outlet" means a fitting, fitting assembly and related components including the sump or bulkhead fitting, cover and hardware, that provides a localized low pressure area for the transfer of water from a water recreation facility. Types of suction outlets include main drains, equalizer line outlets, and submerged outlet drains.

(74) "Swimming pool" means any structure, basin, chamber, or tank containing an artificial body of water for swimming, diving, relaxation, or recreational bathing and having a depth of two feet or more at any point and including all associated facilities.

(75) "Swim spa" means a type of spa pool used primarily for stationary swimming.

(76) "Trunk line" means suction piping between a junction fitting and a pump or a balancing tank.

(77) "TU" means turbidity unit as measured by the nephelometric method.

(78) "Turnover time" means the minimum time necessary to circulate the entire volume of the pool facility through the treatment system.

(79) "UBC" means Uniform Building Code.

(80) "UL" means Underwriters' Laboratories.

(81) "Wading pool" means any artificial pool of water equal to or less than two feet deep and intended for wading purposes.

(82) "Walking surface" means any surface used as a direct access surface for a pool area and the walking surface's change room facilities where the user is barefoot.

(83) "Water treatment operator" means the appointed person operating the physical and mechanical equipment and performing related water quality monitoring and associated record keeping for proper operation of the physical facility.

(84) "Water recreation facility" means any artificial basin or other structure containing water used or intended to be used for recreation, bathing, relaxation or swimming, where body contact with the water occurs or is intended to occur and includes auxiliary buildings and appurtenances. The term includes, but is not limited to:

(a) Conventional swimming pools, wading pools, and spray pools;

(b) Recreational water contact facilities as defined under RCW 70.90.110 and regulated under chapter 246-262 WAC;

(c) Spa pools and tubs using hot water, cold water, mineral water, air induction, or hydrojets; and

(d) Any area designated for swimming in natural waters with artificial boundaries within the waters.

(85) "WRF" means water recreation facility.

(86) "WRPA" means Washington Recreation and Parks Association.

(87) "WSDA" means Washington state department of agriculture.

(88) "YMCA" means Young Men's Christian Association.

The definitions, abbreviations, and acronyms in this section apply throughout this chapter unless the context clearly indicates otherwise.

(1) "Acute" means posing an immediate risk to human health.

(2) "ADD (average day demand)" means the total volume of water produced from all sources of supply over a calendar year divided by three hundred sixty-five.

(3) "APWA" means American Public Works Association.

(4) "ASTM" means American Society for Testing and Materials.

(5) "AWWA" means American Water Works Association.

(6) "Board" means the Washington state board of health.

(7) "Certified lab" means an analytical laboratory meeting requirements under chapters 246-390 and 173-50 WAC for one or more drinking water analytical parameters.

(8) "Coliform bacteria" means a group of rod-shaped bacteria found in the gastrointestinal tract of vertebrate animals. The presence of coliform bacteria in water is an indicator of possible fecal contamination.

(9) "Contaminant" means a substance present in drinking water which may adversely affect the health of the consumer or the aesthetic qualities of the water.

(10) "Critical water supply service area" means a geographical area characterized by a proliferation of small, inadequate water systems, or by water supply problems that threaten the present or future water quality or reliability of service in a manner that efficient and orderly development may best be achieved through coordinated planning by the water utilities in the area.

(11) "Cross-connection" means any actual or potential physical connection between a public water system or a consumer's water system and any source of nonpotable liquid, solid, or gas that could contaminate the potable water supply by backflow.

(12) "Cross-connection control plan" means a document that identifies the procedures the purveyor uses to protect the Group B system from contamination from cross-connections.

(13) "Department" means the Washington state department of health.

(14) "Disinfection" means the use of chlorine or other agent or process the department approves for killing or inactivating microbiological organisms, including pathogenic and indicator organisms.

(15) "Distribution system" means all piping components of a Group B system that serve to convey water from transmission mains linked to source, storage, and treatment facilities to the consumer excluding individual services.

(16) "Drilled well" means a well where the well hole is excavated by mechanical means such as rotary, cable tool, or auger drilling equipment.

(17) "Dwelling unit" means a structure, or unit within a structure, with independent living facilities for one or more persons that includes permanent provisions for living, sleeping, eating, cooking, and sanitation. A dwelling unit includes, but is not limited to:

(a) A single-family residence; or

(b) Each unit of an apartment building or multifamily building.

(18) "Ecology" means the Washington state department of ecology.

(19) "Equalizing storage" means the volume of storage needed to supplement supply to consumers when the peak hourly demand exceeds the total source pumping capacity.

(20) "Expanding Group B system" means a Group B system installing additions, extensions, changes, or alterations to its existing source, transmission, storage, or distribution facilities that will enable the system to increase the size of its existing service area or the number of approved service connections.

(21) "Fire flow" means the maximum rate and duration of water flow needed to suppress a fire under WAC 246-293-640 or as required under local fire protection authority standards.

(22) "Fire suppression storage" means the volume of stored water available during fire suppression activities maintaining a pressure of at least 20 psi (140 kPa) at all points throughout the distribution system, and under the condition where the designed volume of fire suppression and equalizing storage has been depleted.

(23) "Generator disconnect switch" means an electrical device that physically prevents electrical current from flowing back into the main service line.

(24) "gpm" means gallons per minute.

(25) "Group A public water system" is defined and referenced under WAC 246-290-020.

(26) "Group B public water system" or "Group B system" means a public water system that is not a Group A public water system, and is defined and referenced under WAC 246-291-005.

(27) "Guideline" means a department document assisting a purveyor in meeting a rule or statutory requirement.

(28) "GWI (groundwater under the direct influence of surface water)" means any water beneath the surface of the ground, that the department determines has the following characteristics:

(a) Presence of insects or other macroorganisms, algae, or larger-diameter pathogens such as Giardia lamblia or Cryptosporidium; or

(b) Significant and relatively rapid shifts in water conditions such as turbidity, temperature, conductivity, or pH closely correlating to weather or surface water conditions, where natural conditions cannot prevent the introduction of surface water pathogens into the source at the systems' point of withdrawal.

(29) "Health officer" means the health officer of the local health jurisdiction, or an authorized representative.

(30) "Human consumption" means the use of water for drinking, bathing, showering, handwashing, cooking, food preparation, dishwashing, ice-making, or oral hygiene.

(31) "Hydraulic analysis" means the study of the Group B system's distribution main and storage network to determine the system's present or future adequacy for providing service to consumers within the established design parameters for the system under peak flow conditions, including fire flow. The analysis establishes the adequacy of design for distribution system components such as piping, elevated storage, booster stations or similar facilities used to pump and convey water to consumers.

(32) "Infiltration gallery" means a water collection system built of perforated pipe or conduit and placed in permeable earth, for collecting shallow groundwater. An infiltration gallery is usually located close to springs, wetlands, streams, or ponds.

(33) "Intertie" means an interconnection between public water systems permitting the exchange or delivery of water between those systems.

(34) "JPR (joint plan of responsibility)" means a written agreement between the department and local health jurisdiction that:

(a) Lists the roles and responsibilities of the department and health officer for reviewing and approving Group B system designs;

(b) Provides for a level of supervision necessary to effectively achieve the responsibilities in the JPR;

(c) Is signed by an authorized representative from the department and local health jurisdiction; and

(d) Is reviewed at least once every five years and updated as needed.

(35) "kPa" means kilo pascal (Standard International units of pressure).

(36) "Local board of health" means the governing body of a county health department under chapter 70.05 RCW, or a health district under chapter 70.46 RCW.

(37) "Local health jurisdiction" means a county health department under chapter 70.05 RCW, city-county health department under chapter 70.08 RCW, or health district under chapter 70.46 RCW.

(38) "Local permitting authority" means the local building official, health officer, or authorized representative that makes determinations regarding building permits and development proposals.

(39) "MCL (maximum contaminant level)" means the maximum permissible level of a contaminant in water the purveyor delivers to any Group B system consumer, measured at the source before entry to the distribution system.

(40) "MDD (maximum day demand)" means the highest actual or estimated quantity of water that is, or is expected to be, used over a twenty-four hour period, excluding unusual events or emergencies.

(41) "mg/L" means milligrams per liter (1mg/L = 1 part per million).

(42) "ml" means milliliter.

(43) "mm" means millimeter.

(44) "Nonresidential service connection" means a connection to a public water system that provides potable water including, but not limited to a:

(a) Commercial property;

(b) Industrial property;

(c) Civic property;

(d) Municipal property;

(e) Institutional property;

(f) School;

(g) Recreational use as defined in this section; or

(h) Any other authorized use that provides potable water to a nonresidential population.

(45) "PAS" means pitless adaptor standard.

(46) "PHD (peak hourly demand)" means the maximum rate of water use, excluding fire flow that can occur within a defined service area over a continuous sixty minute time period. PHD is typically expressed in gallons per minute (gpm).

(47) "Potable" means water safe for human consumption.

(48) "Potential GWI" means a source identified by the department or local health jurisdiction as possibly under the direct influence of surface water including, but not limited to a:

(a) Well that has a screened interval fifty feet or less from the ground surface at the wellhead and is located within two hundred feet of a freshwater surface water body;

(b) Ranney well;

(c) Infiltration gallery; or

(d) Spring.

(49) "Primary MCL" means a standard based on chronic, nonacute, or acute human health effects.

(50) "psi" means pounds per square inch.

(51) "Public water system" means any system providing water for human consumption through pipes or other constructed conveyances, excluding a system serving only one single-family residence and a system with four or fewer service connections all of which serve residences on the same farm. The term includes:

(a) Collection, treatment, storage, or distribution facilities under the control of a purveyor and used primarily in connection with the system; and

(b) Collection, or pretreatment storage facilities not under the control of a purveyor, and primarily used in connection with the system.

(52) "Purveyor" means an agency, subdivision of the state, municipal corporation, firm, company, mutual or cooperative association, institution, partnership, or person or other entity owning or operating a public water system, or applying to create a public water system. Purveyor also means the authorized agents of these entities.

(53) "Ranney well" means a water well or collection system including a central chamber with horizontal perforated pipes extending out into an aquifer. The perforated pipes may extend out under a surface water body such as a lake or river.

(54) "Recreational service connection" means a connection to a public water system that provides potable water to each:

(a) Campsite; or

(b) Recreational vehicle site.

(55) "Residential service connection" means a connection to a public water system that provides potable water to a dwelling unit.

(56) "Same farm" means a parcel of land or series of parcels connected by covenants and devoted to the production of livestock or agricultural commodities for commercial purposes.

(57) "Sanitary survey" means a review, inspection, and assessment of a public water system by the department or local health jurisdiction.

(58) "SCA (sanitary control area)" is defined under WAC 246-291-125(5).

(59) "SMA (satellite system management agency)" means a person or entity approved by the department in accordance with chapter 246-295 WAC to own or operate public water systems on a regional or county-wide basis without the necessity for a physical connection between the systems.

(60) "Secondary MCL" means a standard based on factors other than health effects.

(61) "Service connection" means a residential, nonresidential, or recreational service connection as defined in this section.

(62) "Single family residence" means a structure in which one or more persons maintain a common household. A structure is not a single family residence if it is used for an activity requiring a permit or license under one or more of the following rules:

(a) Food service, chapter 246-215 WAC;

(b) Food inspection, chapter 16-165 WAC;

(c) Residential treatment facility, chapter 246-337 WAC;

(d) Transient accommodations, chapter 246-360 WAC;

(e) ((Boarding homes)) Assisted living facility licensing rules, chapter 388-78A WAC;

(f) Minimum licensing requirements for child care centers, chapter 170-295 WAC;

(g) School-age child care center minimum licensing requirements, chapter 170-151 WAC; or

(h) Adult family home minimum licensing requirements, chapter 388-76 WAC.

(63) "Spring" means a source of water where the aquifer comes in contact with the land surface.

(64) "Surface water" means a body of water open to the atmosphere and subject to surface runoff, including captured rainfall.

(65) "WSDOT" means Washington state department of transportation.

(66) "Water right" means a permit, claim, or other authorization, on record with or accepted by the department of ecology, authorizing the beneficial use of water in accordance with all applicable state laws.

(67) "Well site inspection" means a physical inspection of the area near an existing or proposed well location, and completion of a department or health officer-approved form that identifies the suitability of the site for a public water supply well.

(1) The following undertakings shall be subject to the provisions of chapter 246-310 WAC, with the exceptions provided for in this section.

(a) The construction, development, or other establishment of a new health care facility:

(i) No new health care facility may be initiated as a health service of an existing health care facility without certificate of need approval as a new health care facility;

(ii) The provision of services by a home health agency or hospice to a county, on a regular and ongoing basis, that was not previously included in the home health agency or hospice service area shall be considered the development of a new home health agency or hospice.

(b) The sale, purchase, or lease of part or all of any existing hospital licensed under chapter 70.41 RCW or a psychiatric hospital licensed under chapter 71.12 RCW;

(c) A change in bed capacity of a health care facility increasing the total number of licensed beds or redistributing beds among acute care, nursing home care, and ((boarding home)) assisted living facility care, as defined under RCW 18.20.020, if the bed redistribution is effective for a period in excess of six months;

(d) Any new tertiary health services offered in or through a health care facility, and not offered on a regular basis by, in, or through such health care facility within the twelve-month period prior to the time the facility will offer such services:

(i) Tertiary services include the following:

(A) Specialty burn services. This is a service designed, staffed, and equipped to care for any burn patient regardless of the severity or extent of the burn. All staff and equipment necessary for any level of burn care are available;

(B) Intermediate care nursery and/or obstetric services level II. Intermediate care nursery is defined in chapter 246-318 WAC. A level II obstetric service is in an area designed, organized, equipped, and staffed to provide a full range of maternal and neonatal services for uncomplicated patients and for the majority of complicated obstetrical problems;

(C) Neonatal intensive care nursery and/or obstetric services level III. Neonatal intensive care nursery is defined in chapter 246-318 WAC. A level III obstetric service is in an area designed, organized, equipped, and staffed to provide services to the few women and infants requiring full intensive care services for the most serious type of maternal-fetal and neonatal illnesses and abnormalities. Such a service provides the coordination of care, communications, transfer, and transportation for a given region. Level III services provide leadership in preparatory and continuing education in prenatal and perinatal care and may be involved in clinical and basic research;

(D) Transplantation of specific solid organs, including, but not limited to, heart, liver, pancreas, lung, small bowel and kidney and including bone marrow. A transplantation service for each solid organ is considered a separate tertiary service;

(E) Open heart surgery and/or elective therapeutic cardiac catheterization including elective percutaneous translumenal coronary angioplasty (PTCA). Open heart surgery includes the care of patients who have surgery requiring the use of a heart lung bypass machine. Therapeutic cardiac catheterization means passage of a tube or other device into the coronary arteries or the heart chambers to improve blood flow. PTCA means the treatment of a narrowing of a coronary artery by means of inflating a balloon catheter at the site of the narrowing to dilate the artery;

(F) Inpatient physical rehabilitation services level I. Level I rehabilitation services are services for persons with usually nonreversible, multiple function impairments of a moderate-to-severe complexity resulting in major changes in the patient's lifestyle and requiring intervention by several rehabilitation disciplines. Services are multidisciplinary, including such specialists as a rehabilitation nurse; and physical, occupational, and speech therapists; and vocational counseling; and a physiatrist. The service is provided in a dedicated unit with a separate nurses station staffed by nurses with specialized training and/or experience in rehabilitation nursing. While the service may specialize (i.e., spinal cord injury, severe head trauma, etc.), the service is able to treat all persons within the designated diagnostic specialization regardless of the level of severity or complexity of the impairments and include the requirements as identified in chapter 246-976 WAC relating to level I trauma rehabilitation services;

(G) Specialized inpatient pediatric services. The service is designed, staffed, and equipped to treat complex pediatric cases for more than twenty-four hours. The service has a staff of pediatric specialists and subspecialists.

(ii) The department shall review, periodically revise, and update the list of tertiary services. The department shall change the tertiary services list following the procedures identified in WAC 246-310-035;

(iii) The offering of an inpatient tertiary health service by a health maintenance organization or combination of health maintenance organizations is subject to the provisions under chapter 246-310 WAC unless the offering is exempt under the provisions of RCW 70.38.111.

(e) Any increase in the number of dialysis stations in a kidney disease center;

(f) Any capital expenditure in excess of the expenditure minimum for the construction, renovation, or alteration of a nursing home. However, a capital expenditure, solely for any one or more of the following, which does not substantially affect patient charges, is not subject to certificate of need review:

(i) Communications and parking facilities;

(ii) Mechanical, electrical, ventilation, heating, and air conditioning systems;

(iii) Energy conservation systems;

(iv) Repairs to, or the correction of, deficiencies in existing physical plant facilities necessary to maintain state licensure, however, other additional repairs, remodeling, or replacement projects that are not related to one or more deficiency citations and are not necessary to maintain state licensure are not exempt from certificate of need review except as otherwise permitted by (f)(vi) of this subsection or RCW 70.38.115(13);

(v) Acquisition of equipment, including data processing equipment, not for use in the direct provision of health services;

(vi) Construction or renovation at an existing nursing home involving physical plant facilities, including administrative, dining, kitchen, laundry, and therapy areas, or support facilities, by an existing licensee who has operated the beds for at least one year;

(vii) Acquisition of land;

(viii) Refinancing of existing debt; and

(ix) Nursing home project granted a replacement authorization under WAC 246-310-044.

(g) Any expenditure for the construction, renovation, or alteration of a nursing home or change in nursing home services in excess of the expenditure minimum made in preparation for any undertaking subject to the provisions under chapter 246-310 WAC and any arrangement or commitment made for financing such undertaking;

(h) No person may divide a project in order to avoid review requirements under any of the thresholds specified under this section; and

(i) The department may issue certificates of need authorizing only predevelopment expenditures, without authorizing any subsequent undertaking for which the predevelopment expenditures are made.

(2) No person shall engage in any undertaking subject to certificate of need review unless:

(a) A certificate of need authorizing such undertaking is issued and remains valid; or

(b) An exemption is granted in accordance with the provisions of this chapter.

(3) If a nursing home or portion of a nursing home constructed or established under the authority of a certificate of need granted from the pool of nursing home beds for ethnic minorities according to the provisions of WAC 246-310-135 is sold or leased within ten years to a party not eligible for an award of such beds under the provisions of WAC 246-310-136(2):

(a) The purchaser or lessee may not operate those beds as nursing home beds without first obtaining a certificate of need for new beds; and

(b) The beds that were awarded from the special pool shall be returned to that pool.

(1) Projects for which the department may establish concurrent review schedules are identified in RCW 70.38.115(7). An annual concurrent review has been scheduled for competing projects proposing:

(a) New nursing homes, not using bed allocations banked under the provisions of RCW 70.38.115(13);

(b) Nursing home bed additions, not using bed allocations banked under the provisions of RCW 70.38.115(13);

(c) The redistribution of beds from the following facility and service categories to nursing home beds:

(i) Acute care((,));

(ii) ((Boarding home,)) Assisted living facility; or

(iii) Intermediate care for the mentally retarded.

(2) Procedures for the concurrent review process shall be as follows:

(a) Submittal of initial applications.

(i) Each applicant shall submit one original and one copy of the application to the department.

(ii) Each applicant if requested in writing shall provide a copy of his or her application to the applicant of each other competing application.

(b) Screening of the initial applications.

(i) The department shall screen each initial application during the screening period of the applicable concurrent review cycle schedule.

(ii) The screening period shall begin on the first working day following the last day of the initial application submittal period for the applicable concurrent review cycle schedule.

(iii) The department by, the end of the screening period of the applicable concurrent review cycle schedule, shall send a written request for supplemental information to each applicant.

(iv) Each applicant, by the end of the final application submittal period, shall respond to the department's written request for supplemental information in one of the following ways:

(A) Submitting the requested written supplemental information((,)); or

(B) Submitting a written request that the incomplete application be reviewed without supplemental information.

(c) Reviewing of final applications.

(i) The department shall commence the review of competing applications on the date prescribed for the applicable concurrent review cycle schedule.

(ii) The total number of days in the public comment and final review periods shall not exceed one hundred and thirty-five, unless extended in accordance with subsection (2)(d) of this section.

(iii) The public comment period shall be a maximum of ninety days from the beginning of the review period, unless the public comment period is extended in accordance with subsection (2)(d) of this section. The first sixty days of the public comment period is reserved for receiving public comment and conducting a public hearing, if requested. The remaining thirty days shall be reserved for the applicant or applicants to provide rebuttal statements to written or oral statements submitted during the first sixty-day period. Any affected person shall also be provided the opportunity to provide rebuttal statements to written or oral statements submitted during the first sixty-day period.

(iv) The department shall conclude its final review and the secretary's designee shall take action on a certificate of need application within forty-five days after the end of the public comment period, unless extended in accordance with subsection (2)(d) of this section.

(d) Extending review of final applications.

(i) The public comment period shall be extended in accordance with the provisions of WAC 246-310-100.

(ii) The final review period may be extended by the department under the following provisions:

(A) The department informs each applicant of the competing applications of the existence of an unresolved pivotal issue.

(B) The department may make a written request for additional information from one or more of the applicants of the competing applications.

(C) The department shall specify in the written request a deadline for receipt of written responses.

(D) Each applicant receiving such written request may provide a written response within the specified deadline.

(E) The department may extend the final review period for all competing applications up to thirty days after the receipt of the last response to the department's request for additional information or after the specified deadline, whichever occurs first.

(1) The department shall review concurrently during review cycles established under subsection (5) of this section the following:

(a) New nursing homes beds not using bed allocations banked under the provisions of RCW 70.38.115(13);

(b) Redistribution of beds from the following facility or service categories to skilled nursing care beds:

(i) Acute care((,));

(ii) ((Boarding home)) Assisted living facility care.

(2) Undertakings by continuing care retirement communities (CCRCs), as defined in this section which do not propose or are not operating within a transition period as defined in this section during development, and which meet the following conditions, shall be reviewed under the regular review process per WAC 246-310-160:

(a) The number of nursing home beds requested in a single undertaking shall not exceed sixty; and

(b) After project completion, the number of nursing home beds, including those with which the CCRC contracts, shall not exceed one bed for each four independent living units within the CCRC. In computing this ratio, only independent living units of the CCRC already existing, and/or scheduled for completion at the same time as the proposed nursing home beds under the same financial feasibility plan, shall be counted.

(3) The annual nursing home concurrent review consists of the following cycles:

(a) One of the annual cycles is reserved for the review of competing applications submitted by or on behalf of:

(i) CCRCs applying for nursing home beds available from the statewide CCRC allotment as described in WAC 246-310-380(5); and

(ii) CCRCs which propose or are operating within a transition period during development and are not applying for nursing home beds available from any nursing home planning area.

(b) Two other cycles are established for review of competing applications for nursing home beds needed. The nursing home planning areas are divided into two separate groups.

(4) The department shall use the following nursing home concurrent review application filing procedures:

(a) Each applicant shall:

(i) File the required number of copies of each application as specified in the application information requirements((,)); and

(ii) Mail or deliver the application so that the department receives it no later than the last day for initial application receipt as prescribed in the schedule for that concurrent review cycle.

(b) The department shall:

(i) Only review applications for which a letter of intent, as described in WAC 246-310-080, was mailed or delivered to the department before the last day for receipt of letters of intent as indicated below;

(ii) Begin screening all applications received during the initial application period on the first working day following the close of that period; and

(iii) Return to the applicant any application received after the last day of the initial application receipt period.

(5) The schedules for the annual nursing home bed concurrent review cycles shall be as follows:

(a) For those applications described in subsection (3)(a) of this section, the concurrent review cycle schedule shall be as follows:

(i) Period for receipt of letters of intent shall begin on the first working day of June and end on the first working day of July((,));

(ii) Period for receipt of initial applications shall begin on the first working day of July and end on the first working day of August((,));

(iii) End of initial application completeness screening period is the first working day of September((,));

(iv) End of final application receipt period is the first working day of October((,)); and

(v) Beginning of concurrent review period is October 16 or first working day after that date.

(b) For competing applications submitted for nursing home beds available for the Chelan/Douglas, Clallam, Clark/Skamania, Cowlitz, Grant, Grays Harbor, Island, Jefferson, King, Kittitas, Klickitat, Okanogan, Pacific, San Juan, Skagit, Spokane, and Yakima nursing home planning areas, the concurrent review cycle schedule shall be as follows:

(i) Period for receipt of letters of intent shall begin on the first working day of July and end on the first working day of August((,));

(ii) Period for receipt of initial applications shall begin on the first working day of August and end on the first working day of September((,));

(iii) End of initial application completeness screening period is the first working day of October((,));

(iv) End of final application receipt period is the first working day of November((,)); and

(v) Beginning of concurrent review period is November 16 or first working day after that date.

(c) For competing applications submitted for nursing home beds available for the Adams, Asotin, Benton, Columbia, Ferry, Franklin, Garfield, Kitsap, Lewis, Lincoln, Mason, Pend Oreille, Pierce, Snohomish, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, and Whitman nursing home planning areas, the concurrent review cycle schedule shall be as follows:

(i) Period for receipt of letters of intent shall begin on the first working day of August and end on the first working day of September((,));

(ii) Period for receipt of initial applications shall begin on the first working day of September and end on the first working day of October((,));

(iii) End of initial application completeness screening period is the first working day of November((,));

(iv) End of final application receipt period is the first working day of December((,)); and

(v) Beginning of concurrent review period is December 16 or first working day after that date.

The determination of need for any project shall be based on the following criteria, except these criteria will not justify exceeding the limitation on increases of nursing home beds provided in WAC 246-310-810.

(1) The population served or to be served has need for the project and other services and facilities of the type proposed are not or will not be sufficiently available or accessible to meet that need. The assessment of the conformance of a project with this criterion shall include, but need not be limited to, consideration of the following:

(a) In the case of a reduction, relocation, or elimination of a service, the need the population presently served has for the service, the extent to which the need will be met adequately by the proposed relocation or by alternative arrangements, and the effect of the reduction, elimination, or relocation of the service on the ability of low-income persons, racial and ethnic minorities, women, handicapped persons, and other underserved groups and the elderly to obtain needed health care;

(b) In the case of health services or facilities proposed to be provided, the efficiency and appropriateness of the use of existing services and facilities similar to those proposed;

(c) In the case of an application by an osteopathic or allopathic facility the need for and the availability in the community of services and facilities for osteopathic and allopathic physicians and their patients, and the impact on existing and proposed institutional training programs for doctors of osteopathy and medicine at the student, internship, and residency training levels; and

(d) In the case of a project not involving health services, the contribution of the project toward overall management and support of such services.

(2) All residents of the service area, including low-income persons, racial and ethnic minorities, women, handicapped persons, and other underserved groups and the elderly are likely to have adequate access to the proposed health service or services. The assessment of the conformance of a project with this criterion shall include, but not be limited to, consideration as to whether the proposed services makes a contribution toward meeting the health-related needs of members of medically underserved groups which have traditionally experienced difficulties in obtaining equal access to health services, particularly those needs identified in the applicable regional health plan, annual implementation plan, and state health plan as deserving of priority. Such consideration shall include an assessment of the following:

(a) The extent to which medically underserved populations currently use the applicant's services in comparison to the percentage of the population in the applicant's service area which is medically underserved, and the extent to which medically underserved populations are expected to use the proposed services if approved;

(b) The past performance of the applicant in meeting obligations, if any, under any applicable federal regulations requiring provision of uncompensated care, community service, or access by minorities and handicapped persons to programs receiving federal financial assistance (including the existence of any unresolved civil rights access complaints against the applicant);

(c) The extent to which medicare, medicaid, and medically indigent patients are served by the applicant; and

(d) The extent to which the applicant offers a range of means by which a person will have access to its services (e.g., outpatient services, admission by house staff, admission by personal physician).

(3) The applicant has substantiated any of the following special needs and circumstances the proposed project is to serve.

(a) The special needs and circumstances of entities such as medical and other health professions schools, multidisciplinary clinics and specialty centers providing a substantial portion of their services or resources, or both, to individuals not residing in the health service areas in which the entities are located or in adjacent health service areas.

(b) The special needs and circumstances of biomedical and behavioral research projects designed to meet a national need and for which local conditions offer special advantages.

(c) The special needs and circumstances of osteopathic hospitals and nonallopathic services.

(4) The project will not have an adverse effect on health professional schools and training programs. The assessment of the conformance of a project with this criterion shall include consideration of:

(a) The effect of the means proposed for the delivery of health services on the clinical needs of health professional training programs in the area in which the services are to be provided; and

(b) If proposed health services are to be available in a limited number of facilities, the extent to which the health professions schools serving the area will have access to the services for training purposes.

(5) The project is needed to meet the special needs and circumstances of enrolled members or reasonably anticipated new members of a health maintenance organization or proposed health maintenance organization and the services proposed are not available from nonhealth maintenance organization providers or other health maintenance organizations in a reasonable and cost-effective manner consistent with the basic method of operation of the health maintenance organization or proposed health maintenance organization. In assessing the availability of health services from these providers, the department shall consider only whether the services from these providers:

(a) Would be available under a contract of at least five years' duration;

(b) Would be available and conveniently accessible through physicians and other health professionals associated with the health maintenance organization or proposed health maintenance organization (for example - whether physicians associated with the health maintenance organization have or will have full staff privileges at a nonhealth maintenance organization hospital);

(c) Would cost no more than if the services were provided by the health maintenance organization or proposed health maintenance organization; and

(d) Would be available in a manner administratively feasible to the health maintenance organization or proposed health maintenance organization.

(6) For nursing home projects including distinct part long-term care units located in a hospital and licensed under chapter 70.41 RCW, the following criterion shall apply in addition to those found in WAC 246-310-380.

(a) In the case of an application for new nursing home beds, the department shall find no need if the state is at or above the statewide estimated bed need, except as referenced in WAC 246-310-380(5). However, the department may put under review and subsequently approve or deny applications that propose to redistribute nursing home beds to a planning area under the established ratio. The department may also consider applications that propose to add beds in planning areas under the established ratio using beds banked and for which the need for the beds is not deemed met, under the provisions of RCW 70.38.115(13). For the above projects, the need for such projects, shall, in part, be determined using individual planning area estimated bed need numbers.

(b) If the state is below the statewide estimated bed need or for those projects referenced above, the department shall determine the need for nursing home beds, including distinct part long-term care units located in a hospital licensed under chapter 70.41 RCW, based on:

(i) The availability of other nursing home beds in the planning area to be served; and

(ii) The availability of other services in the planning area to be served. Other services to be considered include, but are not limited to: Assisted living facilities (as defined in chapter ((74.39A)) 18.20 RCW); ((boarding home (as defined in chapter 18.20 RCW);)) enhanced adult residential care (as defined in chapter 74.39A RCW); adult residential care (as defined in chapter 74.39A RCW); adult family homes (as defined in chapter 70.128 RCW); hospice, home health and home care (as defined in chapter 70.127 RCW); personal care services (as defined in chapter 74.09 RCW); and home and community services provided under the community options program entry system waiver (as referenced in chapter 74.39A RCW). The availability of other services shall be based on data which demonstrates that the other services are capable of adequately meeting the needs of the population proposed to be served by the applicant. The following variables should be evaluated in this analysis when available:

(A) The current capacity of nursing homes and other long-term care services;

(B) The occupancy rates of nursing homes and other long-term care services over the previous two-year period;

(C) Proposed residential care projects scheduled to be completed within the same period of time indicated on the nursing home certificate of need application; and

(D) The ability of the other long-term care services to serve all people regardless of payor source.

(1) The department shall use the following rules in conjunction with the certificate of need review criteria contained in WAC 246-310-210(1) for applications proposing the following:

(a) Construction, development, or other establishment of a new nursing home;

(b) Increase in the licensed bed capacity of a nursing home or a hospital long-term care unit;

(c) Change in license category of beds from the following to nursing home or hospital long-term care unit beds:

(i) Acute care((,)); or

(ii) ((Boarding home)) Assisted living facility care;

(2) The department shall comply with the following time schedule for developing bed need projections:

(a) By the last working day in January of each year, the department shall recalculate the estimated bed projection for each ((planning-area)) planning area.

(b) By the last working day in January of each year, the department shall provide the aging and adult services administration of the department of social and health services with the estimated bed need for each ((planning-area)) planning area, pending the department's decisions on applications submitted during the previous year's nursing home concurrent review cycles.

(c) By the last working day in January of each year, the department shall rank order ((planning-areas)) planning areas from lowest to highest by the projected current supply ratio.

(d) By the first working day of June of each year, the department shall calculate the net estimated bed need for each ((planning-area)) planning area.

(3) The estimated bed projections for the projection period, listed by planning area will be updated annually and distributed to interested parties. When a ((planning-area's)) planning area's estimated bed projection is less than the ((planning-area's)) planning area's bed supply as defined by WAC 246-310-350(4), no beds can be added until the statewide established ratio is reached, except as allowed in this section.

(4) The department shall limit to three hundred the total number of nursing home beds approved for all CCRCs which propose or are operating within a transition period.

(a) These three hundred beds available for CCRCs during transition periods shall be in addition to the net nursing home beds needed in all of the ((planning-areas)) planning areas.

(b) All nursing home beds approved for CCRCs which propose or are operating within a transition period shall be counted as beds within this three hundred bed limitation unless and until the CCRC fully complies with all provisions of the CCRCs performance standards.

(5) The department shall not issue certificates of need approving more than the net estimated bed need indicated for a given ((planning-area)) planning area, unless:

(a) The department finds such additional beds are needed to be located reasonably close to the people they serve; and

(b) The department explains such approval in writing.

The definitions in this section apply throughout this chapter unless the context clearly indicates otherwise:

(1) "Certified" means facilities that must be certified to participate in medicare or medicaid programs and meet physical environment minimum standards as required in the Code of Federal Regulations.

(2) "Change of approved use only" means a change in the function of a room that does not alter the physical elements.

(3) "Finishes" includes, but is not limited to, products such as carpet, vinyl wall covering, wall paper, exterior siding, landscaping, or paneling applied to an existing surface as the exposed surface.

(4) "Licensed" means facilities licensed from the state department of health (DOH) or state department of social and health services (DSHS) that must obtain approval from construction review services before licensure activity.

(5) "Permit" means a recommendation to the licensing or certifying authority from construction review services indicating that a facility meets the physical environment rules and the plan review process is complete.

(6) "Program" means the Washington state department of health, construction review services.

(7) "Project" means a change to a facility including new construction, replacement, alterations, additions, expansions, conversions, change of approved use, improvements, remodeling, renovating, and upgrading of the following types of facilities:

(a) "Ambulatory surgery center" defined as a facility that is required to be certified for participation in medicare or medicaid or ambulatory surgical facilities licensed under chapters 70.230 RCW and 246-330 WAC;

(b) "Birthing centers" (formerly maternity homes) and "childbirth centers" licensed under chapters 18.46 RCW and 246-329 WAC;

(c) "((Boarding homes)) Assisted living facilities" licensed under chapters 18.20 RCW and 388-78A WAC;

(d) "Correctional facilities" as defined under RCW 43.70.130(8);

(e) "Hospice care center" licensed under chapters 70.127 RCW and 246-335 WAC;

(f) "Hospitals" licensed under chapters 70.41 RCW and 246-320 WAC;

(g) "Nursing homes" licensed under chapters 18.51 RCW and 388-97 WAC;

(h) "Private alcohol and chemical dependency hospitals" licensed under chapters 71.12 RCW and 246-324 WAC;

(i) "Private psychiatric and alcoholism hospitals" licensed under chapters 71.12 RCW and 246-322 WAC;

(j) "Residential treatment facilities" licensed under chapters 71.12 RCW and 246-337 WAC; and

(k) "Temporary worker housing" licensed under chapters 70.114A RCW and 246-358 WAC.

(8) "Project cost" means all costs directly associated with the project, initially estimated and corrected by certification to the date of completion of the project and including all fixed and installed clinical equipment in the project and contractor supervision, inspection, and overhead. This cost does not include:

(a) Taxes;

(b) Architectural or engineering fees; and

(c) Land acquisition fees.

(9) "Project sponsor" means the person, persons or organization, planning and contracting for the design and construction of facilities, generally the owner or the owner's representative.

(10) "Technical assistance" means assistance provided by the program to facilities either at the program offices or at the project location including:

(a) Information on the laws, rules and compliance methods and technologies applicable to the regulations;

(b) Information on methods to avoid compliance problems;

(c) Assistance in applying for permits, licensure or certification;

(d) Information on the mission, goals, and objectives of the program; and

(e) Assistance to parties constructing projects not required to be licensed or certified and voluntarily wish to comply with rules or guidelines in the interest of safety or best practices.

(11) "Value of existing construction" means the value of an existing building or portion thereof at the time of project submission, based on the current market value of the structure as documented by the project sponsor, or, as determined by assigning a cost per square foot value.

For the purposes of this chapter and chapter 70.41 RCW, the following words and phrases will have the following meanings unless the context clearly indicates otherwise:

(1) "Abuse" means injury or sexual abuse of a patient indicating the health, welfare, and safety of the patient is harmed:

(a) "Physical abuse" means acts or incidents which may result in bodily injury or death.

(b) "Emotional abuse" means verbal behavior, harassment, or other actions which may result in emotional or behavioral stress or injury.

(2) "Agent," when referring to a medical order or procedure, means any power, principle, or substance, whether physical, chemical, or biological, capable of producing an effect upon the human body.

(3) "Alcoholism" means a disease, characterized by a dependency on alcoholic beverages, loss of control over the amount and circumstances of use, symptoms of tolerance, physiological or psychological withdrawal, or both, if use is reduced or discontinued, and impairment of health or disruption of social or economic functioning.

(4) "Alteration" means any change, addition, or modification to an existing hospital or a portion of an existing hospital.

"Minor alteration" means renovation that does not require an increase in capacity to structural, mechanical or electrical systems, which does not affect fire and life safety, and which does not add beds or facilities in addition to that for which the hospital is currently licensed.

(5) "Assessment" means the:

(a) Systematic collection and review of patient-specific data;

(b) A process for obtaining appropriate and necessary information about individuals seeking entry into a health care setting or service; and

(c) Information used to match an individual with an appropriate setting or intervention. The assessment is based on the patient's diagnosis, care setting, desire for care, response to any previous treatment, consent to treatment, and education needs.

(6) "Authentication" means the process used to verify an entry is complete, accurate, and final.

(7) "Bed, bed space or bassinet" means the physical environment and equipment (both movable and stationary) designed and used for twenty-four hour or more care of a patient including level 2 and 3 bassinets. This does not include stretchers, exam tables, operating tables, well baby bassinets, labor bed, and labor-delivery-recovery beds.

(8) "Child" means an individual under the age of eighteen years.

(9) "Clinical evidence" means the same as original clinical evidence used in diagnosing a patient's condition or assessing a clinical course and includes, but is not limited to:

(a) X-ray films;

(b) Digital records;

(c) Laboratory slides;

(d) Tissue specimens; and

(e) Medical photographs.

(10) "Critical care unit or service" means the specialized medical and nursing care provided to patients facing an immediate life-threatening illness or injury. Care is provided by multidisciplinary teams of highly skilled physicians, nurses, pharmacists or other health professionals who interpret complex therapeutic and diagnostic information and have access to sophisticated equipment.

(11) "Department" means the Washington state department of health.

(12) "Dietitian" means an individual meeting the eligibility requirements for active membership in the American Dietetic Association described in Directory of Dietetic Programs Accredited and Approved, American Dietetic Association, edition 100, 1980.

(13) "Double-checking" means verifying patient identity, agent to be administered, route, quantity, rate, time, and interval of administration by two persons.

(14) "Drugs" as defined in RCW 18.64.011(3) means:

(a) Articles recognized in the official U.S. Pharmacopoeia or the official Homeopathic Pharmacopoeia of the United States;

(b) Substances intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals;

(c) Substances (other than food) intended to affect the structure or any function of the body of man or other animals; or

(d) Substances intended for use as a component of any substances specified in (a), (b), or (c) of this subsection but not including devices or component parts or accessories.

(15) "Electrical receptacle outlet" means an outlet where one or more electrical receptacles are installed.

(16) "Emergency care to victims of sexual assault" means medical examinations, procedures, and services provided by a hospital emergency room to a victim of sexual assault following an alleged sexual assault.

(17) "Emergency contraception" means any health care treatment approved by the Food and Drug Administration that prevents pregnancy, including, but not limited to, administering two increased doses of certain oral contraceptive pills within seventy-two hours of sexual contact.

(18) "Emergency department" means the area of a hospital where unscheduled medical or surgical care is provided to patients who need care.

(19) "Emergency room" means a space where emergency services are delivered and set apart by floor-to-ceiling partitions on all sides with proper access to an exit access and with all openings provided with doors or windows.

(20) "Emergency medical condition" means a condition manifesting itself by acute symptoms of severity (including severe pain, symptoms of mental disorder, or symptoms of substance abuse) that absent immediate medical attention could result in:

(a) Placing the health of an individual in serious jeopardy;

(b) Serious impairment to bodily functions;

(c) Serious dysfunction of a bodily organ or part; or

(d) With respect to a pregnant woman who is having contractions:

(i) That there is inadequate time to effect a safe transfer to another hospital before delivery; or

(ii) That the transfer may pose a threat to the health or safety of the woman or the unborn child.

(21) "Emergency services" means health care services medically necessary to evaluate and treat a medical condition that manifests itself by the acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, and that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction of an organ or part of the body, or would place the person's health, or in the case of a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

(22) "Emergency triage" means the immediate patient assessment by a registered nurse, physician, or physician assistant to determine the nature and urgency of the person's medical need for treatment.

(23) "Family" means individuals designated by a patient who need not be relatives.

(24) "General hospital" means a hospital that provides general acute care services, including emergency services.

(25) "Governing authority/body" means the person or persons responsible for establishing the purposes and policies of the hospital.

(26) "High-risk infant" means an infant, regardless of age, whose existence is compromised, prenatal, natal, or postnatal factors needing special medical or nursing care.

(27) "Hospital" means any institution, place, building, or agency providing accommodations, facilities, and services over a continuous period of twenty-four hours or more, for observation, diagnosis, or care of two or more individuals not related to the operator who are suffering from illness, injury, deformity, or abnormality, or from any other condition for which obstetrical, medical, or surgical services would be appropriate for care or diagnosis. "Hospital" as used in this chapter does not include:

(a) Hospice care centers which come within the scope of chapter 70.127 RCW;

(b) Hotels, or similar places, furnishing only food and lodging, or simply domiciliary care;

(c) Clinics or physicians' offices, where patients are not regularly kept as bed patients for twenty-four hours or more;

(d) Nursing homes, as defined in and which come within the scope of chapter 18.51 RCW;

(e) Birthing centers, which come within the scope of chapter 18.46 RCW;

(f) Psychiatric or alcoholism hospitals, which come within the scope of chapter 71.12 RCW; nor

(g) Any other hospital or institution specifically intended for use in the diagnosis and care of those suffering from mental illness, mental retardation, convulsive disorders, or other abnormal mental conditions((; (h))).

Furthermore, nothing in this chapter will be construed as authorizing the supervision, regulation, or control of the remedial care or treatment of residents or patients in any hospital conducted for those who rely primarily upon treatment by prayer or spiritual means in accordance with the creed or tenets of any well-recognized church or religious denominations.

(28) "Individualized treatment plan" means a written and/or electronically recorded statement of care planned for a patient based upon assessment of the patient's developmental, biological, psychological, and social strengths and problems, and including:

(a) Treatment goals, with stipulated time frames;

(b) Specific services to be utilized;

(c) Designation of individuals responsible for specific service to be provided;

(d) Discharge criteria with estimated time frames; and

(e) Participation of the patient and the patient's designee as appropriate.

(29) "Infant" means an individual not more than twelve months old.

(30) "Invasive procedure" means a procedure involving puncture or incision of the skin or insertion of an instrument or foreign material into the body including, but not limited to, percutaneous aspirations, biopsies, cardiac and vascular catheterizations, endoscopies, angioplasties, and implantations. Excluded are venipuncture and intravenous therapy.

(31) "Licensed practical nurse" means an individual licensed under provisions of chapter 18.79 RCW.

(32) "Maintenance" means the work of keeping something in safe, workable or suitable condition.

(33) "Medical equipment" means equipment used in a patient care environment to support patient treatment and diagnosis.

(34) "Medical staff" means physicians and other practitioners appointed by the governing authority.

(35) "Medication" means any substance, other than food or devices, intended for use in diagnosing, curing, mitigating, treating, or preventing disease.

(36) "Multidisciplinary treatment team" means a group of individuals from various disciplines and clinical services who assess, plan, implement, and evaluate treatment for patients.

(37) "Neglect" means mistreatment or maltreatment; a disregard of consequences or magnitude constituting a clear and present danger to an individual patient's health, welfare, and safety.

(a) "Physical neglect" means physical or material deprivation, such as lack of medical care, lack of supervision, inadequate food, clothing, or cleanliness.

(b) "Emotional neglect" means acts such as rejection, lack of stimulation, or other acts which may result in emotional or behavioral problems, physical manifestations, and disorders.

(38) "Neonate" means a newly born infant under twenty-eight days of age.

(39) "Neonatologist" means a pediatrician who is board certified in neonatal-perinatal medicine or board eligible in neonatal-perinatal medicine, provided the period of eligibility does not exceed three years, as defined and described in Directory of Residency Training Programs by the Accreditation Council for Graduate Medical Education, American Medical Association, 1998 or the American Osteopathic Association Yearbook and Directory, 1998.

(40) "New construction" means any of the following:

(a) New facilities to be licensed as a hospital;

(b) Renovation; or

(c) Alteration.

(41) "Nonambulatory" means an individual physically or mentally unable to walk or traverse a normal path to safety without the physical assistance of another.

(42) "Nursing personnel" means registered nurses, licensed practical nurses, and unlicensed assistive nursing personnel providing direct patient care.

(43) "Operating room (OR)" means a room intended for invasive and noninvasive surgical procedures.

(44) "Patient" means an individual receiving (or having received) preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative health services.

(a) "Inpatient" means services that require admission to a hospital for twenty-four hours or more.

(b) "Outpatient" means services that do not require admission to a hospital for twenty-four hours or more.

(45) "Patient care areas" means all areas of the hospital where direct patient care is delivered and where patient diagnostic or treatment procedures are performed.

(46) "Patient care unit or area" means a physical space of the hospital including rooms or areas containing beds or bed spaces, with available support ancillary, administrative, and services for patient.

(47) "Person" means any individual, firm, partnership, corporation, company, association, or joint stock association, and the legal successor thereof.

(48) "Pharmacist" means an individual licensed by the state board of pharmacy chapter 18.64 RCW.

(49) "Pharmacy" means every place properly licensed by the board of pharmacy where the practice of pharmacy is conducted.

(50) "Physician" means an individual licensed under chapter 18.71 RCW, Physicians, chapter 18.22 RCW, Podiatric medicine and surgery, or chapter 18.57 RCW, Osteopathy—Osteopathic medicine and surgery.

(51) "Prescription" means an order for drugs or devices issued by a practitioner authorized by law or rule in the state of Washington for a legitimate medical purpose.

(52) "Procedure" means a particular course of action to relieve pain, diagnose, cure, improve, or treat a patient's condition.

(53) "Protocols" and "standing order" mean written or electronically recorded descriptions of actions and interventions for implementation by designated hospital staff under defined circumstances under hospital policy and procedure.

(54) "Psychiatric service" means the treatment of patients pertinent to a psychiatric diagnosis.

(55) "Recovery unit" means a physical area for the segregation, concentration, and close or continuous nursing observation of patients for less than twenty-four hours immediately following anesthesia, obstetrical delivery, surgery, or other diagnostic or treatment procedures.

(56) "Registered nurse" means an individual licensed under chapter 18.79 RCW.

(57) "Restraint" means any method used to prevent or limit free body movement including, but not limited to, involuntary confinement, a physical or mechanical device, or a drug given not required to treat a patient's symptoms.

(58) "Room" means a space set apart by floor-to-ceiling partitions on all sides with proper access to a corridor and with all openings provided with doors or windows.

(59) "Seclusion" means the involuntary confinement of a patient in a room or area where the patient is physically prevented from leaving.

(60) "Seclusion room" means a secure room designed and organized for temporary placement, care, and observation of one patient with minimal sensory stimuli, maximum security and protection, and visual and auditory observation by authorized personnel and staff. Doors of seclusion rooms have staff-controlled locks.

(61) "Sexual assault" means one or more of the following:

(a) Rape or rape of a child;

(b) Assault with intent to commit rape or rape of a child;

(c) Incest or indecent liberties;

(d) Child molestation;

(e) Sexual misconduct with a minor;

(f) Custodial sexual misconduct;

(g) Crimes with a sexual motivation; or

(h) An attempt to commit any of the items in (a) through (g) of this subsection.

(62) "Severe pain" means a level of pain reported by a patient of 8 or higher based on a 10 point scale with 1 being the least and 10 being the most pain.

(63) "Specialty hospital" means a subclass of hospital that is primarily or exclusively engaged in the care and treatment of one of the following categories:

(a) Patients with a cardiac condition;

(b) Patients with an orthopedic condition;

(c) Patients receiving a surgical procedure; and

(d) Any other specialized category of services that the secretary of health and human services designates as a specialty hospital.

(64) "Staff" means paid employees, leased or contracted persons, students, and volunteers.

(65) "Surgical procedure" means any manual or operative procedure performed upon the body of a living human being for the purpose of preserving health, diagnosing or curing disease, repairing injury, correcting deformity or defect, prolonging life or relieving suffering, and involving any of the following:

(a) Incision, excision, or curettage of tissue;

(b) Suture or repair of tissue including a closed as well as an open reduction of a fracture;

(c) Extraction of tissue including the premature extraction of the products of conception from the uterus; or

(d) An endoscopic examination.

(66) "Surrogate decision-maker" means an individual appointed to act on behalf of another when an individual is without capacity as defined in RCW 7.70.065 or has given permission.

(67) "Transfer agreement" means a written agreement providing an effective process for the transfer of a patient requiring emergency services to a general hospital providing emergency services and for continuity of care for that patient.

(68) "Treatment" means the care and management of a patient to combat, improve, or prevent a disease, disorder, or injury, and may be:

(a) Pharmacologic, surgical, or supportive;

(b) Specific for a disorder; or

(c) Symptomatic to relieve symptoms without effecting a cure.

(69) "Unlicensed assistive personnel (UAP)" means individuals trained to function in an assistive role to nurses in the provision of patient care, as delegated by and under the supervision of the registered nurse. Typical activities performed by unlicensed assistive personnel include, but are not limited to: Taking vital signs; bathing, feeding, or dressing patients; assisting patient with transfer, ambulation, or toileting. Definition includes: Nursing assistants; orderlies; patient care technicians/assistants; and graduate nurses (not yet licensed) who have completed unit orientation. Definition excludes: Unit secretaries or clerks; monitor technicians; therapy assistants; student nurses fulfilling educational requirements; and sitters who are not providing typical UAP activities.

(70) "Victim of sexual assault" means a person is alleged to have been sexually assaulted and who presents as a patient.

(71) "Vulnerable adult" means, as defined in chapter 74.34 RCW, a person sixty years of age or older who lacks the functional, physical, or mental ability to care for him or herself; an adult with a developmental disability under RCW 71A.10.020; an adult with a legal guardian under chapter 11.88 RCW; an adult living in a long-term care facility (an adult family home, ((boarding home)) assisted living facility or nursing home); an adult living in their own or a family's home receiving services from an agency or contracted individual provider; or an adult self-directing their care under RCW 74.39.050. For the purposes of requesting background checks pursuant to RCW 43.43.832, it shall also include adults of any age who lack the functional, mental, or physical ability to care for themselves. For the purposes of this chapter, it shall also include hospitalized adults.

(72) "Well-being" means free from actual or potential harm, abuse, neglect, unintended injury, death, serious disability or illness.