DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Aging and Long-Term Support Administration)

(1) WAC 388-71-0702 through 388-71-0776 ((contain)) contains the eligibility requirements for ((medicaid-funded)) COPES waiver and roads to community living (RCL) demonstration funded adult day care and adult day health services. These rules also contain the requirements that apply to adult day care or adult day health centers that contract with the department, an area agency on aging, or other department designee to provide ((medicaid)) COPES waiver and RCL services to department clients. Nothing in these rules may be construed as requiring the department, area agency on aging, or other designee to contract with an adult day care or day health center.

(2) An adult day services program is a community-based program designed to meet the needs of adults with impairments through individual plans of care. This type of structured, comprehensive, nonresidential program provides a variety of health, social, and related support services in a protective setting. By supporting families and caregivers, ((an adult day services program enables the person)) the goals are:

(i) To provide the opportunity for the participant to live in ((the)) their community((.));

An adult day services program ((assesses)) evaluates the needs of the ((persons)) participant served and offers services to meet those needs and enhance their quality of life. The ((persons)) participants served attend on a planned basis. The centers evaluate the potential participants to determine if they are able to communicate with each participant in order to meet their identified need/s. Nothing in this generic description ((of adult day services)) may be construed to modify the specific services or eligibility requirements referenced in the definition of adult day care and adult day health.

(3) The following definitions apply under WAC 388-71-0702 through 388-71-0774:

(a) "Adult day care" (ADC) means the services under WAC 388-71-0704 that are provided to clients who meet the eligibility requirement under WAC 388-71-0708.

(b) "Adult day center" means an adult day care or adult day health center. A day care or day health center for purposes of these rules is a center operating in a specific location, whether or not the center's owner also operates adult day centers in other locations.

(c) "Adult day health" (ADH) means the ADC services and the skilled care services listed under WAC 388-71-0706 that are provided to clients who meet the eligibility requirements under WAC 388-71-0710.

(d) "Adult day services" is a generic term referring to adult day care and adult day health services.

(e) "Authorizing Practitioner" means a physician, osteopath, nurse practitioner and physician assistant who has the licensed ability to write medical orders for skilled care interventions requiring a practitioner order.

(g) "Client" means an applicant for or recipient of ((medicaid-)) COPES waiver or RCL reimbursed adult day services.

(((f))) (h) "Direct Care Staff" are the staff in an adult day center that is interacting with participants by providing care, services, and guidance.

(m) "Participant" means clients and other persons receiving adult day services at an adult day center.

Adult day care is a supervised ((daytime)) non-residential program providing ((core)) services as defined in WAC 388-106-0800. ((Core services)) Services are appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's ((physician)) authorizing practitioner. The adult day care center must offer and provide on-site the following ((core)) services. These ((core)) services must meet the level of care needed by the client as assessed by the department case manager for waiver funded clients and do not exceed the scope of services that the adult day care center is able to provide.

(1) Assistance with activities of daily living:

(a) Locomotion outside of room, locomotion in room, ((walk)) walks in room;

(b) Body care;

(c) Eating;

(d) Repositioning;

(e) Medication management that does not require a licensed nurse;

(f) Transfer;

(g) Toileting;

(h) Personal hygiene at a level that ensures client safety while in attendance at the program; and

(i) Bathing at a level that ensures client safety and comfort while in attendance at the program.

(2) Social services on a consultation basis, which may include:

(a) Referrals to other providers for services not within the scope of ((medicaid)) COPES waiver or RCL reimbursed adult day care services;

(b) Caregiver support and education; or

(c) Assistance with coping skills.

(3) Routine health monitoring with consultation from a registered nurse that a consulting nurse acting within the scope of practice can provide with or without ((a physician's)) an authorizing practitioner's order. Examples include:

(a) Obtaining baseline and routine monitoring information on client health status, such as vital signs, weight, and dietary needs;

(b) General health education such as providing information about nutrition, illnesses, and preventative care;

(c) Communicating changes in client health status to the client's caregiver;

(d) Annual and as needed updating of the client's medical record; or

(e) Assistance as needed with coordination of health services provided outside of the adult day care program.

(4) General therapeutic activities that an unlicensed person can provide or that a licensed person can provide with or without ((a physician's)) an authorizing practitioner's order. These services are planned for and provided based on the client's abilities, interests, and goals. Examples include:

(a) Recreational activities;

(b) Diversionary activities;

(c) Relaxation therapy;

(d) Cognitive stimulation; or

(e) Group range of motion or conditioning exercises.

(5) General health education that an unlicensed person can provide or that a licensed person can provide with or without ((a physician's)) an authorizing practitioner's order, including but not limited to topics such as:

(a) Nutrition;

(b) Stress management;

(c) Disease management skills; or

(d) Preventative care.

(6) A nutritional meal and snacks every four hours, including a modified diet if needed and within the scope of the program, as provided under WAC ((388-71-0768)) 388-71-0770;

(7) Supervision and/or protection if needed for client safety;

(8) Assistance with arranging transportation to and from the program; and

(9) First aid and provisions for obtaining or providing care in an emergency. NOTE: If the client requires the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of ((a physician)) an authorizing practitioner, consider adult day health services.

Adult day health is a supervised ((daytime)) non-residential program providing skilled nursing and/or rehabilitative therapy services in addition to ((core)) all services provided in an adult day care center. Adult day health services are only appropriate for adults with medical or disabling conditions that require the skilled intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's ((physician)) authorizing practitioner.

The adult day health center must offer and provide on-site the following services:

(1) All ((core)) services under WAC 388-71-0704; and

(2) Skilled nursing services other than routine health monitoring with nurse consultation; or

(3) At least one of the following skilled therapy services: physical therapy, occupational therapy, or speech-language pathology or audiology, as defined under chapters 18.74, 18.59 and 18.35 RCW; and

(4) Psychological or counseling services, including assessing for psycho-social therapy need, dementia, abuse or neglect, and alcohol or drug abuse; making appropriate referrals; and providing brief, intermittent supportive counseling. These services are provided by social services professionals.

Clients are eligible for adult day care services if they meet criteria outlined in WAC 388-106-0805.

Clients are eligible for adult day health services if they meet the criteria outlined in WAC 388-106-0815 which references WAC 388-106-0300 and 0305.

(1) Skilled nursing services are medically necessary services provided directly or indirectly by a registered nurse under ((physician)) an authorizing practitioner's supervision, or by a licensed practical nurse under physician or registered nurse supervision, that a licensed nurse acting within the scope of practice can provide or supervise. ((Physician)) Authorizing practitioner orders must be obtained when required by applicable state practice laws for licensed nurses. Authorizing practitioner orders must be obtained upon initial service, updated when a significant change occurs changing the nursing intervention or at least annually.

(2) Skilled nursing services must exceed the level of routine health monitoring, general health education, and general therapeutic activities as defined in WAC 388-71-0704, and must be provided with the reasonable expectation that the services will improve, restore, ((or)) maintain function ((as defined in WAC 388-71-0710 (1)(c))) or slow the client's decline of the disease or functional ability. Skilled nursing services are:

(a) Specific to a ((client)) client's diagnosis;

(b) Individualized to the client with planned measurable ((outcomes)) outcome goals; and

(c) ((Evaluated)) Re-evaluated every ninety days or sooner when there is a significant health change for effect on improvement or maintenance of health status, or ((prevention of decline)) slowing the decline of the disease or functional ability.

(3) Skilled nursing services, including the initial client nursing assessment and development of the nursing plan of care, must be provided or supervised by a registered nurse in accordance with nursing practice standards under chapter 246-840 WAC.

(4) A skilled nursing service is not a qualifying adult day health service merely because the service is ordered by ((a physician)) an authorizing practitioner or is provided by a nurse. If, by way of example, the service can be performed by the client or at the client's direction by a person other than a licensed nurse, ((or the client does not meet eligibility criteria,)) it is not a qualifying adult day health service.

(5) Skilled nursing services must be medically necessary as defined under WAC ((388-500-0005)) 182-500-0070. Medically necessary skilled nursing services ((may, but do not necessarily,)) include but at not limited to:

(a) ((Care and assessment)) Assessment, care and evaluation with collaboration of services of an acute or chronic unstable or unpredictable medical condition, with time ((limited)) specific measurable treatment goals, requiring frequent skilled intervention by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse according to WAC 246-840-705 and ordered by the authorizing practitioner;

(b) Evaluation and management of the care plan when unstable medical conditions or complications require complex nonskilled care and skilled nurse oversight to ensure that the nonskilled care is achieving its purpose;

(c) Time-limited training by licensed nursing staff to teach the client and/or the client's caregiver self-care for newly diagnosed, acute, or episodic medical conditions that require the skills of a licensed nurse to teach, and that will optimize client function, as illustrated by the following examples:

(i) Self administration of an injection;

(ii) Prefilling insulin syringes;

(iii) Irrigating a catheter;

(iv) Caring for a colostomy or urostomy;

(v) Wound dressing changes or aseptic technique; or

(vi) Disease self-management.

(d) Skilled interventions provided directly by a licensed nurse such as:

(i) Inserting or irrigating a catheter;

(ii) Administering medications or oxygen;

(iii) Administering and managing infusion therapy; or

(iv) Treating ((decubitis)) decubitus ulcers, or other types of wound care.

(6) Medically necessary skilled nursing services, by way of example, do not include:

(a) Reminding or coaching the client;

(b) Monitoring of a medical condition that does not require frequent skilled nursing intervention or a change in ((physician)) authorizing practitioner treatment orders, or where there is no reasonable expectation that skilled services will maintain, improve, or slow the effect of a progressive disabling condition on the pain, health or functioning of a client;

(c) Medication assistance when the client is capable of self-administration or is having this need met through paid or unpaid caregivers;

(d) Evaluation and management of the care plan when the complexity of care to be provided by nonskilled persons does not require skilled nurse oversight beyond routine health monitoring;

(e) Continued training by nursing staff to teach self-care for newly diagnosed, acute, or episodic medical conditions when it is apparent that the training should have achieved its purpose or that the client is unwilling or unable to be trained;

(f) ((Core)) ADC services that can be provided by an adult day care center, such as routine health monitoring, general health education, or general therapeutic activities; or

(g) Group therapy or training where three or more clients are being simultaneously treated or trained by the nurse.

(7) Skilled nursing services must be documented as provided under WAC 388-71-0746 and ((chapter 388-502)) WAC 182-502-0020.

(1) Skilled rehabilitative therapy services are medically necessary services provided by or under the supervision of a licensed physical, occupational, or speech-language pathology or audiology therapist that the therapist acting within the scope of practice can provide or supervise directly or indirectly. ((Physician)) Authorizing practitioner orders must be initially obtained and updated when a significant change occurs or at least annualy when required by applicable state practice laws for licensed therapists.

(a) Persons that can provide rehabilitative care under the direction and supervision of a licensed therapist include occupational therapy aides, occupational therapy assistants, physical therapy aides, physical therapy assistants, and nurses within their respective scopes of practice. Adult day health program aides, specifically trained in rehabilitative techniques, may also provide care under the direction and supervision of a licensed therapist.

(b) Services, group or individual, must be related to an active written plan of care with time ((limited)) specific measurable treatment goals approved by the ((physician)) authorizing practitioner;

(c) Services, group or individual, must require the assessment, knowledge and skills of a licensed therapist; and

(d) Services, group or individual, must be provided with the reasonable expectation that the services will improve, restore, ((or)) maintain function, or slow decline. Rehabilitative services are:

(i) Specific to a client diagnosis;

(ii) Individualized to the client with planned, measurable outcomes; and

(iii) ((Evaluated)) Re-evaluated every ninety days for effect on improvement of health status or ((prevention of)) slowing the decline.

(2) Skilled rehabilitative therapy is not a qualifying adult day health service merely because the therapy is ordered by ((a physician)) an authorizing practitioner or is provided by a therapist or under the supervision of a therapist. If, by way of example, the therapy can be performed independently by the client or at the client's direction by a person other than a licensed therapist, ((or the client does not meet eligibility criteria,)) it is not a qualifying adult day health service.

Skilled rehabilitative therapy services must be medically necessary as defined under WAC ((388-500-0005)) 182-500-0070.

(3) Medically necessary physical therapy services may, but do not necessarily include:

(a) Assessing baseline mobility level, strength, range of motion, endurance, balance, and ability to transfer;

(b) One to one and group treatment to relieve pain, ((or)) develop, restore, or maintain functioning, with individualized and measurable client treatment goals;

(c) Establishing a maintenance or restorative program with measurable treatment goals, and providing written and oral instruction to the client, caregivers, or program staff as needed to assist the client in implementing the program;

(d) Training the client or the client's caregivers in the use of supportive, adaptive equipment or assistive devices;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that the nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of a physical therapist acting within the therapist's scope of practice.

(4) Medically necessary occupational therapy services may, but do not necessarily include:

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

(b) Teaching and training the client, caregivers, or program staff in the use of therapeutic, creative, and self-care activities to improve or maintain the client's capacity for self-care and independence, and to increase the range of motion, strength and coordination;

(c) One to one and group treatment to develop, restore, or maintain functioning with individualized and measurable client treatment goals;

(d) Training the client or the client's caregivers in the use of supportive, adaptive equipment or assistive devices;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that the nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of an occupational therapist acting within the therapist's scope of practice.

(5) Medically necessary speech-language pathology or audiology services may, but do not necessarily include;

(a) Assessing baseline level of speech, swallowing, auditory, or communication disorders;

(b) Establishing a treatment program to improve speech, swallowing, auditory, or communication disorders;

(c) Providing speech therapy procedures that include auditory comprehension tasks, visual and/or reading comprehensive tasks, language intelligibility tasks, training involving the use of alternative communication devices, or swallowing treatment;

(d) Training the client or the client's caregivers in methods to assist the client in improving speech, communication, or swallowing disorders;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of a speech-language pathology or audiology therapist acting with the therapist's scope of practice.

(6) Medically necessary skilled rehabilitative therapy services, by way of example, do not include:

(a) Reminding or coaching the client in tasks that are not essential to the skilled therapy or intervention in the client's service plan;

(b) Monitoring of a medical condition that does not require frequent skilled therapist intervention or a change in ((physician)) authorizing practitioner treatment orders, or where there is no reasonable expectation that skilled services will maintain, improve, or slow the effect of a progressive disabling condition on the pain, health or functioning of a client;

(c) Massage therapy;

(d) Evaluation and management of the care plan when the complexity of the care to be provided by nonskilled persons does not require the skills of a licensed therapist for oversight;

(e) Continued training by therapy staff to teach self-care for newly diagnosed, acute, or episodic medical conditions when it is apparent that the training should have achieved its purpose or that the client is unwilling or unable to be trained;

(f) ((Core)) ADC services that can be provided by an adult day care center, such as routine health monitoring, general health education, or general therapeutic activities; or

(g) Group therapy or training where the ratio of licensed therapists and assisting program staff to clients is inadequate to ensure that:

(i) The group activity contributes to the individual client's planned therapy goals; and

(ii) The complexity of the individual client's need can be met.

(7) Skilled therapy services must be documented as provided under WAC 388-71-0746 and ((chapter 388-502)) WAC 182-502-0020.

(1) The department or an authorized case manager must perform a comprehensive assessment reporting evaluation (CARE) ((assessment)) to determine a client's need for adult day care, per WAC 388-106-0065. Based on the assessment, the case manager determines whether the client should be referred for day care services or whether the client's needs can be met in other ways.

(2) If the case manager determines an unmet need for ((a core)) an ADC service that may be provided at a day care center, the case manager works with the client and/or the client's representative to develop a service plan that documents the needed services and the number of days per week that the services are to be provided. The case manager refers the client to a waiver-contracted day care center that the client and the case manager agree can potentially meet the client's needs.

(3) Clients receiving adult day care services must be reassessed at least annually.

(1) Upon referral of a COPES or RCL eligible client by the department or authorized case manager, the ((day care)) ADC center will respond in writing to the department or authorized case manager within two working days of receipt of the referral and its ability to process and evaluate the referred client. The ADC center must conduct an intake evaluation based on an interview with the client and/or the client's representative to assess the center's ability to meet the client's needs as identified in the department service plan.

(2) The case manager will provide the client's service plan to the adult day care provider within five working days after the client or client's representative has signed it.

(3) The ADC center will schedule intake evaluations visits with the referral client and/or their representative to evaluate the ADC center's ability to meet the needs of the client as defined in the client's service plan.

(4) Within ten working days ((of)) from the initial date of client attendance at the day care center, the center must determine whether it can meet the client's needs, how those needs will be met, and whether to accept the client to the program. The center must not accept a client whose needs the center cannot meet. The center will document in the client's file the date he/she was accepted into the ADC program.

(((4))) (5) Within thirty calendar days of acceptance into the program, the day care center must work with the client and/or their representative to develop and complete a negotiated care plan signed by the client or the client's representative and the day care center.

(6) This care plan must be updated annually and when their is a significant change in the client's condition and needs. the care plan when updated, annually or after significant change, must be shared with the client's case manager. The care plan must:

(a) Be consistent with the department-authorized service plan and include all day care services authorized in the service plan;

(b) Document the client's needs as identified in the service plan, the adult day care services that will be provided to meet those needs, and when, how, and by whom the services will be provided;

(c) Document the client's choices and preferences concerning the provision of care and services, and how those preferences will be accommodated;

(d) Document potential behavioral issues identified in the assessment, service plan, or through the intake evaluation, and how those issues will be managed;

(e) Document contingency plans for responding to a client's emergent care needs or other crises; and

(f) Be approved by the client's case manager.

(((5))) (7) The adult day care center must keep at least the current negotiated care plan in the client's file, must offer a copy of the plan to the client or client representative, and must provide a copy to the client's case manager. The case manager must review the negotiated care plan for inclusion of services that are appropriate and authorized for the client's care needs.

(((6))) (8) The negotiated care plan must limit the frequency of services to the number of days authorized in the department-authorized service plan.

(((7))) (9) The day care center must review each service in the negotiated care plan if the client's condition changes, and determine if the care plan continues to meet the client's needs. Changes in the client's condition or unanticipated absences of more than three consecutive days of scheduled service must be reported to the client's case manager within one week. Unanticipated absences by way of example may include absences due to client illness or injury, or a change in transportation access. The case manager may follow-up with the client and ((determine)) determines if any updates to the assessment, service plan, and service authorization are needed.

(1) The department or an authorized case manager must perform a CARE assessment to determine a client's need for adult day health, per WAC 388-106-0065. Based on the assessment, the case manager determines whether the client should be referred for day health services or whether the client's needs can be met in other ways.

(2) If the client has a department or area agency on aging case manager, the adult day health center or other referral source must notify the case manager of the client's potential adult day health service need. The case manager must assess the client's need for skilled nursing or skilled rehabilitative therapy within the department's normal time frames for client reassessments.

(3) If the client does not have a department or area agency on aging case manager, the adult day health center or other referral source must notify the department of the referral and the client's potential adult day health service need, or refer the client to the department for intake. The department's assigned case manager must assess the client's need for adult day health services within the department's normal time frames for initial client eligibility assessments.

(4) The case manager may consult with the client's authorized practitioner, department or area agency on aging nursing services staff, or other pertinent collateral contacts, concerning the client's need for skilled nursing or rehabilitative therapy.

(5) If the department or area agency on aging case manager determines and documents a potential unmet need for day health services, the case manager works with the client and/or the client's representative to develop a service plan that documents the potential unmet needs and the anticipated number of days per week that the services are needed. The case manager refers the client to a department contracted adult day health center for evaluation and the development of a preliminary ((negotiated)) service plan ((of care)).

(6) The department or area agency on aging case manager must reassess adult day health clients at least annually. Clients must also be reassessed if they have a break in service of more than thirty days. The adult day health center must inform the case manager of the break in service so payment authorization can be discontinued.

(7) ((Recipients)) COPES and RCL recipients of adult day health services must be assessed by the department or an authorized case manager for initial or continued ((or initial)) eligibility as follows:

(a) Annual reassessment for department clients; or

(b) ((Adult day health quarterly review for current nondepartmental clients as resources allow; and

(c) New referrals for adult day health services are to be forwarded to)) A new client to the center who potentially could be eligible for state paid ADH services are to be referred to the local department offices for intake and assessment for eligibility.

(8) The department or area agency on aging case manager must review a client's continued eligibility for adult day health services every ninety days, coinciding with the quarterly review completed by the adult day health program. At the case manager's discretion, additional information will be gathered through face to face, collateral or other contact methods to determine continued eligibility. Services will be continued, adjusted, or terminated based upon the case manager's determination during the eligibility review.

(1) ((Upon referral of a client by the department or an authorized case manager, the day health center must conduct an intake evaluation and multidisciplinary assessment based on an interview with the client or the client's representative to determine the center's ability to meet the client's core service needs and potential adult day health needs as identified in the preliminary department service plan. The case manager will provide the client's service plan to the day health center within five working days after the client or client's representative has signed it. The day health center must evaluate the client's skilled and core service needs, and may provide up to ten days of paid service to complete the evaluation and develop a preliminary or negotiated plan of care to be provided to the client and the case manager.

(3) Within ten paid days of service, the day health center must determine whether it can meet the client's needs, how those needs will be met, and whether to accept the client to the program. The center must not accept a client whose needs the center cannot meet. The center will be reimbursed under WAC 388-71-0724 for any service days provided from the start of the evaluation if the case manager has authorized services. The evaluation includes acceptance of the client to the center, the development of the initial assessment, and the preliminary negotiated plan of care.)) Upon referral of a COPES or RCL eligible client by the department or an authorized case manager, the ADH center will respond in writing to the department or authorized case manager within two working days of receipt of the referral regarding its ability to process and evaluate the referred client.

(((4))) (7) Upon approval by the case manager of the adult day health preliminary ((or negotiated care)) service plan, the day health center multidisciplinary team must obtain and provide to the case manager any required practitioner's orders for skilled nursing and rehabilitative therapy along with a copy of the ((negotiated)) preliminary service plan ((of care)), according to department documentation requirements. Orders must indicate how often the client is to be seen by the authorized practitioner. The case manager or nursing services staff may follow up with the practitioner or other pertinent collateral contacts concerning the client's need for skilled services. Services may not be authorized for payment without current practitioner orders and the client's consent to follow up with the practitioner.

(((5))) (8) Within thirty calendar days of the client's acceptance into the program, the day health multidisciplinary team must work with the client and/or their representative to develop a negotiated care plan signed by the client or the client's representative and the day health center. The negotiated care plan can be developed initally in lieu of developing a preliminary service plan. The care plan must:

(a) Be consistent with the department-authorized service plan and include all day health services authorized in the service plan;

(b) Include an authorized practitioner's order(s) for skilled nursing and/or skilled rehabilitative therapy according to applicable state practice laws for licensed nurses or therapists. These authorizing practitioner orders must be reviewed, updated or revised when a significant change occurs or at least annually, or sooner if required by the prescriber;

(c) Document that the client or the client's representative has consented to follow up with the primary authorizing practitioner;

(d) Document the client's needs as identified in the service plan, the authorized services that will be provided to meet those needs, and when, how, and by whom the services will be provided;

(e) Establish time((-limited, client)) specific, measurable individualized client goals, not to exceed ninety days from the date of signature of the negotiated care plan, for accomplishing the ((objectives)) goals of adult day health skilled services and/or discharging or transitioning the client to other appropriate settings or services;

(f) Document the client's choices and preferences concerning the provision of care and services, and how those preferences will be accommodated;

(g) Document potential behavioral issues identified in the assessment, service plan, or through the intake evaluation, and how those issues will be managed;

(h) Document contingency plans for responding to a client's emergent care needs or other crises; and

(i) Be approved by the case manager.

(((6))) (9) The adult day health center must keep the negotiated care plan in the client's file, ((the plan)) provide a copy to the client or client representative, and ((must provide)) a copy to the client's case manager, including any required authorizing practitioner orders. The department case manager must review the negotiated care plan for inclusion of services that are appropriate and authorized for the client's care needs.

(((7))) (10) The negotiated care plan must limit the frequency of department-funded services to the number of days in the department-authorized service plan.

(((8))) (11) The day health center must review each service in the negotiated care plan every ninety days or more often if the client's condition changes, or if the client is reassessed for eligibility after a break in service of more than thirty days. Changes in the client's condition or unanticipated absences of more than three consecutive days of scheduled service must be reported to the client's case manager within one week. Unanticipated absences by way of example may include absences due to client illness or injury. The case manager may follow-up with the client and ((determine)) determines if any updates to the assessment, service plan, and service authorization are needed.

(1) The department, or an area agency on aging (or other department designee) as authorized by the department, must determine that the adult day care or day health center meets the applicable adult day care or day health requirements and any additional requirements for contracting with the area agency on aging, according to each AAA's procurement procedure, through a ((COPES)) state contract.

(2) All ADH centers must also have a core provider agreement with the health care authority in order to bill for providing care and services to the COPES or RCL participants. ((or with the department through a medicaid provider contract.))

(3) If a center is contracting for both day care and day health, requirements of both adult day services must be met.

(((a))) (4) A prospective provider desiring to provide adult day services shall be provided an application form from the department or the area agency on aging. A prospective provider convicted of abuse or neglect of a vulnerable adult is not eligible to provide adult day services in any capacity within the organization per chapter 74.34 RCW.

(((b))) (5) The prospective provider will provide the area agency on aging with evidence of compliance with, or administrative procedures to comply with, the adult day service rules under this chapter.

(((c))) (6) The area agency on aging will conduct a site inspection of the adult day center and review of the requirements for contracting.

(((d))) (7) Within thirty days of completing the site visit, the area agency on aging will advise the prospective provider in writing of any deficiencies in meeting contracting requirements.

(((e))) (8) The area agency on aging will verify correction of any deficiencies within thirty days of receiving notice from the prospective provider that deficiencies have been corrected, before contracting can take place.

(((f))) (9) The area agency on aging will provide the department with a written recommendation as to whether or not the center meets contracting requirements.

(((2))) (10) Minimum application information required to apply for contract/s with the department, or an area agency on aging includes:

(a) Mission statement, ((articles of incorporation)) business structure, ((and)) bylaws, ((as)) articles of organization or articles of incorporation if applicable and current business license;

(b) Names and addresses of the center's owners, officers, and directors as applicable;

(c) Organizational chart;

(d) Fiscal policies and procedures;

(e) A business plan to address the future financial needs of the center. This plan must include projected program growth, capital purchases, projected revenue, projected expenses, and plans for fund raising, if applicable. Also include an annual ((Total)) program operating budget including all anticipated revenue sources and expenditures and any fees generated;

(((e))) (f) The most current financial statement prepared in accordance with generally accepted account principles (GAAP) or the latest audit report of the organization by a certified public accountant;

(g) Program policies and operating procedure manual;

(((f))) (h) Personnel policies and job descriptions and qualifications of each paid staff position and volunteer position functioning as staff;

(((g))) (i) Policies and procedures meeting the requirements of mandatory reporting procedures as described in chapter 74.34 RCW to adult protective services for vulnerable adults and local law enforcement for other participants;

(((i))) (j) Floor plan of the facility;

(((j))) (k) Local building inspection, fire department, and health department reports with food handler permits if applicable;

(((k))) (l) Updated TB test results for each staff member according to ((local public health requirements)) WAC 388-71-0750;

(((l))) (m) Sample client case file including all forms that will be used; ((and))

(((m))) (n) Activities calendar for the month prior to application, or a sample calendar if the day service provider is new.

(((3))) (10) The area agency on aging or other department designee monitors the adult day center at least annually to determine continued compliance with adult day care and/or adult day health requirements and the requirements for contracting with the department or the area agency on aging.

(a) The area agency on aging will send a written notice to the provider indicating either compliance with ((contacting)) contracting requirements or any deficiencies based on the annual monitoring visit and request a corrective action plan. The area agency on aging will determine the date by which the corrective action must be completed

(b) The area agency on aging will notify the department of the adult day center's compliance with contracting requirements or corrected deficiencies and approval of the corrective action plan for continued contracting.

(((4))) (11) Adult day care services are reimbursed on an hourly basis up to four hours per day. Service provided four or more hours per day will be reimbursed at the daily rate.

(((5) Payment rates are established on an hourly and daily basis for adult day care centers as may be adopted in rule. Rate adjustments are)) (12) Adult day center reimbursements are adopted by rule with adjustments determined by the state legislature. Providers seeking current reimbursement rates can refer to ((SSPS)) the billing instructions.

(13) A one-time only initial intake evaluation provided by an adult day health center, including development of a negotiated care plan, is reimbursed at an established rate as may be adopted in rule. ((The rate as of July 1, 2002 is eighty-nine dollars and thirty-eight cents.)) Rate adjustments are determined by the state legislature. Separate reimbursement is not available for subsequent evaluations.

(((9))) (14) Transportation to and from the program site is not reimbursed under the adult day care rate. Transportation arrangements are made with locally available transportation ((providers)) companies or informal resources.

(((10))) (15) Transportation to and from the program site is ((not)) reimbursed under the adult day health daily rate. ((Transportation arrangements for eligible medicaid clients are made with local medicaid transportation brokers, informal providers, or other available resources per chapter 388-546 WAC)) Adult day health is required to assist clients in arranging or providing transportation to and from the program sites.

(1) A ((COPES-)) COPES or RCL-eligible client may receive adult day care services on some days and adult day health services on different days if the service plan documents which level of service ((is)) are to be provided on which days. However, ((core)) ADC services must be provided on all days that adult day health skilled services are provided, and reimbursement is limited to the day health rate on days that day health services are provided.

(2) Clients receiving services from the department in an adult family home, ((boarding home)) assisted living, or other licensed community residential facility may not receive ((COPES-)) COPES or RCL-funded adult day care, but may receive ((medicaid)) COPES funded adult day health services when the skilled nursing or rehabilitative services are approved by the client's case manager as part of the client's service plan.

(3) A licensed ((boarding home)) assisted living facility providing department-approved day care under chapter 388-78A WAC is subject to any applicable provisions of that chapter and is also subject to the rules under this chapter if the facility contracts with an area agency on aging or the department to provide COPES waiver or ((other medicaid-)) RCL funded adult day services.

(1) Except as provided under this section, the adult day services rules under this chapter do not apply to adult day care or day health services funded under chapters 74.38 and 74.41 RCW.

(2) An area agency on aging that elects to provide adult day services using Senior Citizens Services Act funding under chapter 74.38 RCW or respite care funding under chapter 74.41 RCW must contract with an adult day center that meets all administrative and facility requirements under WAC 388-71-0736 through 388-71-0774.

(3) The adult day care or day health services funded under chapters 74.38 or 74.41 RCW must be the same as the day care services required under WAC 388-71-0704 or the day health services required under WAC 388-71-0706. The area agency on aging may require additional services by contract.

(4) The area agency on aging may, by contract, establish eligibility and assessment requirements for day care or day health services in accordance with locally identified needs. However, funding provided under chapters 74.38 or 74.41 RCW may only be used to meet the needs of individuals who are not eligible for adult day care under WAC 388-71-0708 or for adult day health under WAC 388-71-0710, or who are eligible for those services and are not receiving them because of funding limitations.

(5) Nothing in this section or chapter may be construed as requiring an area agency on aging to contract with an adult day center, whether or not the center has a COPES ((or other medicaid)) and RCL contract. Nor may anything in this section or chapter be construed as creating an entitlement to state-funded adult day services authorized under chapters 74.38 and 74.41 RCW.

(1) If the department or area agency on aging denies, terminates, or reduces ((an)) a COPES or RCL individual client's adult day care or day health services, the client has the right to ((a fair)) an administrative hearing as provided under chapter 388-02 WAC. If a client funded with senior citizen services act or respite care has a complaint, grievance or dispute, the resolution process is a hearing as outlined in the departments area agency on aging polity and procedure manual chapter 6. The area agency on aging would work with the client through this process.

(2) An adult day care or day health center has those hearing or dispute resolution rights that are afforded under RCW 43.20B.675 and the center's contract with the area agency on aging or the department. An adult day health center has any other applicable hearing or dispute resolution rights under ((chapter 388-502)) WAC 182-502-0220.

(3) Adult day health centers are subject to all applicable provisions of chapter ((388-502)) 182-502 WAC, and the department's aging and ((adult services)) long term support administration may exercise the department's authority under that chapter to the same extent as the ((medical assistance administration)) health care authority.

(1) In order to provide adult day services within the limits of available funding, the department may limit services when program expenditures exceed the budget appropriation or when limiting services is required to prevent expenditures from exceeding the appropriation.

(2) When adult day health program expenditures exceed available funding, the department may limit adult day health services based on the four care level system as determined through the established department assessment and described in chapter 388-105 WAC.

(a) Using the care level determined by the department assessment tool, the department will limit adult day services on a statewide basis to clients whose total scores exceed the assessed need level identified by the department as necessary to provide adult day health services to the extent of available funding.

(b) At least thirty days before implementing the limitation on services under this subsection, the department will notify the area agencies on aging, adult day health centers, and the affected adult day health clients that services are being limited and for what period of time the limitation is estimated to remain in effect.

(c) For purposes of RCW 74.08.080, the reduction in services shall be deemed an assistance adjustment for an entire class of recipients that is required by state laws prohibiting the department from expending funds in excess of appropriations.

(3) The department may adopt additional or alternative rules to control costs, such as, but not limited to, imposing a moratorium on contracting with new adult day centers, limiting services to clients based on level of care need, or reducing the numbers of days per week that clients may receive services.

(1) Adult day centers must have written ((policies, procedures, and)) documentation of the organizational structure and administration of the program.

(2) ((Administrative policies and procedures)) Organizational and administrative documentation must include but are not limited to:

(a) ((Mission statement)) Core values and mission statment of the organization;

(b) ((Articles of incorporation and bylaws, as applicable)) Ethical standards of the center and professional standards of conduct;

(i) Business structure, articles of organization or bylaws, as applicable;

(((c))) (j) Current business license;

(((d))) (k) Names and addresses of the center's owners, officers, and directors, as applicable;

(((e))) (l) Certificates of insurance, including but not limited to property and general liability insurance; business auto if the center uses vehicles to transport clients; professional liability; workers' compensation; employers' liability if applicable; coverage for acts and omissions of employees and volunteers; and certificates of insurance for any subcontractors;

(((f))) (m) Minutes of last three meetings of the board of directors, if applicable, and the advisory committee;

(((g))) (n) Role and functions of an advisory committee, which must meet at least twice a year and which must be representative of the community and include family members of current or past clients and nonvoting staff representatives (When an adult day center is a subdivision of a multifunction organization, a committee or subcommittee of the governing body of the multifunction organization may serve as the advisory committee. A single purpose agency may utilize its governing board as an advisory committee.);

(((h))) (o) An organizational chart illustrating the lines of authority and communication channels of the center, which must be available to all staff and clients;

(((i))) (p) A calendar of programming (or sample calendar if the center is new);

(((j))) (q) A monthly menu (or sample menu if the center is new);

(((k))) (r) Current building, health, food service and fire safety inspection reports, and food handler permits, as applicable; and

(((l))) (s) Quality improvement plans and results.

(1) All policies and procedures must ((be)) include date of initial development and/or revision along with date of being reviewed and approved on a regular basis, at least annually, by the advisory committee, and conform to the requirements outlined in WAC 388-71-0702 through 388-71-0774, as applicable.

(2) Policies and procedures must include:

(a) ((Core values and mission of the organization;

(i))) Procedures for ((assessments, reassessments)) evaluations, re-evaluation, and the development of a negotiated care plan with clients and/or representatives, including provisions for the utilization of a multidisciplinary team for this process;

(((j))) (b) If applicable, research procedures that comply with chapter 388-04 WAC;

(((k) Staffing pattern)) (c) Procedure for developing staffing schedules with staff to participant ratios being at a minimum one staff to six participants;

(((l) A plan for utilizing)) (d) Policy regarding the utilization of community resources;

(((m))) (e) Gift policy;

(((n))) (f) Marketing ((plan)) policy and procedures;

(((o) Contracting)) (g) Policy and procedure for contracting for services; ((and

(p))) (h) Medication policy including but not limited to: disposal of wasted or contaminated medications;

(j) Grievance and complaint ((processes)) policies and procedures for staff and participants((.));

(1) Adult day centers must demonstrate fiscal responsibility ((by using generally accepted accounting principles)). Fiscal policies, procedures, reports, statements and records must be developed ((to)) in accordance with generally accepted accounting principles (GAAP) and enable the administrator to meet the fiscal reporting needs of the governing body.

(2) Adult day centers must develop a yearly plan to address the future financial needs of the center. The plan must include projected program growth, capital purchases, projected revenue, projected expenses, and plans for fund raising, if applicable.

(3) Adult day centers must create a total center operating budget, including all expenditures, revenue sources and participant fees generated annually.

(4) ((A)) An annual financial statement or the latest audit report of the organization by a certified public accountant performed at least every two years must be available.

(5) A statement of charges for services (fee schedule), including private pay rates and/or ancillary charges for additional services outside the scope of these rules, must be available.

(1) The adult day center must ((have)) follow their policies and procedures to ensure that the client's record/chart is appropriately organized and that confidentiality of information is maintained.

(2) Client information forms must be standardized, with each page showing the client's name or identification number.

(3) Individual client files must include:

(a) Personal/biographical data, including addresses, phone numbers, emergency contacts, and client representatives, reviewed and updated as needed;

(b) Application, enrollment, and consent to services forms;

(c) Department-authorized service plan and service authorization;

(d) All client information, including but not limited to the intake evaluation, date of acceptance to the center, negotiated care plan, attendance and service records, progress notes, and correspondence;

(e) Signed authorizations concerning the release of client information, photographs, and receipt of emergency medical care, as appropriate;

(f) Client photograph, with client or client representative permission, updated as needed per change in the client's appearances or picture being difficult to clearly view;

(g) Transportation plans regarding how the client will be transported back and forth from the center and who is responsible for the transportation;

(h) Fee determination forms;

(i) Appropriate medical information, with client consent, including but not limited to significant illnesses, accidents, treatments, medical conditions, ((immunizations,)) allergies, medications, tobacco use, and alcohol or substance use;

(j) Advance directives (if any) and a statement signed by the client that he or she has received the center's policies concerning advance directives; and, as applicable,

(k) ((Physician)) Authorizing practitioner orders for skilled nursing and/or rehabilitative therapy containing department-required information and in accordance with applicable licensing and practice act regulations.

(1) ((Entries in)) If the client's record is hand-written it must be ((typewritten or)) legibly written in ink, dated, and signed by the recording person with his/her title. Identification of the author may be a signature, initials, or other unique identifier within the requirements of applicable licensing standards and center policy. All hand-written documentation must be legible to someone other than the author. If signature is a unique identifier, such as initials, there must be a key readily available for use by the department of their designee. The negotiated care plan must have the center's author's full name and title on the signature line.

(2) If the client's record is an automated electronic record then it must be within a secured client record system to ensure confidentiality for all records, in accordance with state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA). If electronic signature is a unique identifier then there must be a key readily available for use by the Department or their designee. The Negotiated Care Plan must have the center's author's full name and title on the signature line.

(3) Progress notes must be ((chronological,)) entered into the file chronologically and timely((, and recorded at least weekly by adult day health centers and at least monthly by adult day care center)). Adult day health centers' professional interventions must be charted directly after providing the service. Adult day care centers must have progress summary notes at least monthly. Client dates and hours of attendance are to be kept daily.

(((3))) (4) Consultation, ((and/or)) care plan reviews and updating orders, hardcopy or electronic records, must be dated and initialed by the ((physician or other authorizing practitioner who reviewed them. If the reports are presented electronically, there must be representation of review by the ordering practitioner)) center's reviewer/s or authorizing practitioner. The authorizing practitioner must update the skilled clinical orders at least annually or when a significant change occurs warranting a change in the skilled clinical intervention. The authorizing practitioner does not need to review the care plan but does need to update skilled clinical orders as outlined above.

(((4))) (5) Documentation of medication use must include the name of the medication, dosage, frequency of administration, route of administration, site of injection if applicable, date and time and signature or initials of the person administering the medication, title, and date.

(6) If the client records are thinned or achieved, per your policy and procedure, all records must be readily available to the federal, state or their designee for monitoring purposes.

(7) Department-contracted adult day health centers must comply with all other applicable documentation requirements under WAC ((388-502-0020)) 182-502-0020.

(1) The adult day center must maintain a secure client record system to ensure confidentiality for all records, whether paper or electronic, in accordance with state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA).

(2) The adult day center must maintain a permanent registry of all clients with dates of admission, attendance and discharge.

(3) The adult day center must ((have)) follow their written policies concerning((:

(c) The retention and storage of records for at least six years from the last date of service to the client, including contingency plans in the event the center discontinues operation)) record and maintenance and retention, see WAC 388-71-0738 operating policy section.

(4) Client records maintained on the center's premises must be in a secure storage area that includes locking cabinets or storage. Computerized records must be backed up, daily for any changes made in the record that day and a full backup on a weekly basis. Weekly backup records would be ((and)) stored offsite either in a physical, (cd, tape or thumb drive) or electronic file, (through the cloud backup system) compliant with HIPAA.

(1) Personnel policies and procedures must be in place to ensure that staff ((are)) is trained and knowledgeable to provide quality services in a safe environment. Policies must include at least the following:

(a) The center must have policies concerning the recruitment, orientation, training, evaluation, and professional development of staff and volunteers.

(b) The center must have job descriptions for each paid staff and volunteer position, which functions as staff, that are in accordance with ADA requirements and that specify qualifications for the job, delineation of tasks, essential functions and lines of supervision and authority.

(c) Each employee must receive, review, and sign a copy of the job description at the time of employment and whenever job descriptions are modified. Volunteers who function as staff must receive written descriptions of responsibilities.

(d) Probationary evaluations and annual performance evaluations, in accordance with job descriptions, must be conducted and must conform to the policy of the funding or parent organization. Both the employee and supervisor will sign and date the written evaluation. Copies will be kept in locked personnel files.

(e) Each staff person or volunteer, who functions as a staff person, is to have ((a tuberculin test within thirty days of employment. If a test has been performed within twelve months of employment, the results of that test may be accepted. Tuberculin tests will be repeated according to local public health requirements)) tuberculosis (TB) testing according to current local health authorities recommendations.

(f) The center must have policies to restrict a staff person or participant's contact with clients when the staff person or participant has a known communicable disease in the infectious stage that is likely to spread in the center.

(g) Policies must also be established concerning hand washing, universal precautions, infection control, infectious waste disposal, bloodborne pathogens, and laundry and handling of soiled and clean items.

(2) The center must have policies and procedures concerning suspected participant abuse, neglect, or exploitation reporting that include provisions preventing access to any participant until the center investigates and takes action to assure the ((participant's)) participants' safety.

(3) The center must not interfere with the lawful investigation of a complaint, coerce a participant, or conceal evidence of alleged improprieties occurring within the center.

(4) The center must have policies that meet the requirements of mandatory reporting procedures as described in chapter 74.34 RCW to adult protective services for vulnerable adults and to local law enforcement for other participants.

(5) Each employee must receive or have access to a copy of the program's personnel policies at the time of employment.

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

(7) The center must conform to federal and state labor laws and be in compliance with equal opportunity guidelines.

(1) Staff selection is dependent on participant needs, program design, and contracting requirements. The center must have the proper balance of professionals and paraprofessionals or nonprofessionals to adequately meet the needs of participants. Services must be delivered by those with adequate professional training. A staff person can have multiple functions, such as an administrator who is also responsible for providing nursing services or social services.

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

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

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

(5) The administrator must be responsible for the development of a written plan of operation with approval of the governing body and the development, coordination, supervision, fiscal control, and evaluation of services provided through the adult day center.

(6) A nurse or other personnel ((trained in)) with a current first aid and CPR card must be on ((hand)) site whenever participants are ((present)) attending the adult day care or health program.

(7) ((Background checks pursuant to RCW 43.43.830 and 43.43.832 must be performed for all applicants hired, existing employees, and volunteers. Unsupervised access to participants is prohibited until a background check has been completed and the employee's suitability for employment has been determined.

(8))) Required credentials must be verified to ensure that they are current and in good standing for licensed and certified staff.

(((9))) (8) Adult day centers may utilize a range of staff under contract or consulting from a larger parent organization or from a private entity to provide services.

(((10))) (9) Staff commonly utilized by both adult day care and adult day health centers must meet the following requirements:

(a) An activity coordinator must have a bachelor's degree in recreational therapy or a related field and one year of experience (full-time equivalent) in social or health services; or an associate degree in recreational therapy or a related field plus two years of appropriate experience; or three years of paid experience in an activity program and expertise with the population served at the center.

(b) The nurse must be a registered nurse (RN) with valid state credentials in good standing and have at least one-year applicable experience (full-time equivalent) in ambulatory care or hospital nursing or geriatric or preferably in home health or older adult community based nursing and/or work with disabled clients. In addition to a registered nurse, an adult day center can utilize a licensed practical nurse (LPN), but the LPN must be supervised in compliance with all applicable nurse practice acts and standards. The LPN must have valid state credentials in good standing and at least one-year applicable experience (full-time equivalent) in ambulatory care of hospital nursing or geriatric or preferably in home health or older adult community based nursing and/or work with disabled clients. In the adult day care center the RN/LPN does not need to be on site during all hours of operation. In the adult day health center the RN and/or LPN must be on site when the attending participants' who need nursing services are attending the ADH program. If there are no participants who have nursing service interventions identified on their negotiated care plan in attendance then the nurse is not required to be on site during the ADH program time.

(c) The social services professional must have a master's degree in social work, gerontology, or other human services field, or counseling and at least one year of professional work experience (full-time equivalent), or a bachelor's degree in social work, counseling, or a related field and two years of experience in a human services field.

(d) Program assistant/aides or personal care aides must have ((one or more years of experience (full-time equivalent) in working with adults in a health care or social service setting)) the appropriate knowledge, skills and training to meet the individual needs of the participants before they are allowed to provide care and services. The assistant/aide competencies must be documented demonstrating their qualification to meet the needs of the center's participants within their job description.

(e) Consultants from a larger parent organization without formal contracts may be utilized whenever the center is part of a larger organization that has the ability to provide professional services within the larger framework.

(f) Consultants, with appropriate, valid state credentials may be utilized as needed to meet the requirements outlined in this chapter. The rehabilitative consultants must perform the professional assessment of the participant, train the staff regarding the participants therapy needs and therapeutic intervention/s, monitor the rehabilitation program and evaluate the participants progress for discharge planning.

(g) Secretary/bookkeepers must have at least a high school diploma or equivalent and skills and training to carry out the duties of the position.

(h) If the adult day center provides transportation drivers must have a valid and appropriate state driver's license, a safe driving record, and training in first aid and CPR. The driver must meet all state requirements for licensure or certification.

(i) Volunteers may be individuals or groups who desire to work with adult day center clients and must take part in program orientation and training. Volunteers and staff must mutually determine the duties of volunteers. Duties to be performed under the supervision of a staff member must either supplement staff in established activities or provide additional services for which the volunteer has special talents. Volunteers will be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualification standards of the organization, and have designated responsibilities.

(j) Dietitians must be certified with valid state credentials and have a minimum of one year applicable experience (full-time equivalent).

(1) ((Staffing levels)) Direct care staff in adult day centers will vary based upon the number of participants and ((the)) their care ((provided)) and service requirements. The centers must provide sufficient numbers of qualified staff to meet the participants' needs, but at a minimum must have one staff to six clients for:

(g) Provision of a safe environment.

(2) The staffing level must be sufficient to serve the number and functioning levels of adult day center participants, meet program objectives, and provide access to other community resources.

(3) There must be sufficient maintenance and housekeeping personnel to assure that the facility is clean, sanitary, and safe at all times.

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

(5) As the number of participants with functional impairments, skilled nursing or skilled rehabilitative therapy needs increases, the required staff-participant ratio must be adjusted accordingly.

(6) ((All centers must have written policies regarding staff-participant ratios. The ratio must be a minimum of one staff to six participants. The provider must ensure that appropriate professionals provide needed services to the participants based upon the participants' service and care plans. The center is also required to employ sufficient staff to meet the needs of the participants)) Direct service staff to participant ratio must be met according to each program the center is contracted to provide, i.e. COPES/RCL and memory care and wellness services (MCWS). The center is required to have daily documentation outlining how they met the staff to resident ratio. This data would include but not be limited to names/titles of employees with date and hours worked and participants' names and date and hours attended.

(7) Staff counted in the staff-participant ratio ((are)) is those who are trained and able to provide direct service to participants. When there is ((more than)) one participant present, to ensure safety of participant, there must be at least two organizational staff members ((on the premises, one of whom is directly supervising the participants)) who have the skills, knowledge and ability to meet the clients need and at least one is currently certified in CPR and First Aid.

(1) ((Minimum)) The minimum staffing requirements for adult day care centers include an administrator/program director, activity coordinator, a consulting registered nurse, and a consulting social worker.

(2) The administrator/program director must have a master's degree and one year of supervisory experience in health or social services (full-time equivalent); or a bachelor's degree in health, social services or a related field, with two years of supervisory experience (full-time equivalent) in a social or health service setting; or a high school diploma or equivalent and four years of experience in a health or social services field, of which two years must be in a supervisory position, and have expertise with the populations served at the center.

(1) ((Minimum)) The minimum staffing requirements for adult day health centers include an administrator, program director, registered nurse, activity coordinator, a PT/OT or speech therapist, and a social worker. The administrator and program director may be the same person.

(2) The program administrator must have a master's degree and one year of supervisory experience in health or social services (full-time equivalent), or a bachelor's degree and two years of supervisory experience in a social or health service setting. The degree may be in nursing.

(3) The program director must have a bachelor's degree in health, social services or a related field with one year of supervisory experience (full-time equivalent) in a social or health service setting. Upon approval by the department, a day health center may request an exception for an individual with an associate's or vocational degree in health, social services, or a related field with four years of experience in a health or social service setting, of which two years must be in a supervisory position.

(4) Registered nurses and licensed practical nurses per WAC 388-71-0752.

(5) Therapists, regardless of specific expertise, such as physical therapists, occupational therapists, speech therapists, recreation therapists, mental health therapists, or any other therapists used, must have valid state credentials and one year of experience in a social or health setting.

(((5))) (6) Rehabilitative therapeutic assistants must be certified with valid state credentials, have at least one year of applicable experience (full-time equivalent), and meet the requirements of chapter 246-915, 246-847, or 246-828 WAC.

(((6))) (7) A certified or registered nursing assistant must meet the requirements of chapter 18.88A. RCW ((18.88A.020)).

(1) Each employee must have an individual file containing the employee's application, verification of references, TB status, signed job description, and all performance evaluations. Copies of current license, ((or)) certificate, or registration and verification of current good standing, and a current certification of CPR and first aid training, if applicable, must also be in the file.

(2) Centers must maintain employee records for the duration of staff employment and at least seven years after termination of employment.

(3) Employee records must contain ((all records of training, such as staff orientation and training pertinent to duties or regulatory compliance, including CPR, first aid, and universal precautions training)) documentation demonstrating the employee was oriented to the facility, job and possesses the knowledge, skills and ability to perform their assigned duties. The record should also contain documentation demonstrating the employee understands and will follow the center's policies and procedures regarding but not limited to medication disposal, the emergency and evacuation plan, the abuse, neglect, abandonment and financial exploitation of vulnerable adults and universal precaution policies and procedures.

(4) ((Employee records must contain criminal history disclosure and background checks)) Background checks pursuant to RCW 43.43.830 and 43.43.832 must be performed for all applicants hired, existing employees, and volunteers who function as staff or who have unsupervised access to participants. Unsupervised access to participants is prohibited until a background check has been completed and the employee's suitability for employment has been determined. Background checks must be updated every two years and documentation maintained in the employees' or volunteers' functioning as staff, record.

(1) Provision must be made for orientation of new employees, contractors, and volunteers.

(2) ((All)) Every year, all staff, contractors, and volunteers, functioning as staff, must receive, at a minimum, quarterly in-service training and staff development that meets their individual training needs to support program services. This must be documented and readily accessible in the personnel file ((and in a general file)).

(3) Staff, contractors, and volunteers, who function as staff, must receive training ((about documentation, reporting requirements, and universal precautions)) regarding the following at a minimum:

(ii) Local health department procedure for disease outbreak.

(4) At a minimum, one staff person per shift must ((be trained and certified)) have current training and certification in CPR/First Aid.

(5) Staff and volunteers functioning as staff, must receive education and training on all applicable policies and procedures within two weeks of employment.

(1) The center must develop written medication policies that ((are)) support and promote safe medication storage and administration for each participant and meet the requirements of chapter 69.41 RCW and chapter 246-88 WAC and other applicable statutes. These policies must be explained and accessible to all staff, contractors, volunteers, and participants that have responsibility in this area. ((At a minimum, policies must meet the following requirements:

(2) Participants who need to take medications while at the center, and who are able to self medicate, must be encouraged and expected to bring and take their own medications as prescribed. Some participants may need assistance with their medications, and ((a few)) some may need to have their medications administered by qualified program staff.

(3) In order for the center staff to administer any prescribed medication, there must be a written authorization from the participant's authorizing practitioner stating that the medication is to be administered at the program site.

(4) Staff must be trained to observe medication usage and effects, and to document and report any concerns or difficulties with medications.

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

(2) Centers must have available a current floor plan of the facility indicating usage of space with interior measurements, building inspection report from the local, city or county, building department, if applicable, fire department inspection report, and the local health department kitchen inspection report and permit if operating ((a)) an on-site kitchen.

(3) ((The facility must comply with applicable state, county, and local building regulations, zoning, fire, and health codes or ordinances.

(4))) When possible, the facility should be located at street level. If the facility is not located at street level, it is essential to have a ramp and/or elevators. All new adult day service centers contracted with the department after February 1, 2014 must have a ramp, at least a 1:12 slope, for emergency evacuation if the center has any step or stairs to be navigated during an emergency evacuation. An evacuation plan for relocation of participants to another building must also be in place in the event of an emergency. The center must post a floor plan of the center and indicate the evacuation route from each room to the outside meeting place.

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

(6) Each center must provide appropriate hardware on doors of storage rooms, closets, bathrooms, and other rooms to prevent participants from being accidentally locked in.

(7) When possible, the location should be within a transit authority's core service area.

Centers must provide meal service to all participants as outlined in WAC 388-71-0704 and 388-71-0706

(1) All meals provided are to meet one-third of the minimum required daily allowance or dietary reference intake as determined by the Food and Nutrition Board of the Institute of Medicine.

(2) The center must ensure that food served meets nutritional needs, takes into consideration individual and ethnic preferences to the extent reasonably possible, caloric need, special dietary requirements, and any physical condition making food intake difficult.

(3) The center must provide a variety of foods and not repeat menus for a minimum of three weeks.

(4) Participant input must be gathered when planning meals.

(5) Menus must be posted at least one week in advance; indicate the date, day of the week, month and year; and include all food and snacks served that contribute to nutritional requirements.

(6) Nutrient concentrates, supplements, and dysphagia-modified diets related to a choking or aspiration risk, are to be served only with the written approval of the participant's ((physician)) authorizing practitioner.

(7) Safe and sanitary handling, storage, preparation, and serving of food must be assured. If meals are prepared on the premises, kitchen appliances, food preparation area, and equipment must meet state and local requirements and pass inspections annually.

(8) All staff and volunteers handling or serving meals must have the appropriate food handler's permits, if applicable.

(9) In the event meals are prepared at a separate kitchen facility, the adult day center must ensure that persons preparing food have a food handler's permit and that the food is transported in airtight containers to prevent contamination.

(10) The center must ensure that the food is transported and served at the appropriate and safe temperature.

(1) A written emergency/disaster/earthquake plan must be ((posted)) readily available to all staff at each program site and in all program owned vehicles. Staff must be trained to ensure smooth implementation of the emergency plan.

(2) All staff and volunteers must be trained in evacuation/fire safety procedures.

(3) ((A)) The center's written illness/injury/medical emergency/death procedure must be followed in the event a participant becomes ill, is injured, or dies. The procedures must be ((posted in at least one visible location at all program sites)) readily available to all staff during program hours and must be explained to staff, volunteers, and participants. ((The procedures must describe arrangements for hospital inpatient and emergency room service and include directions on how to secure ambulance transportation and complete incident reports.))

(4) Procedures for fire safety as approved by the local fire authority must be adopted and ((posted)) readily available to all staff, including provisions for fire drills, inspection and maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. The center must conduct and document quarterly fire drills and document the center's ability to meet procedures. Improvements must be based on the fire drill evaluation. The center must post their building's floor plan with evacuation route from each room to the outside pre-determined meeting place. Smoke detectors must also be used and serviced on a routine basis per the center's policy.

(5) Each center must provide adequate emergency lighting or flashlights in all areas.

(6) Each center must provide and maintain first aid kits with manuals in adequate numbers to meet the needs of the participant and staff.

(7) Each center must ensure, in accordance with local emergency procedures, that supplies, food, water and equipment are available in the event power, heat and/or electricity are not available during an emergency.

(1) ((Every)) All adult day ((center)) centers must develop ((a)) an annual quality improvement plan((, with)) that identifies specific concerns regarding the quality of care and services to clients. The plan must also include a description of the plan of action that would address the concerns. The plan must have specific measurable objectives, designed to meet requirements of any licensing, funding sources, professional standards, or regulatory compliance.

(2) Policies and procedures for monitoring program quality and determining further action must be developed by the administrator with the advice of the multidisciplinary staff team and the advisory committee, and with the approval of the governing body and center clients and/or representatives.

(3) Quality assurance and improvement plans may include but are not limited to annual program evaluations, utilization reviews, ((participant)) participants' and former participants' satisfaction surveys, and sampling participant ((improvement and/or care plan audits)) care plans to audit for assurances of meeting the WAC requirements.

WAC 388-71-0702 through 388-71-0776 ((are)) is effective February 1, 2014.