WSR 17-22-119

PROPOSED RULES

DEPARTMENT OF HEALTH

[Filed October 31, 2017, 1:31 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 15-18-100.

Title of Rule and Other Identifying Information: Chapter 246-335 WAC, In-home services agencies, updating licensing and operational rules. The department is proposing a reorganization and clarification of its in-home services agencies chapter to bring it in line with current standards of practice and reassess fees.

Hearing Location(s): On December 6, 2017, at 1:00 p.m., at the Department of Health, Point Plaza East, 310 Israel Road S.E., Room 152, Tumwater, WA 98501.

Date of Intended Adoption: December 27, 2017.

Submit Written Comments to: John Hilger, Department of Health, P.O. Box 47852, Olympia, WA 98504-7852, email https://fortress.wa.gov/doh/policyreview, fax 360-236-2901, by December 6, 2017.

Assistance for Persons with Disabilities: Contact John Hilger, phone 360-236-2929, fax 360-236-2901, TTY 360-833-6388 or 711, email john.hilger@doh.wa.gov, by December 1, 2017.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of the proposed rule is to amend, repeal, and add new sections to chapter 246-335 WAC to promote safe and quality care for individuals receiving services from licensed in-home services agencies. The last comprehensive chapter update took place in 2002. The proposed rule represents a thorough chapter revision which includes a significant restructuring of WAC sections in order to clarify the requirements for each service category (home care, home health, and hospice). This restructuring requires repealing most of the current sections and moving content into newly created number sections. The proposed rule also updates language and terminology to represent current industry standards and practices.

Reasons Supporting Proposal: (1) Stakeholders participated in eight rules workshops and were invested in partnering with the department to craft the proposed rule language. (2) Restructuring chapter sections will better assist licensees in navigating the rules and understanding service category specific requirements. (3) Updating language and terminology to reflect current industry standards and practices will modernize the rules. (4) Clarifying existing requirements and adding new requirements will promote increased safety and quality of care for clients and patients.

Statutory Authority for Adoption: RCW 70.127.120, 43.70.250.

Statute Being Implemented: Chapter 70.127 RCW, RCW 43.70.250.

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

Name of Proponent: Department of health, governmental.

Name of Agency Personnel Responsible for Drafting and Implementation: John Hilger, 111 Israel Road S.E., Tumwater, WA, 360-236-2929; and Enforcement: Nancy Tyson, 111 Israel Road S.E., Tumwater, WA, 360-236-4796.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting John Hilger, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-2929, fax 360-236-2910, TTY 360-833-6388 or 711, email john.hilger@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect; rules set or adjust fees under the authority of RCW 19.02.075 or that set or adjust fees or rates pursuant to legislative standards, including fees set or adjusted under the authority of RCW 19.80.045; and rules adopt, amend, or repeal a procedure, practice, or requirement relating to agency hearings; or a filing or related process requirement for applying to an agency for a license or permit.

Explanation of exemptions: Although the proposed rule includes new documentation and care standards for licensees, portions of the proposed rule are exempt from requirements of the Regulatory Fairness Act. Either in its entirety or portions thereof, the following proposed sections are exemption [exempt] under RCW 34.05.310 (4)(d): WAC 246-335-301 [246-335-300], 246-335-305, 246-335-310, 246-335-315, 246-335-340, 246-335-345, 246-335-350, 246-335-355, 246-335-405, 246-335-410, 246-335-430, 246-335-435, 246-335-450, 246-335-455, 246-335-505, 246-335-510, 246-335-530, 246-335-535, 246-335-540, 246-335-550, 246-335-555, 246-335-560, 246-335-605, 246-335-610, 246-335-630, 246-335-635, 246-335-640, 246-335-650, 246-335-655, 246-335-660, 246-335-705, 246-335-710, 246-335-712, 246-335-714, 246-335-716, 246-335-718, 246-335-722, 246-335-724, 246-335-726, 246-335-728, 246-335-730, 246-335-732, 246-335-734, 246-335-736, 246-335-738, 246-335-740, 246-335-742, 246-335-744, 246-335-746, 246-335-748, 246-335-750, 246-335-752, 246-335-754, 246-335-756, 246-335-758, 246-335-760, 246-335-762, 246-335-764, 246-335-766, and 246-335-768. The following proposed sections are also exempt under RCW 34.05.310 (4)(g)(ii): WAC 246-335-315, 246-335-320, 246-335-325, 246-335-330, 246-335-340, 246-335-345, and 246-335-350. The following current section is exempt under RCW 34.05.310 (4)(f): WAC 246-335-990 Fees.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The portions of the proposed rule that are significant were analyzed in the cost-benefit analysis as required under RCW 34.05.328 and estimated probable costs were determined. The North American Industry Classification System (NAICS) was used to determine code 621610 (Home Health Care Services) as best representing Washington state licensed home care, home health, and hospice agencies. The United States Census Bureau, County Business Partners 2013 data for Washington state identified the following for NAICS code 621610: Total establishments 304; Annual payroll $352,575. Dividing annual payroll by total establishments results in a one percent minimum threshold in the amount of $11,600. The total costs of the proposed rules range from $901 to $6,509 (contact the department of health for the cost-benefit/significant analysis document for cost details). The high end of the estimated cost impact, $6,509 is below the one percent minimum threshold and therefore it was determined that a small business economic impact statement is not needed.

October 31, 2017

John Wiesman, DrPH, MPH

Secretary

PARTS 1 THROUGH 4

REQUIREMENTS FOR IN-HOME SERVICES AGENCIES LICENSED TO PROVIDE HOME CARE, HOME HEALTH, AND HOSPICE SERVICES

Part 1 – General Requirements Applicable to All Service Categories

NEW SECTION

WAC 246-335-300 Scope and purpose.

(1) These rules implement chapter 70.127 RCW which requires the department of health to set minimum health and safety standards for in-home services agencies licensed to provide home care, home health, hospice, or hospice care center services.

(2) Applicants and licensees must meet the requirements of this chapter and other applicable state and local laws.

(3) This chapter does not apply to services provided by persons exempt from requirements of chapter 70.127 RCW as provided in RCW 70.127.040 and 70.127.050.

NEW SECTION

WAC 246-335-305 Applicability.

The requirements in WAC 246-335-300 through 246-335-660 apply to in-home services agencies licensed to provide home care, home health, and/or hospice services unless otherwise noted in the specific sections. The requirements in WAC 246-335-705 through 246-335-768 apply to hospice care centers. The fee requirements in WAC 246-335-990 apply to all in-home services agencies licensed to provide home care, home health, hospice, and hospice care center services.

NEW SECTION

WAC 246-335-310 Definitions—General.

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

(1) "Activities of daily living" or "ADL" means routine activities performed around the home or in the community and includes:

(a) "Ambulation" means how an individual moves between locations in their immediate living environment and how they move to and return from more distant areas. Assistance with ambulation includes supervising or guiding the client or patient when walking alone or with the help of a mechanical device such as a walker, assisting with difficult parts of walking such as climbing stairs, supervising or guiding the client or patient if they are able to propel a wheelchair, pushing of the wheelchair, and providing constant or standby physical assistance to the client or patient if totally unable to walk alone or with a mechanical device.

(b) "Bathing" means how an individual takes a full-body bath or shower, sponge bath, and transfers in and out of the tub or shower. Assistance with bathing includes supervising or guiding the client or patient to bathe, assisting the client or patient with difficult tasks such as getting in or out of the tub or shower, washing their back and other hard to reach areas, and completely bathing the client or patient if they are totally unable to wash self.

(c) "Body care" means how an individual performs applications of dressings and ointments or lotions to their body, trims their toenails, and applies lotion to their feet. Assistance with body care includes general skin care and the application of over-the-counter ointments or lotions. Body care excludes foot care for clients or patients who are diabetic or have poor circulation, and changing bandages or dressings when sterile procedures are required.

(d) "Dressing" means how an individual puts on, fastens, and takes off all items of clothing, including donning or removing a prosthesis. Assistance with dressing includes supervising or cuing the client or patient to dress and assisting them with difficult tasks such as putting on socks, pants, shoes, and fastening, zipping, or tying clothing related items.

(e) "Eating" means how an individual eats and drinks, regardless of skill. Assistance with eating includes supervising or guiding the client or patient when they are able to feed themselves, assisting with difficult tasks such as cutting food or buttering bread, and orally feeding the client or patient when they are unable to feed themselves.

(f) "Medication management" means how an individual ingests or applies medications or herbal supplements. Assistance with medication management includes reminding, coaching, and handing medication containers to the client or patient.

(g) "Personal hygiene" means how an individual maintains their personal hygiene. Assistance with personal hygiene includes helping the client or patient with combing hair, brushing teeth, shaving, applying makeup, washing and drying face, trimming finger nails, applying nail polish, and perineum (menses care).

(h) "Positioning" means how an individual moves to and from a lying position, turns side to side, and positions their body while in bed, in a recliner, or other type of furniture. Assistance with positioning includes helping the client or patient to assume a desired position, helping with turning, and setting up for the client or patient to perform exercises or active range of motion. Positioning assistance may also include passive range of motion to maintain joint flexibility or prevent complications, such as contractures and pressure sores.

(i) "Toileting" means how an individual uses the toilet room, commode, bedpan, or urinal. Assistance with toileting includes helping the client or patient to and from the bathroom, assisting with bedpan routines, using incontinent briefs, cleaning after elimination, and assisting the client or patient on and off the toilet.

(j) "Transfer" means how an individual moves between surfaces such as to and from a bed, chair, wheelchair, or standing position. Assistance with transferring includes helping the client or patient with getting in and out of a bed or wheelchair or on and off the toilet or in and out of the bathtub. Transfer includes supervising or guiding the client or patient when they are able to transfer, providing steadying assistance, and helping the client or patient when they are able to assist in their own transfers. This does not include transfers when the client or patient is unable to assist in their own transfer or needs assistive devices unless specific training or skills verification has occurred consistent with agency policies and procedures.

(2) "Administrator" means an individual responsible for managing the operation of an agency.

(3) "Advanced directive" means a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. Advanced directives are not intended to guide the actions of emergency medical personnel.

(4) "Area agencies on aging" or "AAA" means an agency established under 42 U.S.C. chapter 35 and designated by the department of social and health services (DSHS) to contract for home care services on behalf of DSHS.

(5) "Authenticated" means a written signature or unique identifier verifying accuracy of information.

(6) "Back-up care" means substitute care for a client or patient arranged by the agency's administration when caregiving staff, aides, or health services cannot be provided as scheduled.

(7) "Client abandonment" or "patient abandonment" occur when an in-home services agency establishes a care relationship with a client or patient, as evidenced by signed admission forms and plan of care, and the agency ends the care relationship without referring to an appropriate alternative agency or caregiver, or not following applicable discharge requirements in WAC 246-335-420, 246-335-520, and 246-335-620.

(8) "Clinical judgment" means an interpretation or conclusion by a physician licensed under chapter 18.57 or 18.71 RCW, a podiatric physician and podiatric surgeon licensed under chapter 18.22 RCW, an advanced registered nurse practitioner licensed under chapter 18.79 RCW, a registered nurse licensed under chapter 18.79 RCW, a physical therapist licensed under chapter 18.74 RCW, an occupational therapist licensed under chapter 18.59 RCW, or a speech and language therapist licensed under chapter 18.35 RCW about a client or patient's needs, concerns, or health problems. Clinical judgment includes the decision to take action or not, use or modify standard approaches, or improvise new ones as deemed appropriate by the client or patient's response.

(9) "Contractor" means a person who is self-employed who enters into agreement with an in-home services agency to provide client or patient care services or equipment.

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

(11) "Directed plan of correction" means a plan developed by the department, based on a current statement of deficiencies and a licensee's survey history, which specifies the corrective actions the licensee must take and time frames in which those actions are to be completed.

(12) "Document" means the process of recording information relating to client or patient care verified by signature or unique identifier, title, and date.

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

(14) "Family" means individuals who are important to, and designated by, the patient or client and who need not be relatives.

(15) "Health care professional" means an individual who provides health or health-related services within the individual's authorized scope of practice and who is licensed, registered or certified under Title 18 RCW.

(16) "In-home services agency" means a person licensed to administer or provide home health, home care, hospice services, or hospice care center services directly or through a contract arrangement to individuals in a place of temporary or permanent residence.

(17) "In-home services category" means home care, home health, hospice, or hospice care center services.

(18) "Instrumental activities of daily living" or "IADL" means routine activities performed around the home or in the community and includes:

(a) "Meal preparation" means how an individual prepares their meals. Assistance with meal preparation includes planning meals for clients or patients, cooking, assembling ingredients, setting out food, utensils, and cleaning up after meals.

(b) "Ordinary housework" means how an individual performs ordinary work around the house. Assistance with ordinary housework includes washing dishes and cookware, dusting, vacuuming, mopping, making bed, tidying up, laundry, taking out garbage, or other like activities.

(c) "Essential shopping" means how an individual completes shopping tasks to meet their health and nutritional needs. Assistance with essential shopping includes trips in the local area to shop for food, medical necessities and household items required specifically for a client or patient's health, maintenance, or well-being. Shopping assistance can be done with a client or patient or on their behalf. Within the context of IADL services, essential shopping does not include client or patient transfer assistance.

(d) "Wood supply" means how an individual supplies their home with wood when wood is used as the sole source of fuel for heating or cooking. Assistance with wood supply includes splitting, stacking, carrying wood, or other like activities.

(e) "Travel to medical services" means how an individual travels by vehicle, bus, or taxi to a physician's office or clinic in the local area to obtain medical diagnosis or treatment. Assistance with travel to medical services includes driving the client or patient yourself, or traveling as a support person in a personal vehicle, bus, or taxi. Within the context of IADL services, travel to medical services does not include client or patient transfer assistance.

(f) "Managing finances" means how an individual manages their personal finances. Assistance with managing finances includes helping the client or patient to pay bills, balance checkbook, or other like activities.

(g) "Telephone use" means how an individual makes and receives telephone calls and text messages. Assistance with telephone use includes bringing a phone to the client or patient, helping with dialing numbers, helping with sending and retrieving text messages, helping with general phone operation, or other like activities.

(19) "Licensee" means the person to whom the department issues the in-home services license.

(20) "Managed care plan" means a plan controlled by the terms of the reimbursement source.

(21) "Mandatory reporter" means an administrator, authorizing practitioner, director of clinical services, health care professional, home care aide, home health aide, medical director, licensed nurse, social worker, supervisor of direct care services, therapist, therapy assistant, volunteer, or other individuals associated with an in-home services agency.

(22) "Medication self-administration with assistance" means reminding or coaching the client or patient to take their medication, handing the medication container to the client or patient, opening the medication container, using an enabler, or placing the medication in the hand of the client or patient, along with other assistance, as defined by the pharmacy quality assurance commission in chapter 246-888 WAC.

(23) "Minimum health care credentialing" or "minimum credentialing" means the minimum credential level necessary to provide safe and quality care to adequately meet the care needs of clients and patients:

(a) For home care agencies, minimum health care credentialing is a certified home care aide or higher credential. Minimum health care credentialing is not required for long-term care workers who meet the exemption criteria in chapter 246-980 WAC;

(b) For home health and hospice agencies, minimum health care credentialing is a certified nursing assistant or higher level health care credential necessary to meet patient care needs.

(24) "Nonmedical services" means ADL and IADL tasks which do not require clinical judgment and are ordinarily performed by the client or patient, which if not for the client or patient's functional, physical, or mental limitation(s), would be completed independently by the client or patient, or family.

(25) "Nursing assistant certified" means an individual certified as a nursing assistant under chapter 18.88A RCW.

(26) "Nursing assistant registered" means an individual registered as a nursing assistant under chapter 18.88A RCW.

(27) "Nurse delegation" means the process, as described in RCW 18.79.260 (3)(e), WAC 246-840-910 through 246-840-970, and 246-980-130, a registered nurse takes to transfer the performance of selected nursing tasks in selected situations to competent nursing assistants or home care aides. The registered nurse delegating the task retains the responsibility and accountability for the nursing care of the client or patient. Except for the delegation of the administration of insulin by injection for the purpose of caring for individuals with diabetes, nurse delegation does not include delegating the administration of medications by injection, sterile procedures, and central line maintenance.

(28) "Occupational exposure" means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of the employee's duties.

(29) "One-time visit" means a single visit by one individual to provide home care, home health, or hospice services with no predictable need for continuing visits, not to exceed twenty-four hours.

(30) "On-site" means the location where client or patient services are provided.

(31) "Person" means any individual, business, firm, partnership, corporation, company, association, joint stock association, public or private organization, or the legal successor thereof that employs or contracts with two or more individuals.

(32) "Personnel" means individuals employed and compensated by the licensee.

(33) "Plan of care" means a written document based on assessment of individual needs that identifies services to meet these needs.

(34) "Plan of correction" means a licensee authored document based on a statement of deficiencies, and includes specific corrective actions that must be taken to correct identified deficiencies to include, but not limited to:

(a) How the deficiency will be or was corrected;

(b) What measures or monitors will be put in place to ensure the deficient practice does not recur;

(d) When each deficiency will be corrected.

(35) "Physician orders for life sustaining treatment" or "POLST" means a set of medical orders intended to guide emergency medical personnel in the initial treatment for persons with advanced life limiting illness based on their current medical condition and goals. The POLST form is not a living will or advanced directive but a physician order that communicates the details of those documents.

(36) "Quality improvement" means reviewing and evaluating appropriateness and effectiveness of services provided under this chapter.

(37) "Range of motion" or "ROM" means the extent or limit to which a part of the body can be moved around a joint or a fixed point; the totality of movement a joint is capable of doing. ROM exercises are active or passive movements to assess, maintain, or restore the motion of joints in the body:

(a) "Active range of motion." Independent exercises performed by an individual to restore or maintain their joint function to its optimal range (may require cuing or reminders by an agency worker).

(b) "Passive range of motion." Exercises performed by a trained individual to restore or maintain an individual's joint function to its optimal range when they are unable to independently move their joint. Passive ROM involves performing movements to each joint only to the extent the joint is able to move. Passive ROM, for either restoration or maintenance purposes, may be performed by home health agencies, hospice agencies, and hospice care centers following the established program. Passive range of motion, for maintenance purposes only, may be performed by home care.

(38) "Record" means all documented information, regardless of its characteristics, media, physical form, and the manner in which it is recorded or stored.

(39) "Service area" means the geographic area in which the department has given prior approval to a licensee to provide home health, hospice, or home care services.

(40) "Statement of deficiencies" means a survey or investigation report completed by the department identifying one or more violations of chapter 70.127 RCW or the rules adopted thereunder. The report clearly identifies the specific law or rule that has been violated along with a description of the reasons for noncompliance.

(41) "Survey" means an inspection conducted by the department to evaluate and monitor an agency's compliance with this chapter.

(42) "Vital signs" means clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure that indicate the state of a client or patient's essential body functions.

(43) "Volunteer" means an individual who provides direct care to a client or patient and who:

(a) Is not compensated by the in-home services licensee; and

(b) May be reimbursed for personal mileage incurred to deliver services; and

Volunteers providing services to vulnerable persons are considered permissive reporters and are subject to the mandatory reporting laws in chapters 74.34 and 26.44 RCW.

(44) "Vulnerable person" means a person:

(a) Sixty years of age or older who has the functional, mental, or physical inability to care for himself or herself;

(b) Found incapacitated under chapter 11.88 RCW;

(d) Admitted to any facility; or

(e) Receiving services from home care, home health, or hospice agencies licensed or required to be licensed under chapter 70.127 RCW.

NEW SECTION

WAC 246-335-315 License required.

A person must possess a current license issued by the department before advertising, operating, managing, conducting, opening or maintaining an in-home services agency unless exempt under RCW 70.127.040 or 70.127.050. Any person who employs or contracts with two or more individuals to provide any one or combination of in-home services as defined by chapter 70.127 RCW and this chapter is subject to licensure.

NEW SECTION

WAC 246-335-320 Initial application.

An applicant for initial licensure must:

(1) Complete a department sponsored in-home services orientation class prior to submitting a state licensing application. The purpose of the orientation class is to provide prospective applicants an overview of the state licensing process, explain the differences between home care, home health, and hospice service categories, and department expectations of licensees providing care to vulnerable persons.

(2) Submit to the department:

(a) A completed initial licensing application on forms provided by the department;

(b) Evidence of current commercial general liability insurance indicating the following minimum coverage:

(i) Bodily injury, property damage, and contractual liability, in the amount of one million dollars per occurrence; or

(ii) Combined single limit coverage of two million dollars.

(d) Copies of criminal history background checks and disclosure statements in accordance with the following:

(i) RCW 43.43.830 through 43.43.842;

(A) For home care agencies, copies are required for the administrator and the supervisor of direct care services;

(B) For home health agencies and hospice agencies, copies are required for the administrator and the director of clinical services;

(ii) Criminal history background checks must be processed through the Washington state patrol;

(iii) Disclosure statements must be approved by the department; and

(vi) Criminal history background checks and disclosure statements must be obtained within three months of the application date.

(e) A description of the agency's organizational structure. For example, an organizational chart or narrative describing key positions and duties;

(f) A copy of the current business license(s);

(g) Policies and procedures addressing the content of this chapter for the service category(ies) to be provided. Policies and procedures must clearly demonstrate compliance with the applicable chapter requirements.

(i) Home care agency policies and procedures will not reference federal medicare requirements and may only reference an accrediting organization's requirements if they are accredited by that organization.

(ii) Home health and hospice agency policies and procedures may only reference federal medicare requirements or accrediting organization requirements if they are medicare certified or accredited;

(h) A copy of the in-home services orientation class certificate of completion;

(i) Other information as required by the department; and

(j) Fees specified in WAC 246-335-990.

(3) An applicant must meet the requirements of this chapter as determined by an initial announced survey conducted by the department.

(4) With the exception of a hospice care center applicant, an applicant has nine months from the application submission date to complete all steps required for initial licensure or adding one or more service categories to an existing license.

(a) The department may close out an application, with no refund of licensing fees being issued, if an applicant has not completed all steps required for licensure within nine months.

(b) An applicant whose application has been closed due to the nine-month time period lapsing is eligible to reapply at any time by submitting an initial application and appropriate fees.

(5) A licensee adding a new service category to their existing license must comply with subsections (2), (3) and (4) of this section. Licensees are not required to complete an orientation class in order to add a new service category to their license.

NEW SECTION

WAC 246-335-325 License renewal.

At least thirty days before the expiration date of the current license, the licensee must submit to the department:

(1) A completed renewal licensing application on forms provided by the department;

(2) Evidence of continuing insurance coverage according to WAC 246-335-320 (2)(b);

(3) A completed and signed full-time equivalent employee worksheet on forms provided by the department;

(4) Copies of the most current criminal history background checks and disclosure statements for the administrator, director of clinical services, or supervisor of direct care services in accordance with WAC 246-335-320 (2)(d). All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check;

(5) A description of the agency's current organizational structure. For example, an organizational chart or narrative describing key positions and duties;

(6) Documentation required under WAC 246-335-350, if initially applying or reapplying for substantial equivalency status;

(7) Other information as required by the department; and

(8) Fees specified in WAC 246-335-990.

NEW SECTION

WAC 246-335-330 Change of ownership.

A change of ownership on an in-home services agency includes any of the following:

(1) Transferring ownership, either whole or part, to a new owner;

(2) Dissolving a partnership or corporation;

(3) Merging with another entity taking on that entity's identity;

(4) Consolidating with another entity, creating a new identity; or

(5) A change of the unified business identifier number and/or federal employer identification number.

(6) At least thirty days prior to changing ownership of an in-home services agency, the licensee must submit to the department a change of ownership form as provided by the department. The form must include:

(a) The full name, address and phone number of the current and prospective owner;

(b) The name, address, and phone number of the currently licensed in-home services agency and the name under which the prospective agency will operate; and

(7) At least thirty days prior to changing ownership of an in-home services agency, the prospective new owner must submit a change of ownership application, on forms provided by the department:

(a) Information listed in WAC 246-335-320 (2)(a) through (f); and

(b) The change of ownership fee specified in WAC 246-335-990.

(8) Home health or hospice agencies that are certified by the Centers for Medicare and Medicaid Services must inform the department's certificate of need program of the pending change in ownership and receive program approval before the state change of ownership application can be approved.

(9) The department may conduct a survey after the change of ownership approval to assess the new ownership's delivery of care to clients or patients.

NEW SECTION

WAC 246-335-335 Applicant or licensee responsibilities.

An applicant or licensee must:

(1) Comply with the provisions of chapter 70.127 RCW and this chapter;

(2) Maintain at least one in-state office location where records are kept, secured, and accessible;

(3) Display the license issued by the department in an area within the main office that is visible to the public, including branch office locations if applicable;

(4) Cooperate with the department during surveys which may include reviewing licensee records and conducting on-site visits with client or patient consent;

(5) Notify the department in writing within thirty days of any of the following:

(a) Changes of administrator, director of clinical services, or supervisor of direct care services;

(b) Beginning or ceasing operation of any office location(s);

(d) Decreasing home care, home health, or hospice service areas; and

(e) Survey or monitoring decisions and findings from a department approved accrediting organization, DSHS, or area agency on aging for agencies approved through substantial equivalency according to WAC 246-335-350.

(6) Request approval to expand state licensing home care, home health, or hospice service areas, by submitting an amended application, on forms provided by the department, which lists all service areas for which the agency is seeking approval and information based on the criteria in WAC 246-335-415(6), 246-335-515(6), or 246-335-615(6).

(a) To request approval to expand services areas for home health or hospice agencies that are certified by the Centers for Medicare and Medicaid Services, a licensee must contact the department's certificate of need program and follow their separate application and approval process.

(b) Licensees must receive department approval for service area expansion prior to providing services in the proposed expanded service area(s).

NEW SECTION

WAC 246-335-340 Survey and investigation.

To ensure compliance with chapters 246-335 WAC and 70.127 RCW, the department may:

(1) Conduct unannounced surveys at any time and at least once during a licensure period, except for agencies approved through substantial equivalency according to WAC 246-335-350;

(2) Survey a licensee at any time if the department has reason to believe the licensee is providing unsafe, insufficient, inadequate or inappropriate client or patient care;

(3) Investigate any person suspected of advertising, operating, managing, conducting, opening or maintaining an in-home services agency or providing in-home services, including hospice care center services, without a license unless exempt from licensure under RCW 70.127.040 and 70.127.050;

(4) Investigate complaints against in-home services licensees that allege noncompliance with chapter 70.127 RCW and this chapter;

(5) Investigate allegations of noncompliance with RCW 43.43.830 through 43.43.842, and, when necessary, in consultation with law enforcement personnel; and

(6) Require the licensee to complete additional criminal history background checks and disclosure statements for an individual associated with the licensee or having direct contact with children under sixteen years of age, people with developmental disabilities, or vulnerable persons if the department has reason to believe that offenses specified under RCW 43.43.830 have occurred since completion of the previous disclosure statement and criminal background inquiry.

NEW SECTION

WAC 246-335-345 Statement of deficiencies, plan of correction, and enforcement action.

To ensure compliance with chapters 246-335 WAC and 70.127 RCW, the department may:

(1) Issue a statement of deficiencies following a survey which identifies noncompliance with chapter 70.127 RCW and this chapter. The statement of deficiencies will include a brief statement of what is required to achieve compliance, the date by which the department requires compliance to be achieved, contact information for any technical assistance services provided by the department, and notice of the process and timeline for requesting an extension of time for good cause to achieve compliance.

(2) Require licensee to submit a written plan of correction within ten working days of receipt of the statement of deficiencies to address deficiencies that are determined to not be significant, broadly systemic, or recurring.

(a) Under this chapter, a "plan of correction" is a form developed by the department and completed by the licensee that describes:

(i) How each deficiency will be or was corrected;

(ii) What measures or monitors will be put in place to ensure the deficiencies do not recur;

(iii) Who is responsible for correcting each deficiency; and

(iv) When each deficiency will be or has been corrected.

(b) The licensee must complete all corrections within sixty days, unless the department authorizes a longer time frame for correction of some of the deficiencies. Implementation of the plan of correction is subject to verification by the department.

(3) Issue a directed plan of correction following a survey which identifies deficiencies that are determined to be significant, broadly systemic, and are not in the categories specified in RCW 70.127.180(3) for which a licensee may be subject to a formal enforcement action.

(a) The department may choose to issue a directed plan of correction if the department deems the plan of correction submitted by the licensee to be unacceptable because the actions proposed will not correct the deficiencies, will take too long, or fails to protect the public health, safety, and welfare;

(b) Implementation, progression, and completion of the directed plan of correction may be verified by the department.

(4) Deny, restrict, condition, modify, suspend, or revoke a license and assess civil monetary penalties as authorized in RCW 70.127.170 and 70.127.180(3).

(5) Summarily suspend or limit a license pending an enforcement action as authorized in RCW 34.05.479 if deficiencies are identified that pose an imminent risk of harm to clients or patients.

(6) The licensee shall sign and return the completed plan of correction or directed plan of correction to the department on or before the required date.

(7) Neither the requirement to submit a plan of correction nor a directed plan of correction is an agency action for which an adjudicative hearing must be afforded to the licensee.

(8) The failure to correct the deficiencies in the statement of deficiencies or the failure to comply with the plan of correction or directed plan of correction may be grounds for an action against the license or a civil monetary penalty under RCW 70.127.170 and 70.127.180(3).

(9) If the department initiates action to deny, restrict, condition, modify, suspend or revoke a license or to assess civil monetary penalties as authorized in RCW 70.127.170 and 70.127.180(3), the applicant or licensee will be afforded an adjudicative hearing opportunity under chapter 34.05 RCW, RCW 43.70.115, and chapter 246-10 WAC.

NEW SECTION

WAC 246-335-350 Substantial equivalency to the state survey requirement.

To ensure compliance with chapters 246-335 WAC and 70.127 RCW, the following substantial equivalency options apply that satisfy the state survey requirement:

(1) An in-home services licensee that is approved to provide home health or hospice services and is certified by the federal medicare program is not subject to the state survey requirement when the following have been met:

(a) The department has determined that the applicable survey standards of the certification program are substantially equivalent to those required by this chapter and chapter 70.127 RCW;

(b) Verification that an on-site medicare survey has been conducted during the previous twenty-four months; and

(c) The licensee or the federal medicare program submits to the department the information required in subsection (4) of this section.

(2) An in-home services licensee that is approved to provide home health or hospice services and is accredited by a department approved certification or accrediting organization is not subject to the state survey requirement when the following have been met:

(a) The department has determined that the applicable survey standards of the certification or accrediting program are substantially equivalent to those required by this chapter and chapter 70.127 RCW;

(b) Verification that an on-site accreditation survey has been conducted during the previous twenty-four months; and

(c) The licensee or the certification or accrediting program submits to the department the information required in subsection (4) of this section.

(3) An in-home services licensee that is approved to provide home care services under contract with and monitored by DSHS or the AAA to provide home care services is not subject to the state survey requirement when the following have been met:

(a) The department has determined that the applicable survey standards of DSHS or the AAA are substantially equivalent to those required by this chapter and chapter 70.127 RCW;

(b) Verification that an on-site DSHS or AAA monitoring has been conducted during the previous twenty-four months;

(d) DSHS or the AAA submits to the department copies of monitoring reports and other relevant reports or finding that indicate compliance with licensure requirements, and the monitoring reports include samples of private pay clients, if applicable.

(4) An in-home services licensee that is approved to provide home health or hospice services and is accredited by a department approved accrediting organization or certified by the federal medicare program, that wants to be exempt from the state survey requirement as authorized in RCW 70.127.085, must submit to the department:

(a) Verification of initial or ongoing accreditation or certification; and

(b) A copy of the most recent decisions and findings of the accrediting organization or the federal medicare program based on an on-site survey within the twenty-four month period preceding the request for state survey exemption.

(5) Nothing in this section shall prevent the department from:

(a) Conducting validation surveys of agencies consistent with RCW 70.127.085;

(b) Conducting initial surveys for applicants applying for initial licensure or licensees applying to add a new service category to their existing license under this chapter;

(c) Surveying in-home services licensees who have service categories that are not medicare certified, accredited, or monitored by DSHS or the AAA; and

(d) Investigating complaints against in-home services licensees approved through substantial equivalency.

NEW SECTION

WAC 246-335-355 Exemptions and alternative methods.

To request an exemption from specific requirements in this chapter, the applicant or licensee must submit a written request to the department including:

(1) A description of the requested exemption and alternatives, if appropriate;

(2) Rationale for the exemption;

(3) Impact of the exemption on public health and safety; and

(4) Any other information the department requests.

(5) The department may grant the applicant or licensee an exemption from a requirement of this chapter if:

(a) The department determines the exemption will not jeopardize public health or safety; and

(b) The exemption is not contrary to the intent of chapter 70.127 RCW and the requirements of this chapter.

(6) The licensee must retain a copy of each approved exemption and have them available at all times.

(7) An exemption is limited to a specific requirement and for the licensee who receives it. The exemption does not apply to a new owner due to a change of ownership under WAC 246-335-330.

Part 2 - Requirements Specific to Home Care Agency Services

NEW SECTION

WAC 246-335-405 Applicability.

The requirements in WAC 246-335-405 through 246-335-455 apply to all in-home services agencies licensed to provide home care services.

NEW SECTION

WAC 246-335-410 Definitions—Home care.

The definitions in this section apply throughout WAC 246-335-405 through 246-335-455 unless the context clearly indicates otherwise:

(1) "Certified home care aide" or "home care aide" means an individual credentialed under chapters 18.88B RCW and 246-980 WAC.

(2) "Client" means an individual receiving home care services.

(3) "Comprehensive assessment reporting evaluation" or "CARE" means the DSHS assessment tool used by case managers to document a client's functional ability, determine eligibility for long-term care services, evaluate what and how much assistance a client will receive, and develop a plan of care.

(4) "Home care agency" means a person administering or providing home care services directly or through a contract arrangement to individuals in places of permanent or temporary residence. A home care agency that provides delegated tasks of nursing under RCW 18.79.260 (3)(e) is not considered a home health agency for purposes of this chapter.

(5) "Home care services" means nonmedical services and assistance provided to ill, disabled, or vulnerable individuals that enable them to remain in their residences. Home care services include, but are not limited to: Personal care such as assistance with dressing, feeding, and personal hygiene to facilitate self-care; homemaker assistance with household tasks, such as housekeeping, shopping, meal planning and preparation, and transportation; respite care assistance and support provided to the family; or other nonmedical services or delegated tasks of nursing under RCW 18.79.260 (3)(e).

(6) "Long-term care worker" means an individual providing hands-on personal care services to the elderly or persons with disabilities according to RCW 74.39A.009. A long-term care worker employed by a home care agency is either credentialed as a certified home care aide under chapters 18.88A RCW and 246-980 WAC or meets the exemption criteria according to chapter 246-980 WAC.

(7) "Supervisor of direct care services" means an individual responsible for services that support the plan of care provided by an in-home services agency licensed to provide home care services.

NEW SECTION

WAC 246-335-415 Plan of operation.

The applicant or licensee must develop and implement a plan of operation which includes:

(1) A description of the organizational structure;

(2) Personnel job descriptions according to WAC 246-335-425(2);

(3) Responsibilities of contractors and volunteers;

(4) Services to be provided;

(5) The days and hours of agency operation; and

(6) Criteria for management and supervision of home care services throughout all approved service areas, which includes:

(a) How the initial intake and development of the plan of care will be completed per WAC 246-335-440;

(b) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-445;

(c) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-425 (14) and (15); and

(d) How the quality improvement program required in WAC 246-335-455 will be applied throughout all approved service areas.

(7) A process to inform clients of alternative services prior to ceasing operation or when the licensee is unable to meet the client's needs;

(8) A plan for preserving records, including the process to preserve or dispose of records prior to ceasing operation according to WAC 246-335-450 (7) and (8); and

(9) Time frames for filing documents in the client records;

(10) Emergency preparedness that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal agency operation. Include, at minimum: Risk assessment and emergency planning, communication plan, informing local officials of clients in need of evacuation, and staff training and drills to test emergency plan;

(11) The applicant or licensee must identify an administrator. The administrator must be a home care employee and possess education and experience required by the agency's policies. The administrator is responsible to:

(a) Oversee the day-to-day operation and fiscal affairs of the agency;

(b) Implement the provisions of this section;

(d) Provide management and supervision of services throughout all approved service areas according to subsection (6) of this section;

(e) Arrange for necessary services;

(f) Keep contracts current and consistent with WAC 246-335-425(4);

(g) Serve as a liaison between the licensee, personnel, contractors and volunteers;

(h) Ensure personnel, contractors and volunteers are currently credentialed by the state of Washington, when appropriate, according to applicable practice acts and consistent with WAC 246-335-425(5);

(i) Ensure personnel, contractors and volunteers comply with the licensee's policies and procedures;

(j) Implement a quality improvement process consistent with WAC 246-335-455;

(k) Manage recordkeeping according to WAC 246-335-450;

(l) Ensure supplies and equipment necessary to client care are available, maintained, and in working order;

(m) Ensure the accuracy of public information materials; and

(n) Ensure current written policies and procedures are accessible to personnel, contractors, and volunteers during hours of operation.

(12) The licensee must continue to update its plan of operation to reflect current practice, services provided by the agency, and state and local laws.

NEW SECTION

WAC 246-335-420 Delivery of services.

The applicant or licensee must develop and operationalize delivery of services policies and procedures that describe:

(1) Admission, transfer, discharge, and referral processes:

(a) In order to minimize the possibility of client abandonment, clients must be given at least a forty-eight hour written or verbal notice prior to discharge that will be documented in the client record;

(b) Forty-eight hour notice is not required if home care agency worker safety, significant client noncompliance, or client's failure to pay for services rendered are the reason(s) for the discharge;

(c) A home care agency discharging a client that is concerned about their ongoing care and safety may submit a self-report to appropriate state agencies which identifies the reasons for discharge and the steps taken to mitigate safety concerns;

(2) Specific nonmedical services available to meet client, or family needs as identified in the plan of care;

(3) Home care services starting within seven calendar days of receiving and accepting a referral for services. Longer time frames are permitted when one or more of the following is documented:

(a) Longer time frame for the start of services is requested by the client, designated family member, or legal representative, or referral source;

(b) Longer time frame for the start of services is agreed upon by the client, designated family member, or legal representative, or referral source in order for agency to select and hire an appropriate caregiver to meet the needs of the client;

(c) Start of services was delayed due to agency having challenges contacting client, designated family member, or legal representative;

(d) Home care agencies under contract with DSHS or the AAA may follow different time frames for the start of services as established in the terms of the contract.

(4) Agency personnel, contractor, and volunteer roles and responsibilities related to medication self-administration with assistance;

(5) Coordination of care, including:

(a) Coordination among services being provided by a licensee having an additional home health or hospice service category; and

(b) Coordination with other agencies when the care being provided impacts client health;

(6) Actions to address client, or family communication needs;

(7) Emergency care of the client;

(8) Providing back-up care to the client when services cannot be provided as scheduled. Back-up care which requires assistance with client ADLs must be provided by staff with minimum credentialing or workers who meet the exemption criteria in chapter 246-980 WAC. Noncredentialed staff may provide back-up care only when assisting a client with IADLs or in emergency situations;

(9) Actions to be taken upon death of a client;

(10) Actions to be taken when client has a signed advanced directive;

(11) Actions to be taken if a client has a signed POLST form. Any section of the POLST form not completed implies full treatment for that section. At minimum, include: In the event of a client medical emergency and agency staff are present, provide emergency medical personnel with a client's signed POLST form;

(12) If the home care agency chooses to offer assistance with taking vital signs, then relevant policies and procedures must comply with the following minimum requirements:

(a) Assistance with taking vital signs for informational purposes only, due to client being unable to complete tasks independently. Home care agency workers may only assist clients in the process of taking their own vital signs. Examples of assistance include, but are not limited to, handing client a digital thermometer, sliding blood pressure cuff over client's arm, turning on a device, recording digital readings and communicating those readings back to the client, designated family member, or legal representative. Devices used must be electronically operated with digital readouts; and

(b) Assistance with taking vital signs to determine when to take or exclude prescribed medications, or what dosage of medication to take due to client being unable to complete tasks independently. Agencies must contract with a registered nurse to determine if nurse delegation is appropriate and train agency worker(s) on taking specific vital signs and to understand how the readings relate to the medications that the client needs to take;

(13) If a home care agency chooses to offer assistance with passive range of motion exercises for maintenance purposes only, then relevant policies and procedures must comply with the following minimum requirements:

(a) Ensure the client provides the agency with a copy of their passive range of motion exercise plan established by a physical therapist licensed under chapter 18.74 RCW, an occupational therapist licensed under chapter 18.59 RCW, or qualified registered nurse licensed under chapter 18.79 RCW. The date of the plan must be within twelve months of requesting assistance with passive range of motion. The plan must clearly state that the passive range of motion is for maintenance purposes only. Passive range of motion for purposes of restoring joint function is outside the scope of a home care agency to provide;

(b) If the exercise plan is older than twelve months or does not clearly state for maintenance purposes only, the agency will direct client to get an updated or new passive range of motion plan from their health care provider;

(c) Ensure and document passive range of motion skills verification of assigned agency workers, consistent with WAC 246-335-425(9), prior to the provision of these services;

(d) Ensure clients receiving passive range of motion submit to the agency an updated exercise plan from their health care provider at least annually; and

(14) Nurse delegation according to the following:

(a) Delegation is only permitted for stable and predictable clients requiring specific nursing tasks that do not require clinical judgment;

(b) Home care agencies are not required to provide nurse delegation services and do not need a policy if they do not provide these services;

(i) Contract with a registered nurse for any client needing nurse delegation;

(ii) DSHS or the AAA that contracts with licensees to provide home care services to medicaid eligible clients are responsible to establish contracts with registered nurse delegators for any client needing nurse delegation; and

(d) Home care agency credentialed workers must complete the core delegation training from DSHS prior to participating in the delegation process. Home care agency workers must also comply with any nurse delegation requirements specific to their department issued credential.

NEW SECTION

WAC 246-335-425 Personnel, contractor, and volunteer policies.

The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe:

(1) Employment criteria regarding discrimination consistent with chapter 49.60 RCW;

(2) Job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules;

(3) References for personnel, contractors and volunteers;

(4) Contracting process when using a contractor. The contract should include, at minimum, a description of the duties the contractor will perform, and a statement indicating that the contractor, not the employer, is responsible for withholding any necessary taxes. As with personnel and volunteers, contractors are subject to all applicable requirements in this chapter;

(5) Credentials of health care professionals that are current and in good standing;

(6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons according to RCW 43.43.830 through 43.43.842 and the following:

(a) Criminal history background checks must be processed through the Washington state patrol (WSP);

(b) Disclosure statements must be approved by the department; and

(c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check;

(7) Character, competence, and suitability determination conducted for personnel, contractors, volunteers, and students whose background check results reveal nondisqualifying convictions, pending charges, or negative actions. Factors to consider when making a determination include, but are not limited to:

(a) Whether there is a reasonable, good faith belief that they would be unable to meet the care needs of the client;

(b) Level of vulnerability of the client under their care;

(d) Pattern of offenses or other behaviors that may put the client at risk;

(e) Number of years since the conviction, negative action, or other issue;

(f) Whether they self-disclosed the conviction(s), pending charge(s) or negative action(s);

(g) Other health and safety concerns; and

(h) Although a licensee may determine, based on their assessment process, that an employee is suitable to work with vulnerable clients, the department has the final authority to deny, revoke, modify, or suspend any professional credential it issues based on application and criminal background check information.

(8) Mandatory reporting:

(a) Mandatory reporters shall report failure to comply with the requirements of chapters 246-335 WAC and 70.127 RCW to the department. The report must be submitted on department forms. Reports must be submitted within fourteen calendar days after the reporting person has knowledge of noncompliance that must be reported;

(b) Mandatory reporters shall report suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of RCW 74.34.020 or 26.44.030 to the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred;

(9) In-person contact with personnel, contractors, and volunteers prior to providing client services;

(10) In-person orientation to current agency policies and procedures and verification of skills or training prior to independently providing client care. Examples of skills verification include written testing, skills observation, and evidence of previous training and experience such as long-term care worker training as detailed in RCW 74.39A.074 and certified nursing assistant training as detailed in WAC 246-841-400;

(11) Ongoing training pertinent to client care needs;

(12) Safe food storage, preparation and handling practices consistent with the United States Food and Drug Administration's recommendations for "food safety at home" for personnel, contractors, and volunteers involved in food preparation services on behalf of clients. Personnel, contractors, and volunteers may not provide clients with homemade food items or baked goods that they themselves prepared;

(13) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum:

(a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment;

(b) Availability of personal protective equipment and other equipment necessary to implement client plans of care;

(i) Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency's responsibility to conduct TB testing of new employees. If TB testing is required, follow the department's tuberculosis risk assessment form testing recommendations;

(ii) Conducting an annual assessment of new TB risk factors for all employees. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine agency's responsibility to conduct TB testing of employees. Retesting should only be done for persons who previously tested negative and have new risk factors since the last assessment; and

(iii) Ensuring workers receive TB related training and education at the time of hire or during new employee orientation. Training and education must be consistent with the department's tuberculosis program's online posted educational materials.

(d) Actions to take when personnel, volunteers, contractors, or clients exhibit or report symptoms of a communicable disease in an infectious stage in accordance with chapters 246-100 and 246-101 WAC;

(e) Exposure to bloodborne pathogens such as Hepatitis B and HIV and other potentially infectious materials in compliance with the department of labor and industries, chapter 296-823 WAC. Key elements include, but are not limited to:

(i) Conducting an initial risk assessment of the environment in which personnel, volunteers, and contractors perform their assigned duties to determine occupational exposure. The results of the risk assessment will inform policy and procedure development and level of employee training and education. Annually, agencies must determine if significant changes have occurred that would require a new risk assessment to be performed;

(ii) If the risk assessment concludes that workers have a reasonably anticipated risk of occupational exposure to blood and other potentially infectious materials, agencies must offer workers the Hepatitis B vaccine series at the agency's expense. Workers have the right to decline the Hepatitis B vaccine series; and

(f) Agencies must document an annual review of applicable state and federal health authority recommendations related to infection control practices, communicable disease testing, and vaccinations and update trainings and policies and procedures as necessary.

(14) Annual performance evaluations of all personnel and volunteers providing direct client care, including on-site observation of care and skills specific to the care needs of clients; and

(15) Annual evaluations of services provided by contractors providing direct client care.

NEW SECTION

WAC 246-335-430 Personnel, contractor, and volunteer records.

The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include:

(1) Current practice certification, credential, licensure, or documentation that noncredentialed long-term care workers meet the exemption criteria in chapter 246-980 WAC, as applicable;

(2) Documentation of references;

(3) Evidence of orientation to current agency policies and procedures;

(4) Contracts when using contractors;

(5) Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of clients;

(6) Evidence of initial and subsequent criminal history background checks and disclosure statements according to RCW 43.43.830 through 43.43.842 and this chapter;

(7) Training on current and revised agency policies and procedures, including client care issues;

(8) Documentation for personnel, contractors, and volunteers who prepare food for the client independent of the client's assistance, including:

(a) A current food worker card per chapter 246-215 WAC; or

(b) Training equivalent to United States Food and Drug Administration; or

(c) Home care aide certification for personnel, contractors, and volunteers involved in food preparation services on behalf of clients.

(9) Communicable disease testing and vaccination according to current state and federal health authority recommendations; and

(10) Documentation of performance evaluations of personnel and volunteers providing direct client care and evaluations of services provided by contractors providing direct client care as required in WAC 246-335-425 (15) and (16).

NEW SECTION

WAC 246-335-435 Bill of rights.

A home care agency at the time of admission must provide each client, designated family member, or legal representative with a written bill of rights affirming each client's right to:

(1) Receive quality services from the home care agency for services identified in the plan of care;

(2) Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of services;

(3) A statement advising of the right to ongoing participation in the development of the plan of care;

(4) A statement advising of the right to have access to the department's listing of licensed home care agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations;

(5) A listing of the total services offered by the home care agency and those being provided to the client;

(6) Refuse specific services;

(7) The name of the individual within the home care agency responsible for supervising the client's care and the manner in which that individual may be contacted;

(8) Be treated with courtesy, respect, and privacy;

(9) Be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, and discrimination;

(10) Have property treated with respect;

(11) Privacy and confidentiality of personal information and health care related records;

(12) Be informed of what the home care agency charges for services, to what extent payment may be expected from care insurance, public programs, or other sources, and what charges the client may be responsible for paying;

(13) A fully itemized billing statement upon request, including the date of each service and the charge. Agencies providing services through a managed care plan are not required to provide itemized billing statements;

(14) Be informed about advanced directives and POLST, and the agency's scope of responsibility;

(15) Be informed of the agency's policies and procedures regarding the circumstances that may cause the agency to discharge a client;

(16) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled;

(17) A description of the agency's process for clients and family to submit complaints to the home care agency about the services and care they are receiving and to have those complaints addressed without retaliation;

(18) Be informed of the department's complaint hotline number to report complaints about the licensed agency or credentialed health care professionals; and

(19) Be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults.

(20) The home care agency must ensure that the client rights under this section are implemented and updated as appropriate.

NEW SECTION

WAC 246-335-440 Home care plan of care.

Except as provided in subsections (5) and (6) of this section, the licensee must:

(1) Develop and implement a written home care plan of care for each client with input and written approval by the client, designated family member, or legal representative;

(2) Ensure each plan of care is developed by appropriately trained or credentialed agency personnel, lists services requested or recommended to meet client needs, and is based on an on-site visit and according to agency policies and procedures;

(3) Ensure the home care plan of care includes:

(a) The client's functional limitations;

(b) Nutritional needs and food allergies for meal preparation;

(d) Indication that the client has a signed advanced directive or POLST, if applicable;

(e) Nurse delegation tasks, if applicable; and

(f) Specific nonmedical services to be provided and their frequency.

(4) Develop and implement a system to:

(a) Ensure the plan of care is reviewed on-site, updated, approved and signed by appropriate agency personnel and the client, designated family member, or legal representative every twelve months and whenever significant changes to client care needs are identified; and

(b) Inform the supervisor of direct care services regarding changes in the client's condition that indicate a need to update the plan of care.

(5) Home care agencies providing a one-time visit for a client may provide the following written documentation in lieu of the home care plan of care and client record requirements in WAC 246-335-450(3):

(a) Client name, age, current address, and phone number;

(b) Confirmation that the client was provided a written bill of rights under WAC 246-335-435;

(d) Documentation of services provided.

(6) Home care agencies that have a contract with the AAA to provide home care services to medicaid eligible clients may use the DSHS CARE assessment details and service summary, or successor assessment tool, as the plan of care if it covers all items in subsection (3) of this section.

NEW SECTION

WAC 246-335-445 Supervision of home care services.

(1) The licensee must employ a supervisor of direct care services;

(2) The supervisor of direct care services must designate in writing a similarly qualified alternate to act in the supervisor's absence;

(3) The licensee shall ensure the supervisor of direct care services and the designated alternate completes a minimum of ten hours of training annually. Training must be documented and maintained in the personnel files. Training may include a combination of topics related to supervisory duties and the delivery of home care services. Examples of appropriate training include, but are not limited to:

(a) Agency sponsored in-services;

(b) Community venues;

(d) Conferences;

(e) Seminars;

(f) Continuing education related to the supervisor's professional credential, if applicable; and

(g) Supervisory responsibilities in the event of a natural disaster, man-made incident, or public health emergency.

(4) The supervisor or designee must be available during all hours of client care;

(5) The supervisor of direct care services must ensure:

(a) Supervision of all client care provided by personnel and volunteers;

(b) Evaluation of services provided by contractors;

(d) Participation in coordination of services when more than one licensee is providing care to the client;

(e) Compliance with the plan of care;

(f) All direct care personnel, contractors, and volunteers observe and recognize changes in the client's condition and needs, and report any changes to the supervisor of direct care services or the designee;

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy;

(h) Each home care agency worker reviews the plan of care and any additional written instructions for the care of each client prior to providing home care services and whenever there is a change in the plan of care; and

(i) Each home care agency worker assists with medications according to agency policy and this chapter.

(6) The supervisor of direct care services must conduct and document client contact by phone or visit every six months to evaluate compliance with the plan of care and to assess client satisfaction with care.

NEW SECTION

WAC 246-335-450 Client records.

The licensee must:

(1) Maintain a current record for each client consistent with chapter 70.02 RCW;

(2) Ensure that client records are:

(a) Accessible in the licensee's office location for review by appropriate direct care personnel, volunteers, contractors, and the department;

(b) Written legibly in permanent ink or retrievable by electronic means;

(d) In a legally acceptable manner;

(e) Kept confidential;

(f) Chronological in its entirety or by the service provided;

(g) Fastened together to avoid loss of record contents (paper documents); and

(h) Kept current with all documents filed according to agency time frames per agency policies and procedures.

(3) Except as provided in subsection (4) of this section, include documentation of the following in each record:

(a) Client's name, age, current address, and phone number;

(b) Client's consent for services and care;

(d) Plan of care according to WAC 246-335-440, depending upon the services provided;

(e) Signed or electronically authenticated and dated notes documenting and describing services provided during each client contact;

(f) Supervision of home care services according to WAC 246-335-445; and

(g) Other documentation as required by this chapter.

(4) For clients receiving a one-time visit, provide the documentation required in WAC 246-335-440(5) in lieu of the requirements in subsection (3) of this section;

(5) Consider the records as property of the licensee and allow the client access to his or her own record; and

(6) Upon request and according to agency policy and procedure, provide client information or a summary of care when the client is transferred or discharged to another agency or facility.

(7) The licensee must keep client records for:

(a) Adults - Three years following the date of termination of services;

(b) Minors - Three years after attaining age eighteen, or five years following discharge, whichever is longer; and

(c) Client death - Three years following the last date or termination of services if client was on services when death occurred.

(8) The licensee must:

(a) Store client records in a safe and secure manner to prevent loss of information, to maintain the integrity of the record, and to protect against unauthorized use;

(b) Maintain or release records in accordance with chapter 70.02 RCW; and

(c) After ceasing operation, retain or dispose of client records in a confidential manner according to the time frames in subsection (7) of this section.

NEW SECTION

WAC 246-335-455 Quality improvement program.

Every home care licensee must develop and operationalize a quality improvement program to ensure the quality of care and services provided throughout all approved service areas including, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services provided;

(2) A method to identify, monitor, evaluate, and correct problems identified by clients, families, personnel, contractors, or volunteers; and

(3) A system to assess client satisfaction with the overall services provided by the agency.

Part 3 - Requirements Specific to Home Health Agency Services

NEW SECTION

WAC 246-335-505 Applicability.

The requirements in WAC 246-335-505 through 246-335-560 apply to all in-home services agencies licensed to provide home health services.

NEW SECTION

WAC 246-335-510 Definitions—Home health.

The definitions in the section apply throughout WAC 246-335-505 through 246-335-560 unless the context clearly indicates otherwise:

(1) "Acute care" means care provided by an in-home services agency licensed to provide home health services for patients who are not medically stable or have not attained a satisfactory level of rehabilitation. These patients require frequent monitoring by a registered nurse licensed under chapter 18.79 RCW, a physical therapist licensed under chapter 18.74 RCW, a respiratory therapist licensed under chapter 18.89 RCW, an occupational therapist licensed under chapter 18.59 RCW, a speech therapist licensed under chapter 18.35 RCW, a dietician certified under chapter 18.138 RCW, or social worker licensed under chapter 18.320 RCW to assess health status and progress.

(2) "Assessment" means an evaluation performed by an appropriate health care professional of a patient's needs.

(3) "Authorizing practitioner" means the individual practitioners licensed in Washington state, or another state according to the exemption criteria established in chapters 18.57, 18.71, and 18.79 RCW, and authorized to approve a home health plan of care:

(a) A physician licensed under chapter 18.57 or 18.71 RCW;

(b) A podiatric physician and surgeon licensed under chapter 18.22 RCW; or

(4) "Cardiopulmonary resuscitation" or "CPR" means a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) or whose heart has stopped (cardiac arrest).

(5) "Dietician" means a person certified under chapter 18.138 RCW or registered by the Academy of Nutrition and Dietetics.

(6) "Director of clinical services" means an individual responsible for nursing, therapy, nutritional, social, and related services that support the plan of care provided by in-home health and hospice agencies.

(7) "Home health agency" means a person administering or providing two or more home health services directly or through a contract arrangement to individuals in places of temporary or permanent residence. A person administering or providing nursing services only may elect to be designated a home health agency for purposes of licensure.

(8) "Home health aide" means an individual who is a nursing assistant certified or nursing assistant registered under chapter 18.88A RCW.

(9) "Home health aide services" means services provided by a home health agency or a hospice agency under the supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract to a home health or hospice agency. Such care includes ambulation and exercise, assistance with self-administered medications, reporting changes in patients' conditions and needs, completing appropriate records, and personal care or homemaker services.

(10) "Home health services" means services provided to ill, disabled, or vulnerable individuals. These services include, but are not limited to, nursing services, home health aide services, physical therapy services, occupational therapy services, speech therapy services, respiratory therapy services, nutritional services, medical social services, and home medical supplies or equipment services.

(11) "Home medical supplies or equipment services" means diagnostic, treatment, and monitoring equipment and supplies provided for the direct care of individuals within a plan of care.

(12) "Licensed practical nurse" or "LPN" means an individual licensed under chapter 18.79 RCW.

(13) "Licensed nurse" means a licensed practical nurse or registered nurse under chapter 18.79 RCW.

(14) "Maintenance care" means care provided by in-home services agencies licensed to provide home health services that are necessary to support an existing level of health, to preserve a patient from further failure or decline, or to manage expected deterioration of disease. Maintenance care consists of periodic monitoring by a licensed nurse, therapist, dietician, or social worker to assess a patient's health status and progress.

(15) "Medication administration" means assistance with the application, instillation, or insertion of medications according to a plan of care, for patients of an in-home services agency licensed to provide home health services and are under the direction of appropriate agency health care personnel. The assistance is provided in accordance with the Nurse Practice Act as defined in chapters 18.79 RCW and 246-840 WAC and the nursing assistant scope of practice as defined in chapters 18.88A RCW and 246-841 WAC.

(16) "Palliative care" means patient and family-centered care that optimizes quality of life and comfort by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.

(17) "Patient" means an individual receiving home health services.

(18) "Professional medical equipment assessment services" means periodic care provided by a registered nurse licensed under chapter 18.79 RCW, a physical therapist licensed under chapter 18.74 RCW, an occupational therapist licensed under chapter 18.59 RCW, a respiratory therapist licensed under chapter 18.89 RCW, or dietician certified under chapter 18.138 RCW within their scope of practice, for patients who are medically stable, for the purpose of assessing the patient's medical response to prescribed professional medical equipment, including, but not limited to, measurement of vital signs, oximetry testing, and assessment of breath sounds and lung function (spirometry).

(19) "Registered nurse" or "RN" means an individual licensed under chapter 18.79 RCW.

(20) "Social worker" means a person with a degree from a social work educational program accredited and approved as provided in RCW 18.320.010 or who meets qualifications provided in 42 C.F.R. Sec. 418.114 as it existed on January 1, 2012.

(21) "Telehealth" means a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services.

(22) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. "Telemedicine" does not include the use of audio-only telephone, facsimile, or electronic mail.

(23) "Therapist" means an individual who is:

(a) A physical therapist licensed under chapter 18.74 RCW;

(b) A respiratory therapist licensed under chapter 18.89 RCW;

(d) A speech therapist licensed under chapter 18.35 RCW; or

(e) A massage therapist licensed under chapter 18.108 RCW.

(24) "Therapy assistant" means a licensed occupational therapy assistant defined under chapter 18.59 RCW or physical therapist assistant defined under chapter 18.74 RCW.

NEW SECTION

WAC 246-335-515 Plan of operation.

The applicant or licensee must develop and implement a plan of operation which includes:

(1) A description of the organizational structure;

(2) Personnel job descriptions according to WAC 246-335-525(2);

(3) Responsibilities of contractors and volunteers;

(4) Services to be provided;

(5) The days and hours of agency operation;

(6) Criteria for management and supervision of home health services throughout all approved service areas, which include:

(a) How the initial assessment and development of the plan of care will be completed per WAC 246-335-540;

(b) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-545;

(c) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-525 (16) and (17); and

(d) How the quality improvement program required in WAC 246-335-555 will be applied throughout all approved service areas.

(7) A process to inform patients of alternative services prior to ceasing operation or when the licensee is unable to meet the patient's needs;

(8) A plan for preserving records, including the process to preserve or dispose of records prior to ceasing operation according to WAC 246-335-550 (7) and (8);

(9) Time frames for filing documents in the patient records;

(10) Emergency preparedness that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal agency operation. Include, at minimum: Risk assessment and emergency planning, communication plan, informing local officials of patients in need of evacuation, and staff training and drills to test emergency plan;

(11) The applicant or licensee must identify an administrator. The administrator must be a home health employee and possess education and experience required by the agency's policies. The administrator is responsible to:

(a) Oversee the day-to-day operation and fiscal affairs of the agency;

(b) Implement the provisions of this section;

(d) Provide management and supervision of services throughout all approved service areas according to subsection (6) of this section;

(e) Arrange for necessary services;

(f) Keep contracts current and consistent with WAC 246-335-525(4);

(g) Serve as a liaison between the licensee, personnel, contractors and volunteers;

(h) Ensure personnel, contractors and volunteers are currently credentialed by the state of Washington, when appropriate, according to applicable practice acts and consistent with WAC 246-335-525(5);

(i) Ensure personnel, contractors and volunteers comply with the licensee's policies and procedures;

(j) Implement a quality improvement process consistent with WAC 246-335-555;

(k) Manage recordkeeping according to WAC 246-335-550;

(l) Ensure supplies and equipment necessary to patient care are available, maintained, and in working order;

(m) Ensure the accuracy of public information materials; and

(n) Ensure current written policies and procedures are accessible to personnel, contractors, and volunteers during hours of operation.

(12) The licensee must continue to update its plan of operation to reflect current practice, services provided by the agency, and state and local laws.

NEW SECTION

WAC 246-335-520 Delivery of services.

The applicant or licensee must develop and operationalize delivery of services policies and procedures that describe:

(1) Admission, transfer, discharge, and referral processes:

(a) In order to minimize the possibility of patient abandonment, patients must be given at least a forty-eight hour written or verbal notice prior to discharge that will be documented in the patient record;

(b) Forty-eight hour notice is not required if home health agency worker safety, significant patient noncompliance, or patient's failure to pay for services rendered are the reason(s) for the discharge;

(c) A home health agency discharging a patient that is concerned about their ongoing care and safety may submit a self-report to appropriate state agencies which identifies the reasons for discharge and the steps taken to mitigate safety concerns;

(2) Specific home health services, including any nonmedical services, available to meet patient or family needs as identified in plans of care;

(3) Home health services starting within seven calendar days of receiving and accepting a physician or practitioner referral for services. Longer time frames are permitted when one or more of the following is documented:

(a) Longer time frame for the start of services is requested by physician or practitioner;

(b) Longer time frame for the start of services is requested by the patient, designated family member, legal representative, or referral source; or

(c) Start of services was delayed due to agency having challenges contacting patient, designated family member, or legal representative;

(4) Agency personnel, contractor, and volunteer roles and responsibilities related to medication self-administration with assistance and medication administration;

(5) Coordination of care, including:

(a) Coordination among services being provided by a licensee having an additional home care or hospice service category; and

(b) Coordination with other agencies when the care being provided impacts patient health.

(6) Actions to address patient, or family communication needs;

(7) Utilization of telehealth or telemedicine for patient consultation purposes or to acquire patient vitals and other health data in accordance with state and federal laws;

(8) Management of patient medications and treatments in accordance with appropriate practice acts;

(9) Emergency care of the patient;

(10) Actions to be taken upon death of a patient;

(11) Providing back-up care to the patient when services cannot be provided as scheduled. Back-up care which requires assistance with patient ADLs or patient health services must be provided by staff with minimum health care credentialing. Noncredentialed staff may provide back-up care only when assisting a patient with IADLs or in emergency situations;

(12) Actions to be taken when the patient has a signed advanced directive;

(13) Actions to be taken if a patient has a signed POLST form. Any section of the POLST form not completed implies full treatment for that section. Also include: In the event of a patient medical emergency and agency staff are present, provide emergency medical personnel with a patient's signed POLST form;

(14) Nurse delegation according to the following:

(a) Delegation is only permitted for stable and predictable patients requiring specific nursing tasks that do not require clinical judgment;

(b) A licensee with an approved home health service category only may use their RN on staff for patient nurse delegation needs;

(c) A licensee with approved home health and home care service categories may provide nurse delegation in the following ways:

(i) Use an RN from their home health side to contract with and delegate to their home care side; or

(ii) Transfer a home care client needing delegation to the agency's home health side;

(d) Home health aides must complete the DSHS nurse delegation class prior to participating in the delegation process. If the tasks are ones considered by the nursing quality assurance commission to be simple care tasks, such as blood pressure monitoring, personal care services, diabetic insulin device set up, and verbal verification of insulin dosage for sight-impaired individuals, the DSHS training is not required.

NEW SECTION

WAC 246-335-525 Personnel, contractor, and volunteer policies.

The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe:

(1) Employment criteria regarding discrimination consistent with chapter 49.60 RCW;

(2) Job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules;

(3) References for personnel, contractors and volunteers;

(5) Credentials of health care professionals that are current and in good standing;

(6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following:

(a) Criminal history background checks must be processed through the Washington state patrol;

(b) Disclosure statements must be approved by the department; and

(c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check;

(a) Whether there is a reasonable, good faith belief that they would be unable to meet the care needs of the patient;

(b) Level of vulnerability of the patient under their care;

(d) Pattern of offenses or other behaviors that may put the patient at risk;

(e) Number of years since the conviction, negative action, or other issue;

(f) Whether they self-disclosed the conviction(s), pending charge(s) and/or negative action(s);

(g) Other health and safety concerns; and

(h) Although a licensee may determine, based on their assessment process, that an employee is suitable to work with vulnerable patients, the department has the final authority to deny, revoke, modify, or suspend any professional credential it issues based on application and criminal background check information.

(8) Mandatory reporting:

(9) In-person contact with personnel, contractors, and volunteers prior to providing patient services;

(10) In-person orientation to current agency policies and procedures and verification of skills or training prior to independently providing patient care. Examples of skills verification include written testing, skills observation, and evidence of previous training and experience such as a certified nursing assistant training as detailed in WAC 246-841-400;

(11) The process for personnel and contractors holding a nursing assistant registration to become credentialed as a nursing assistant certified. The policies and procedures must include, at minimum:

(a) Personnel and contractors holding a nursing assistant registration must become credentialed as a nursing assistant certified within twelve months of the date of hire. The date of hire is specific to each registered nursing assistant, not to the employer, and does not change if the registered nursing assistant changes employers;

(b) Personnel and contractors who hold a nursing assistant registration and do not become credentialed as a nursing assistant certified within twelve months of the date of hire cannot continue to provide patient care; and

(c) Personnel and contractors hired by an in-home services licensee prior to March 1, 2018, who held a nursing assistant registration and have maintained their registration and employment with the licensee are not required to become credentialed as a nursing assistant certified.

(12) Training on the use of telehealth or telemedicine for patient consultation and the transmission of health data;

(13) Ongoing training pertinent to patient care needs;

(14) Safe food storage, preparation and handling practices consistent with the United States Food and Drug Administration's recommendations for "food safety at home" for personnel, contractors, and volunteers involved in food preparation services on behalf of patients. Personnel, contractors, and volunteers may not provide patients with homemade food items or baked goods that they themselves prepared;

(15) Current cardiopulmonary resuscitation (CPR) training consistent with agency policies and procedures for direct care personnel and contractors. Internet-based classroom training is permissible but demonstration of skills must be hands on and observed by a certified trainer;

(16) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum:

(a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment;

(b) Availability of personal protective equipment and other equipment necessary to implement client plans of care;

(e) Exposure to bloodborne pathogens such as Hepatitis B and HIV, and other potentially infectious materials in compliance with the department of labor and industries chapter 296-823 WAC. Key elements include, but are not limited to:

(17) Annual performance evaluations of all personnel and volunteers providing direct patient care, including on-site observation of care and skills specific to the care needs of patients; and

(18) Annual evaluations of services provided by contractors providing direct patient care.

NEW SECTION

WAC 246-335-530 Personnel, contractor, and volunteer records.

The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include:

(1) Current practice certification, credential or licensure, as applicable;

(2) Documentation of references;

(3) Contracts when using contractors;

(4) Evidence of orientation to current agency policies and procedures;

(5) Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients;

(6) Documentation that personnel and contractors holding a nursing assistant registration became credentialed as a nursing assistant certified under chapter 246-841 WAC within twelve months of the date of hire or met the exemption criteria in WAC 246-335-525 (10)(c);

(7) Evidence of initial and subsequent criminal history background checks and disclosure statement(s) according to RCW 43.43.830 through 43.43.842 and this chapter;

(8) Training on current and revised agency policies and procedures, including patient care issues;

(9) Current CPR training for direct care personnel and contractors;

(10) Documentation for personnel, contractors, and volunteers who prepare food for the patient independent of the patient's assistance, including:

(a) A current food worker card per chapter 246-215 WAC; or

(b) Training equivalent to United States Food and Drug Administration for personnel, contractors, and volunteers involved in food preparation services on behalf of patients;

(11) Communicable disease testing and vaccination according to current state and federal health authority recommendations; and

(12) Documentation of performance evaluations of personnel and volunteers providing direct patient care and evaluations of services provided by contractors providing direct patient care as required in WAC 246-335-525 (17) and (18).

NEW SECTION

WAC 246-335-535 Bill of rights.

A home health agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient's right to:

(1) Receive effective treatment and quality services from the home health agency for services identified in the plan of care;

(2) Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of services;

(3) A statement advising of the right to ongoing participation in the development of the plan of care;

(4) A statement advising of the right to have access to the department's listing of licensed home health agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations;

(5) A listing of the total services offered by the home health agency and those being provided to the patient;

(6) Refuse specific treatments or services;

(7) The name of the individual within the home health agency responsible for supervising the patient's care and the manner in which that individual may be contacted;

(8) Be treated with courtesy, respect, and privacy;

(9) Be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, and discrimination;

(10) Have property treated with respect;

(11) Privacy and confidentiality of personal information and health care related records;

(12) Be informed of what the home health agency charges for services, to what extent payment may be expected from health insurance, public programs, or other sources, and what charges the patient may be responsible for paying;

(14) Be informed about advanced directives and POLST and the agency's scope of responsibility;

(15) Be informed of the agency's policies and procedures regarding the circumstances that may cause the agency to discharge a patient;

(16) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled;

(17) A description of the agency's process for patients and family to submit complaints to the home health agency about the services and care they are receiving and to have those complaints addressed without retaliation;

(18) Be informed of the department's complaint hotline number to report complaints about the licensed agency or credentialed health care professionals; and

(19) Be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults.

(20) The home health agency must ensure that the patient rights under this section are implemented and updated as appropriate.

NEW SECTION

WAC 246-335-540 Home health plan of care.

Except as provided in subsections (5) and (6) of this section, the licensee must:

(1) Develop and implement a written home health plan of care for each patient with input from the patient, designated family member, or legal representative and authorizing practitioner;

(2) Ensure each plan of care is developed by appropriately trained or credentialed agency personnel and is based on a patient assessment;

(3) Ensure the home health plan of care includes:

(a) Current diagnoses and information on health status;

(b) Goals and outcome measures which are individualized for the patient;

(d) Palliative care, if applicable;

(e) Use of telehealth or telemedicine, if applicable;

(f) Home medical equipment and supplies used by the patient;

(g) Orders for treatments and their frequency to be provided and monitored by the licensee;

(h) Special nutritional needs and food allergies;

(i) Orders for medications to be administered and monitored by the licensee including name, dose, route, and frequency;

(j) Medication allergies;

(k) The patient's physical, cognitive and functional limitations;

(l) Discharge and referral plan;

(m) Patient and family education needs pertinent to the care being provided by the licensee;

(n) Indication that the patient has a signed advanced directive or POLST, if applicable. Include resuscitation status according to advance directives or POLST, if applicable; and

(o) The level of medication assistance to be provided.

(4) Develop and implement a system to:

(a) Ensure and document that the plan of care is reviewed and updated by appropriate agency personnel according to the following time frames:

(i) For patients requiring acute care services, every two months;

(ii) For patients requiring maintenance services, every six months; and

(iii) For patients requiring only professional medical equipment assessment services or home health aide only services, every twelve months.

(b) Ensure the plan of care is signed or authenticated and dated by appropriate agency personnel and the authorizing practitioner, according to the time frames in (a) of this subsection;

(c) Ensure the signed or authenticated plan care is returned to the agency within sixty days of the initial date of service or date of review and update;

(d) Inform the authorizing practitioner regarding changes in the patient's condition that indicate a need to update the plan of care;

(e) Obtain approval from the authorizing practitioner for additions and modifications;

(f) Ensure all verbal orders for modification to the plan of care are immediately documented in writing and signed or authenticated and dated by an agency individual authorized within their scope of practice to receive the order and signed or authenticated by the authorizing practitioner and returned to the agency within sixty days of the date the verbal orders were received.

(5) Home health agencies providing only home health aide services to a patient:

(a) May develop a modified plan of care by providing only the following information on the plan of care:

(i) Types and frequency of services to be provided;

(ii) Home medical equipment and supplies used by the patient;

(iii) Special nutritional needs and food allergies;

(iv) The patient's physical, cognitive and functional limitations; and

(v) The level of medication assistance to be provided.

(b) Do not require an authorizing practitioner signature on the plan of care.

(6) Home health agencies providing a one-time visit for a patient may provide the following written documentation in lieu of the home health plan of care and patient record requirements in WAC 246-335-550(3):

(a) Patient name, age, current address, and phone number;

(b) Confirmation that the patient was provided a written bill of rights under WAC 246-335-535;

(d) Authorizing practitioner orders; and

(e) Documentation of services provided.

NEW SECTION

WAC 246-335-545 Supervision of home health services.

(1) A licensee must employ a director of clinical services;

(2) The director of clinical services must designate in writing a similarly qualified alternate to act in the director's absence;

(3) The licensee shall ensure the director of clinical services and the designated alternate completes a minimum of ten hours of training annually. Written documentation of trainings must be available upon request by the department. Training may include a combination of topics related to clinical supervision duties and the delivery of home health services. Examples of appropriate training include, but are not limited to:

(a) Agency sponsored in-services;

(b) Community venues;

(d) Conferences;

(e) Seminars;

(f) Continuing education related to the director's health care professional credential, if applicable; and

(g) Supervisory responsibilities in the event of a natural disaster, man-made incident, or public health emergency.

(4) The director of clinical services or designee must be available during all hours patient care is being provided;

(5) The director of clinical services or designee must ensure:

(a) Coordination, development, and revision of written patient care policies and procedures related to each service provided;

(b) Supervision of all patient care provided by personnel and volunteers. The director of clinical services may delegate staff supervision responsibilities to a registered nurse or other appropriately credentialed professional;

(d) Coordination of services when one or more licensed agencies are providing care to the patient;

(e) Compliance with the plan of care;

(f) All direct care personnel, contractors, and volunteers observe and recognize changes in the patient's condition and needs, and report any changes to the director of clinical services or designee; and

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy.

(6) The licensee must document supervision including, but not limited to:

(a) RN supervision when using the services of an RN or LPN, in accordance with chapter 18.79 RCW;

(b) For patients receiving acute care services, supervision of the home health aide services during an on-site visit with or without the home health aide present must occur once a month to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit must be conducted by a licensed nurse or therapist in accordance with the appropriate practice acts;

(c) For patients receiving maintenance care or home health aide only services, supervision of the home health aide services during an on-site visit with or without the home health aide present must occur every six months to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit must be conducted by a licensed nurse or licensed therapist in accordance with the appropriate practice acts; and

(d) Supervision by a licensed therapist when using the services of a therapy assistant in accordance with the appropriate practice acts.

(7) The licensee using home health aides must ensure:

(a) Each home health aide reviews the plan of care and any additional written instructions for the care of each patient prior to providing home health aide services and whenever there is a change in the plan of care; and

(b) Each home health aide assists with medications according to agency policy and this chapter.

NEW SECTION

WAC 246-335-550 Patient records.

The licensee must:

(1) Maintain a current record for each patient consistent with chapter 70.02 RCW;

(2) Ensure that patient records are:

(a) Accessible in the licensee's office location for review by appropriate direct care personnel, volunteers, contractors, and the department;

(b) Written legibly in permanent ink or retrievable by electronic means;

(d) In a legally acceptable manner;

(e) Kept confidential;

(f) Chronological in its entirety or by the service provided;

(g) Fastened together to avoid loss of record contents (paper documents); and

(h) Kept current with all documents filed according to agency time frames per agency policies and procedures.

(3) Except as provided in subsection (4) of this section, include documentation of the following in each record:

(a) Patient's name, age, current address and phone number;

(b) Patient's consent for services, care, and treatments;

(d) Initial assessment when providing home health services, except when providing home health aide only services under WAC 246-335-540(5);

(e) Plan of care according to WAC 246-335-540, depending upon the services provided;

(f) Signed or electronically authenticated and dated notes documenting and describing services provided during each patient contact;

(g) Observations and changes in the patient's condition or needs;

(h) For patients receiving home health, with the exception of home health aide only services per WAC 246-335-540(5), authorized practitioner orders and documentation of response to medications and treatments ordered;

(i) Supervision of home health aide services according to WAC 246-335-545(7); and

(j) Other documentation as required by this chapter.

(4) For patients receiving a one-time visit, provide the documentation required in WAC 246-335-540(6) in lieu of the requirements in subsection (3) of this section;

(5) Consider the records as property of the licensee and allow the patient access to his or her own record; and

(6) Upon request and according to agency policy and procedure, provide patient information or a summary of care when the patient is transferred or discharged to another agency or facility.

(7) The licensee must keep patient records for:

(a) Adults - Three years following the date of termination of services;

(b) Minors - Three years after attaining age eighteen, or five years following discharge, whichever is longer; and

(c) Patient death - Three years following the last date or termination of services if patient was on services when death occurred.

(8) The licensee must:

(a) Store patient records in a safe and secure manner to prevent loss of information, to maintain the integrity of the record, and to protect against unauthorized use;

(b) Maintain or release records in accordance with chapter 70.02 RCW; and

(c) After ceasing operation, retain or dispose of patient records in a confidential manner according to the time frames in subsection (7) of this section.

NEW SECTION

WAC 246-335-555 Quality improvement program.

Every home health licensee must develop and operationalize a quality improvement program to ensure the quality of care and services provided throughout all approved service areas including, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services provided;

(2) A method to identify, monitor, evaluate, and correct problems identified by patients, families, personnel, contractors, or volunteers; and

(3) A system to assess patient satisfaction with the overall services provided by the agency.

NEW SECTION

WAC 246-335-560 Home medical supplies and equipment.

This section applies to home health agencies providing or contracting for medical supplies or equipment services.

(1) The applicant or licensee must develop and implement policies and procedures to:

(a) Maintain medical supplies and equipment;

(b) Clean, inspect, repair and calibrate equipment per the manufacturers' recommendations, and document the date and name of individual conducting the activity;

(d) Inform the patient, designated family member, or legal representative of the cost and method of payment for equipment, equipment repairs and equipment replacement;

(e) Document the patient, designated family member, or legal representative's approval;

(f) Instruct each patient, designated family member, or legal representative to use and maintain supplies and equipment in a language or format the patient or family understands, using one or more of the following:

(i) Written instruction;

(ii) Verbal instruction; or

(iii) Demonstration.

(g) Document the patient, designated family member, or legal representative understanding of the instructions provided;

(h) Replace supplies and equipment essential for the health or safety of the patient; and

(i) Identify and replace equipment recalled by the manufacturer.

(2) If the applicant or licensee contracts for medical supplies or equipment services, develop and implement policies and procedures to ensure that contractors have policies and procedures consistent with subsection (1) of this section.

Part 4 - Requirements Specific to Hospice Agency Services

NEW SECTION

WAC 246-335-605 Applicability.

The requirements in WAC 246-335-605 through 246-335-660 apply to all in-home services agencies licensed to provide hospice services.

NEW SECTION

WAC 246-335-610 Definitions—Hospice.

The definitions in this section apply throughout WAC 246-335-605 through 246-335-660 unless the context clearly indicates otherwise:

(1) "Assessment" means an evaluation performed by an appropriate health care professional of a patient's physical, psychosocial, emotional and spiritual status related to their terminal illness and other health conditions. This includes evaluating the caregiver's and family's willingness and capability to care for the patient.

(2) "Authorizing practitioner" means the individual practitioners licensed in Washington state or another state according to the exemption criteria established in chapters 18.57 and 18.71 RCW, and authorized to approve a hospice plan of care:

(a) A physician licensed under chapter 18.57 or 18.71 RCW; or

(b) An advanced registered nurse practitioner as authorized under chapter 18.79 RCW.

(3) "Bereavement services" means emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment.

(4) "Dietician" means a person certified under chapter 18.138 RCW or registered by the academy of nutrition and dietetics.

(5) "Director of clinical services" means an individual responsible for nursing, therapy, nutritional, social, or related services that support the plan of care provided by in-home health and hospice agencies.

(6) "Home health aide" means an individual who is a nursing assistant certified under chapter 18.88A RCW.

(7) "Hospice agency" means a person administering or providing hospice services directly or through a contract arrangement to individuals in places of permanent or temporary residence under the direction of an interdisciplinary team composed of at least a nurse, social worker, physician, spiritual counselor, and a volunteer.

(8) "Hospice services" means symptom and pain management to a terminally ill individual, and emotional, spiritual and bereavement services for the individual and their family in a place of temporary or permanent residence, and may include the provision of home health and home care services for the terminally ill individual.

(9) "Interdisciplinary team" means the group of individuals involved in patient care providing hospice services including, at a minimum, a physician, registered nurse, social worker, spiritual counselor and volunteer.

(10) "Licensed practical nurse" or "LPN" means an individual licensed under chapter 18.79 RCW.

(11) "Medication administration" means assistance in the application, instillation or insertion of medications according to a plan of care, for patients of an in-home services agency licensed to provide hospice or hospice care center services and are under the direction of appropriate agency health care personnel. The assistance is provided in accordance with the Nurse Practice Act as defined in chapters 18.79 RCW, 246-840 WAC, and the nursing assistant scope of practice as defined in chapters 18.88A RCW and 246-841 WAC.

(12) "Medical director" means a physician licensed under chapter 18.57 or 18.71 RCW responsible for the medical component of patient care provided in an in-home services agency licensed to provide hospice services according to WAC 246-335-615 (4)(a).

(13) "Patient" means an individual receiving hospice services.

(14) "Palliative care" means patient and family-centered care that optimizes quality of life and comfort by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.

(15) "Registered nurse" or "RN" means an individual licensed under chapter 18.79 RCW.

(16) "Restraint" means:

(a) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. Restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm, or to physically guide a patient from one location to another; or

(b) A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard hospice or palliative care treatment or dosage for the patient's condition.

(17) "Seclusion" means the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.

(18) "Social worker" means a person with a degree from a social work educational program accredited and approved as provided in RCW 18.320.010 or who meets qualifications provided in 42 C.F.R. Sec. 418.114 as it existed on January 1, 2012.

(19) "Spiritual counseling" means services provided or coordinated by an individual with knowledge of theology, pastoral counseling or an allied field.

(20) "Telehealth" means a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services.

(21) "Telemedicine" means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. Telemedicine does not include the use of audio-only telephone, facsimile, or electronic mail.

NEW SECTION

WAC 246-335-615 Plan of operation.

The applicant or licensee must develop and implement a plan of operation which includes:

(1) A description of the organizational structure;

(2) Personnel job descriptions according to WAC 246-335-625(2);

(3) Responsibilities of contractors and volunteers;

(4) Services to be provided;

(5) The days and hours of agency operation; and

(6) Criteria for management and supervision of hospice services throughout all approved service areas, which include:

(a) How the initial assessment and development of the plan of care will be completed per WAC 246-335-640;

(b) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-645;

(c) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-625 (16) and (17); and

(d) How the quality improvement program required in WAC 246-335-655 will be applied throughout all approved service areas.

(7) A process to inform patients of alternative services prior to ceasing operation or when the licensee is unable to meet the patient's needs;

(8) A plan for preserving records, including the process to preserve or dispose of records prior to ceasing operation according to WAC 246-335-650 (7) and (8); and

(9) Time frames for filing documents in the patient records;

(10) Emergency preparedness that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal agency operation. Include, at minimum: Risk assessment and emergency planning, communication plan, informing local officials of patients in need of evacuation, and staff training and drills to test emergency plan;

(11) Availability of a bereavement program for up to one year after a patient's death;

(12) Availability of social services, spiritual counseling, volunteer services, and respite care;

(13) Assuring direct care personnel, contractors and volunteers have training specific to the needs of the terminally ill patients and their families;

(14) The applicant or licensee must identify an administrator. The administrator is appointed by and reports to the agency owner or governing body, is a hospice employee, and possesses education and experience required by the agency's policies or the hospice's governing body. The administrator is responsible to:

(a) Oversee the day-to-day operation and fiscal affairs of the agency;

(b) Implement the provisions of this section;

(d) Provide management and supervision of services throughout all approved service areas according to subsection (6) of this section;

(e) Arrange for necessary services;

(f) Keep contracts current and consistent with WAC 246-335-625(4);

(g) Serve as a liaison between the licensee, personnel, contractors and volunteers;

(h) Ensure personnel, contractors and volunteers are currently credentialed by the state of Washington, when appropriate, according to applicable practice acts and consistent with WAC 246-335-625(5);

(i) Ensure personnel, contractors and volunteers comply with the licensee's policies and procedures;

(j) Implement a quality improvement process consistent with WAC 246-335-655;

(k) Manage recordkeeping according to WAC 246-335-650;

(l) Ensure supplies and equipment necessary to patient care are available, maintained, and in working order;

(m) Ensure the accuracy of public information materials; and

(n) Ensure current written policies and procedures are accessible to personnel, contractors, and volunteers during hours of operation.

(15) The applicant or licensee must identify a medical director who is responsible to:

(a) Advise the licensee on policies and procedures;

(b) Serve as liaison with a patient's authorizing practitioner;

(d) Approve modifications in individual plans of care; and

(e) Participate in interdisciplinary team conferences as required by WAC 246-335-640, hospice plan of care.

(16) The licensee must continue to update its plan of operation to reflect current practice, services provided by the agency, and state and local laws.

NEW SECTION

WAC 246-335-620 Delivery of services.

The applicant or licensee must develop and operationalize policies and procedures that describe:

(1) Admission, transfer, discharge, and referral processes:

(b) Forty-eight hour notice is not required if hospice agency worker safety, significant patient noncompliance, or patient's failure to pay for services rendered are the reason(s) for the discharge;

(c) A Hospice agency discharging a patient that is concerned about their ongoing care and safety may submit a self-report to appropriate state agencies which identifies the reasons for discharge and the steps taken to mitigate safety concerns;

(2) Specific hospice services, including palliative care and any nonmedical services, available to meet patient, or family needs as identified in plans of care;

(3) Initial patient assessment completed by a registered nurse within seven calendar days of receiving and accepting a physician or practitioner referral for hospice services. Longer time frames are permitted when one or more of the following is documented:

(a) Longer time frame for completing the initial patient assessment is requested by physician or practitioner;

(b) Longer time frame for completing the initial patient assessment is requested by the patient, designated family member, or legal representative; or

(c) Initial patient assessment was delayed due to agency having challenges contacting the patient, designated family member, or legal representative.

(4) Agency personnel, contractor, and volunteer roles and responsibilities related to medication self-administration with assistance and medication administration;

(5) Coordination of care, including:

(a) Coordination among services being provided by a licensee having an additional home health or home care service category; and

(b) Coordination with other agencies when care being provided impacts patient health.

(6) Actions to address patient or family communication needs;

(7) Utilization of telehealth or telemedicine for patient consultation or to acquire patient vitals and other health data in accordance to state and federal laws;

(8) Management of patient medications and treatments in accordance with appropriate practice acts;

(9) Utilization of restraints and/or seclusion following an individualized patient assessment process;

(10) Emergency care of the patient;

(11) Actions to be taken upon death of a patient;

(12) Providing back-up care to the patient when services cannot be provided as scheduled. Back-up care which requires assistance with patient ADLs or patient health services must be provided by staff with minimum health care credentialing. Noncredentialed staff may provide back-up care only when assisting a patient with IADLs or in emergency situations;

(13) Actions to be taken when the patient has a signed advanced directive;

(14) Actions to be taken when the patient has a signed POLST form. Any section of the POLST form not completed implies full treatment for that section. Also include: In the event of a patient medical emergency and agency staff are present, provide emergency medical personnel with a patient's signed POLST form; and

(15) Nurse delegation according to the following:

(a) Delegation is only permitted for patients requiring specific nursing tasks that do not require clinical judgment.

(b) Hospice agencies coordinating patient care with a separate home care agency must ensure that a formal delegation contract has been established between the two agencies in order for the hospice nurse to delegate to the home care agency workers.

NEW SECTION

WAC 246-335-625 Personnel, contractor, and volunteer policies.

The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe:

(1) Employment criteria regarding discrimination consistent with chapter 49.60 RCW;

(2) Job descriptions that contain responsibilities and are consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules;

(3) References for personnel, contractors and volunteers;

(5) Credentials of health care professionals that are current and in good standing;

(6) Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities, or vulnerable persons according to RCW 43.43.830 through 43.43.842 and the following:

(a) Criminal history background checks must be processed through the Washington state patrol;

(b) Disclosure statements must be approved by the department; and

(c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check.

(a) Whether there is a reasonable, good faith belief that they would be unable to meet the care needs of the patient;

(b) Level of vulnerability of the patient under their care;

(d) Pattern of offenses or other behaviors that may put the patient at risk;

(e) Number of years since the conviction, negative action, or other issue;

(f) Whether they self-disclosed the conviction(s), pending charge(s) and/or negative action(s);

(g) Other health and safety concerns; and

(8) Mandatory reporting:

(9) In-person contact with personnel, contractors, and volunteers prior to providing patient services;

(10) In-person orientation to current agency policies and procedures and verification of skills or training prior to independently providing patient care. Examples of skills verification include written testing, skills observation, and evidence of previous training and experience such as the nursing assistant training detailed in WAC 246-841-400;

(11) Training on the use of telehealth or telemedicine for patient consultation and the transmission of health data, if applicable;

(12) Ongoing training pertinent to patient care needs;

(13) Safe food storage, preparation and handling practices consistent with the United States Food and Drug Administration's recommendations for "food safety at home" for personnel, contractors, and volunteers involved in food preparation services on behalf of patients. Personnel, contractors, and volunteers may not provide patients with homemade food items or baked goods that they themselves prepared;

(14) Current cardiopulmonary resuscitation (CPR) training consistent with agency policies and procedures for direct care personnel and contractors. Internet-based classroom training is only permissible when the demonstration of skills is hands on and observed by a certified trainer;

(15) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum:

(a) Standard precautions such as hand hygiene, respiratory hygiene and cough etiquette, and personal protective equipment;

(b) Availability of personal protective equipment and other equipment necessary to implement client plans of care;

(iii) Ensuring workers receive TB related training and education at the time of hire or during new employee orientation. Training and education must be consistent with the department's Tuberculosis program's online posted educational materials.

(16) Annual performance evaluations of all personnel and volunteers providing direct patient care, including on-site observation of care and skills specific to the care needs of patients; and

(17) Annual evaluations of services provided by contractors providing direct patient care.

NEW SECTION

WAC 246-335-630 Personnel, contractor, and volunteer records.

The licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include:

(1) Current practice certification, credential or licensure, as applicable;

(2) Documentation of references;

(3) Evidence of orientation to current agency policies and procedures;

(4) Contracts when using contractors;

(5) Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients;

(6) Evidence of initial and subsequent criminal history background checks and disclosure statements according to RCW 43.43.830 through 43.43.842 and this chapter;

(7) Training on current and revised agency policies and procedures, including patient care issues;

(8) Current CPR training for direct care personnel and contractors;

(9) Documentation for personnel, contractors, and volunteers who prepare food for the patient independent of the patient's assistance, including:

(a) A current food worker cards per chapter 246-215 WAC; or

(b) Training equivalent to United States Food and Drug Administration for personnel, contractors, and volunteers involved in food preparation services on behalf of patients;

(10) Communicable disease testing and vaccination according to current state and federal health authority recommendations; and

(11) Documentation of performance evaluations of personnel and volunteers providing direct patient care and evaluations of services provided by contractors providing direct patient care as required in WAC 246-335-625 (16) and (17).

NEW SECTION

WAC 246-335-635 Bill of rights.

A hospice agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient's right to:

(1) Receive effective pain management and symptom control and quality services from the hospice agency for services identified in the plan of care;

(2) Be cared for by appropriately trained or credentialed personnel, contractors and volunteers with coordination of services;

(3) A statement advising of the right to ongoing participation in the development of the plan of care;

(4) Choose his or her attending physician;

(5) A statement advising of the right to have access to the department's listing of licensed hospice agencies and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations;

(6) A listing of the total services offered by the hospice agency and those being provided to the patient;

(7) Refuse specific services;

(8) The name of the individual within the hospice agency responsible for supervising the patient's care and the manner in which that individual may be contacted;

(9) Be treated with courtesy, respect, and privacy;

(10) Be free from verbal, mental, sexual, and physical abuse, neglect, exploitation, discrimination, and the unlawful use of restraint or seclusion;

(11) Have property treated with respect;

(12) Privacy and confidentiality of personal information and health care related records;

(13) Be informed of what the hospice agency charges for services, to what extent payment may be expected from health insurance, public programs, or other sources, and what charges the patient may be responsible for paying;

(14) A fully itemized billing statement upon request, including the date of each service and the charge. Agencies providing services through a managed care plan are not required to provide itemized billing statements;

(15) Be informed about advanced directives and POLST and the agency's scope of responsibility;

(16) Be informed of the agency's policies and procedures regarding the circumstances that may cause the agency to discharge a patient;

(17) Be informed of the agency's policies and procedures for providing back-up care when services cannot be provided as scheduled;

(18) A description of the agency's process for patients and family to submit complaints to the hospice agency about the services and care they are receiving and to have those complaints addressed without retaliation;

(19) Be informed of the department's complaint hotline number to report complaints about the licensed agency or credentialed health care professionals; and

(20) Be informed of the DSHS end harm hotline number to report suspected abuse of children or vulnerable adults.

(21) The hospice agency must ensure that the patient rights under this section are implemented and updated as appropriate.

NEW SECTION

WAC 246-335-640 Hospice plan of care.

Except as provided in subsection (5) of this section, the licensee must:

(1) Develop and implement a written hospice plan of care for each patient with input from the authorizing practitioner, appropriate interdisciplinary team members, and the patient, designated family member, or legal representative;

(2) Ensure each plan of care is developed by appropriately trained or credentialed agency personnel and is based on a patient and family assessment;

(3) Ensure the hospice plan of care includes:

(a) Current diagnoses and information on health status;

(b) Goals and outcome measures which are individualized for the patient;

(d) Types and frequency of services to be provided;

(e) Palliative care, if applicable;

(f) Use of telehealth or telemedicine, if applicable;

(g) Home medical equipment and supplies used by the patient;

(h) Orders for treatments and their frequency to be provided and monitored by the licensee;

(i) Special nutritional needs and food allergies;

(j) Orders for medications to be administered and monitored by the licensee including name, dose, route, and frequency;

(k) Medication allergies;

(l) The patient's physical, cognitive and functional limitations;

(m) Patient and family education needs pertinent to the care being provided by the licensee;

(n) Indication that the patient has a signed advanced directive or POLST, if applicable. Include resuscitation status according to advance directives or POLST, if applicable; and

(o) The level of medication assistance to be provided.

(4) Develop and implement a system to:

(a) Ensure and document that the plan of care is reviewed by the appropriate interdisciplinary team members within the first week of admission and every two weeks thereafter;

(b) Ensure the plan of care is signed or authenticated and dated by appropriate agency personnel and the authorizing practitioner;

(c) Ensure the signed or authenticated plan of care is returned to the agency within sixty days from the initial date of service;

(d) Inform the authorizing practitioner regarding changes in the patient's condition that indicates a need to update the plan of care;

(e) Obtain approval from the authorizing practitioner for additions and modifications; and

(f) Ensure all verbal orders for modification to the plan of care are immediately documented in writing and signed or authenticated and dated by an agency individual authorized within the scope of practice to receive the order and signed or authenticated by the authorizing practitioner and returned to the agency within sixty days from the date the verbal orders were received.

(5) Hospice agencies providing a one-time visit for a patient may provide the following written documentation in lieu of the hospice plan of care and patient record requirements in WAC 246-335-650(3):

(a) Patient's name, age, current address, and phone number;

(b) Confirmation that the patient was provided a written bill of rights under WAC 246-335-635;

(d) Authorizing practitioner orders; and

(e) Documentation of services provided.

NEW SECTION

WAC 246-335-645 Supervision of hospice services.

(1) A licensee must employ a director of clinical services.

(2) The director of clinical services must designate in writing a similarly qualified alternate to act in the director's absence.

(3) The licensee shall ensure the director of clinical services and the designated alternate completes a minimum of ten hours of training annually. Written documentation of trainings must be available upon request by the department. Training may include a combination of topics related to clinical supervision duties and the delivery of hospice services. Examples of appropriate training include, but are not limited to:

(a) Agency sponsored in-services;

(b) Community venues;

(d) Conferences;

(e) Seminars;

(f) Continuing education related to the director's health care professional credential, if applicable; and

(g) Supervisory responsibilities in the event of a natural disaster, man-made incident, or public health emergency.

(4) The director of clinical services or designee must be available twenty-four hours per day, seven days per week.

(5) The director of clinical services or designee must ensure:

(a) Coordination, development, and revision of written patient and family care policies and procedures related to each service provided;

(b) Supervision of all patient and family care provided by personnel and volunteers. The director of clinical services may assign staff supervision responsibilities to a registered nurse or other appropriately credentialed professional;

(d) Coordination of services when one or more licensed agency is providing care to the patient and family;

(e) Compliance with the plan of care;

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy.

(6) The licensee must document supervision including, but not limited to:

(a) RN supervision when using the services of an RN or LPN, in accordance with chapter 18.79 RCW;

(b) Licensed nurse supervision of home health aide services during an on-site visit with or without the home health aide present once a month to evaluate compliance with the plan of care and patient and family satisfaction with care; and

(c) Supervision by a licensed therapist when using the services of a therapy assistant in accordance with the appropriate practice acts.

(7) The licensee using home health aides must ensure:

(b) Each home health aide assists with medications according to agency policy and this chapter.

NEW SECTION

WAC 246-335-650 Patient records.

The licensee must:

(1) Maintain a current record for each patient consistent with chapter 70.02 RCW;

(2) Ensure that patient records are:

(a) Accessible in the licensee's office location for review by appropriate direct care personnel, volunteers, contractors, and the department;

(b) Written legibly in permanent ink or retrievable by electronic means;

(d) In a legally acceptable manner;

(e) Kept confidential;

(f) Chronological in its entirety or by the service provided;

(g) Fastened together to avoid loss of record contents (paper documents); and

(h) Kept current with all documents filed according to agency time frames per agency policies and procedures.

(3) Except as provided in subsection (4) of this section, include documentation of the following in each record:

(a) Patient's name, age, current address and phone number;

(b) Patient's consent for services and care;

(d) Initial assessment when providing hospice and hospice care center services;

(e) Plan of care according to WAC 246-335-640, depending on the services provided;

(f) Signed or electronically authenticated and dated notes documenting and describing services provided during each patient contact;

(g) Observations and changes in the patient's condition or needs;

(h) For patients receiving hospice and hospice care center services, authorized practitioner orders and documentation of response to medications and treatments ordered; and

(i) Other documentation as required by this chapter.

(4) For patients receiving a one-time visit, provide the documentation required in WAC 246-335-640(5) in lieu of the requirements in subsection (3) of this section.

(5) Consider the records as property of the licensee and allow the patient access to his or her own record.

(6) Upon request and according to agency policy and procedure, provide patient information or a summary of care when the patient is transferred or discharged to another agency or facility.

(7) The licensee must keep patient records for:

(a) Adults - Three years following the date of termination of services;

(b) Minors - Three years after attaining age eighteen, or five years following discharge, whichever is longer; and

(c) Patient death - Three years following the last date or termination of services if patient was on services when death occurred.

(8) The licensee must:

(a) Store patient records in a safe and secure manner to prevent loss of information, to maintain the integrity of the record, and to protect against unauthorized use;

(b) Maintain or release records in accordance to chapter 70.02 RCW; and

(c) After ceasing operation, retain or dispose of patient records in a confidential manner according to the time frames in subsection (7) of this section.

NEW SECTION

WAC 246-335-655 Quality improvement program.

Every hospice licensee must establish and implement a quality improvement program to ensure the quality of care and services provided throughout all approved service areas or within a hospice care center that includes, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services provided;

(2) A method to identify, monitor, evaluate, and correct problems identified by patients, families, personnel, contractors, or volunteers; and

(3) A system to assess patient satisfaction with the overall services provided by the agency.

NEW SECTION

WAC 246-335-660 Home medical supplies and equipment.

This section applies only to hospice agencies and hospice care centers providing or contracting for medical supplies or equipment services.

(1) The applicant or licensee must develop and implement policies and procedures to:

(a) Maintain medical supplies and equipment;

(b) Clean, inspect, repair and calibrate equipment per the manufacturers' recommendations, and document the date and name of individual conducting the activity;

(d) Inform the patient, designated family member, or legal representative of the cost and method of payment for equipment, equipment repairs and equipment replacement;

(e) Document the patient, designated family member, or legal representative's approval;

(f) Instruct each patient or family to use and maintain supplies and equipment in a language or format the patient or family understands, using one or more of the following:

(i) Written instruction;

(ii) Verbal instruction; or

(iii) Demonstration.

(g) Document the patient, designated family member, or legal representative understanding of the instructions provided;

(h) Replace supplies and equipment essential for the health or safety of the patient; and

(i) Identify and replace equipment recalled by the manufacturer.

PARTS 2 THROUGH 12

REQUIREMENTS FOR THE LICENSING, OPERATION, AND CONSTRUCTION OF HOSPICE CARE CENTERS

Part 5 – Requirements Specific to Licensing and Operation of Hospice Care Centers

NEW SECTION

WAC 246-335-705 Applicability.

The requirements in WAC 246-335-705 through 246-335-768 apply to hospice care center services.

NEW SECTION

WAC 246-335-710 Definitions.

The definitions in this section apply throughout WAC 246-335-705 through 246-335-768 unless the context clearly indicates otherwise:

(1) "Construction" means:

(a) New building(s) to be used as a hospice care center;

(b) Addition(s) to or conversion(s), either in whole or in part, of an existing building or buildings to be used as a hospice care center or a portion thereof; or

(2) "Homelike" means an environment having the qualities of a home, including privacy, comfortable surroundings, opportunities for patient self-expression, and supporting interaction with the family, friends, and community.

(3) "Hospice care center" or "in-home services agency licensed to provide hospice care center services" means a homelike, noninstitutional facility where hospice services are provided, and that meet the requirements for operation under RCW 70.127.280 and applicable rules.

(4) "Hospice care center service category" means the following different levels of care provided in a hospice care center:

(a) "Continuous care" means care for patients requiring a minimum of eight hours of one-to-one services in a calendar day, with assessment and supervision by an RN. An RN, LPN or home health aide may provide the care or treatment, according to practice acts and applicable rules, of acute or chronic symptoms, including a crisis in their caregiving;

(b) "General inpatient care" means care for patients requiring an RN on-site twenty-four hours a day, for assessment and supervision. An RN, LPN or home health aide may provide the care or treatment, according to practice acts and applicable rules, of acute or chronic symptoms, including a crisis in their caregiving;

(c) "Inpatient respite care" means care for patients whose caregivers require short-term relief of their caregiving duties;

(d) "Routine home care" means the core level of service for patients not receiving continuous care, general inpatient care, or inpatient respite care.

(5) "Hospice care center services" means hospice services provided in a hospice care center and may include any of the levels of care defined as hospice care center service categories.

(6) "Pressure relationships" of air to adjacent areas means:

(a) Positive (P) pressure is present in a room when the:

(i) Room sustains a minimum of 0.001 inches of H2O pressure differential with the adjacent area, the room doors are closed, and air is flowing out of the room; or

(ii) Sum of the air flow at the supply air outlets (in CFM) exceeds the sum of the air flow at the exhaust/return air outlets by at least 70 CFM with the room doors and windows closed.

(b) Negative (N) pressure is present in a room when the:

(i) Room sustains a minimum of 0.001 inches of H2O pressure differential with the adjacent area, the room doors are closed, and air is flowing into the room; or

(ii) Sum of the air flow at the exhaust/return air outlets (in CFM) exceeds the sum of the air flow at the supply air outlets by at least 70 CFM with the room doors and windows closed.

(i) Room sustains a pressure differential range of plus or minus 0.0002 inches of H2O with the adjacent area, and the room doors are closed; or

(ii) Sum of the air flow at the supply air outlets (in CFM) is within ten percent of the sum of the air flow at the exhaust/return air outlets with the room doors and windows closed.

(7) "Sink" means one of the following:

(a) "Clinic service sink (siphon jet)" means a plumbing fixture of adequate size and proper design for waste disposal with siphon jet or similar action sufficient to flush solid matter of at least two and one-eighth inch diameter;

(b) "Service sink" means a plumbing fixture of adequate size and proper design for filling and emptying mop buckets;

(c) "Handwash sink" means a plumbing fixture of adequate size and proper design to minimize splash and splatter and permit handwashing without touching fixtures with hands, with adjacent soap dispenser with foot control or equivalent and single service hand drying device.

(8) "WISHA" means the Washington Industrial Safety and Health Act, chapter 49.17 RCW.

NEW SECTION

WAC 246-335-712 License required.

(1) A person must possess a current license issued by the department before advertising, operating, managing, conducting, opening or maintaining a hospice care center.

(2) Prior to being approved to provide hospice care center services, an applicant must:

(a) Be licensed under chapter 70.127 RCW as an in-home services agency licensed to provide hospice services;

(b) Submit to the department an application to add hospice care center services to their existing in-home services license;

(d) Obtain a certificate of need under chapter 70.38 RCW. A separate application and fee is required to go through the certificate of need process;

(e) Complete the department's construction review services process. A separate application and fee is required to go through the construction review services process;

(f) Receive a certificate of occupancy by local building officials;

(g) Develop and operationalize policies and procedures addressing the content of this chapter for the service category(ies) to be provided and consistent with WAC 246-335-320 (2)(g);

(h) Provide other information as required by the department; and

(i) Meet the requirements of this chapter as determined by an initial survey completed by the department.

NEW SECTION

WAC 246-335-714 General licensing requirements.

(1) Initial application. To apply for a hospice care center license, an applicant must meet the initial application requirements in WAC 246-335-320 (2)(a) through (g), (i), and (j), WAC 246-335-712(2), and submit documentation that no more than forty-nine percent of patient care days, in the aggregate on a biennial basis, will be provided in a hospice care center, as required under RCW 70.127.280 (1)(d).

(2) A hospice care center licensee must meet the renewal requirements in WAC 246-335-325.

(3) Change of ownership. A hospice care center licensee must meet the change of ownership requirements in WAC 246-335-330.

(4) Applicant or licensee responsibilities. A hospice care center applicant or licensee must meet the applicant or licensee responsibilities requirements in WAC 246-335-335.

(5) Survey and investigation. The department's survey and investigation responsibilities in WAC 246-335-340 apply to hospice care center applicants and licensees.

(6) Plan of operation. A hospice care center applicant or licensee must meet the plan of operation requirements in WAC 246-335-615, and ensure pets or animals living on the premises:

(a) Have regular examinations and immunizations, appropriate for the species, by a veterinarian licensed in Washington state;

(b) Be veterinarian certified as free of diseases transmittable to humans;

(d) Include only those customarily considered domestic pets.

(7) Delivery of services. A hospice care center applicant or licensee must:

(a) Meet the delivery of services requirements in WAC 246-335-620; and

(b) Establish and implement policies and procedures that ensure:

(i) Auditory and physical privacy for the patient and family during the admitting process;

(ii) Patient rooms are private, unless the patient requests a roommate. Only two patients may share a room;

(iii) Each patient is provided a bed with a mattress appropriate to the special needs and size of the patient; and

(iv) Availability of clean bed and bath linens that are in good condition and free of holes and stains.

(8) Personnel, contractor, and volunteer policies. A hospice care center applicant or licensee must:

(a) Meet the personnel, contractor and volunteer policy requirements in WAC 246-335-625; and

(b) Ensure training in the safe storage and handling of oxygen containers and other equipment as necessary.

(9) Personnel, contractor, and volunteer records. A hospice care center applicant or licensee must meet the personnel, contractor, and volunteer records requirements in WAC 246-335-630.

(10) Bill of rights. A hospice care center applicant or licensee must:

(a) Meet the bill of rights requirements in WAC 246-335-635; or

(b) For patients already being served by the hospice agency operating the hospice care center, ensure:

(i) The bill of rights requirements have been provided to the patient, designated family member, or legal representative; and

(ii) Provide any additional information needed specific to the hospice care center.

(11) Plan of care. A hospice care center applicant or licensee must:

(a) Meet the plan of care requirements in WAC 246-335-640; or

(b) For patients already being served by the hospice agency operating the hospice care center, review the plan of care for any necessary revisions, and maintain the plan of care with any revisions in the hospice care center.

(12) Supervision. A hospice care center applicant or licensee must:

(a) Meet the supervision requirements in WAC 246-335-645; and

(b) Develop any necessary supervision requirements specific to:

(i) The hospice care center service category staffing requirements; and

(ii) Supervising personnel, volunteers and contractors who are employed by a separately licensed hospice agency.

(13) Patient records. A hospice care center applicant or licensee must meet the requirements in WAC 246-335-650.

(14) Quality improvement. A hospice care center applicant or licensee must:

(a) Meet the quality improvement requirements in WAC 246-335-655; or

(b) Ensure the hospice agency operating the hospice care center has a quality improvement program that applies to the hospice care center; or

(15) Home medical supplies and equipment. A hospice care center applicant or licensee must meet the home medical supplies and equipment requirements in WAC 246-335-660.

(16) Staffing requirements. A hospice care center applicant or licensee must implement the following staffing requirements:

(a) There must be adequate staffing on duty at all times. Considerations for determining adequate staffing include, but are not limited to:

(i) Number of patients currently admitted and residing in the center;

(ii) Specific patient care requirements;

(iii) Family care needs; and

(iv) Availability of support from other interdisciplinary team members.

(b) Two people, who may either be personnel, contractors or volunteers, must be on duty twenty-four hours per day, seven days per week;

(c) A registered nurse must be available twenty-four hours per day for consultation and direct participation in nursing care;

(d) A registered nurse must be on-site when required to perform duties specified in chapter 18.79 RCW;

(e) When providing general inpatient services, a hospice care center must comply with the staffing requirements in (a) through (d) of this subsection, and ensure:

(i) A registered nurse is present twenty-four hours per day, seven days per week, to direct nursing services; and

(ii) Care is provided by either an RN, LPN or home health aide to meet the needs of each patient in accordance with the plan of care; and

(f) When providing continuous care services, a hospice care center must, in addition to the staffing requirements in (a) through (d) of this subsection, ensure:

(i) One-on-one staffing, directed by an RN, for a minimum of eight hours to a maximum of twenty-four hours per calendar day; and

(ii) Care is provided by either an RN, LPN or home health aide to meet the needs of each patient in accordance with the plan of care.

(17) A hospice care center may either be owned or leased. If the hospice agency leases space, all delivery of interdisciplinary services, including staffing and management, must be done by the hospice agency per RCW 70.127.280 (1)(g).

NEW SECTION

WAC 246-335-716 Nutritional services.

(1) Nutritional services must be supervised by an RN or certified dietician.

(2) Appropriate nutritional consultation must be provided to the patient and family regarding the patient's dietary needs.

(3) Food must be prepared and served at intervals appropriate to the needs of patients, recognizing the unique dietary needs and changes of the terminally ill.

(4) Nutritional services must either be provided directly or through written agreement with a food service company.

(5) Food service sanitation must meet the requirements of chapter 246-215 WAC.

(6) Policies and procedures on nutritional services must include:

(a) Food storage;

(b) Food preparation;

(d) Scheduled cleaning of all food service equipment and work areas.

(7) A copy of the procedures must be kept within or adjacent to the food service area and must be available for reference by nutritional service personnel and other personnel at all times.

NEW SECTION

WAC 246-335-718 Infection control.

A hospice care center applicant or licensee must develop and implement written policies and procedures addressing infection control pertinent to the hospice care center and consistent with WAC 246-335-625(15).

NEW SECTION

WAC 246-335-720 Emergency preparedness.

A hospice care center applicant or licensee must:

(1) Develop and operationalize written policies and procedures governing emergency preparedness and fire protection;

(2) Develop a written emergency preparedness plan, rehearsed at least annually with personnel, contractors, and volunteers that addresses service delivery when natural disasters, man-made incidents, or public health emergencies occur that prevent normal facility operation. Include, at minimum: Risk assessment and emergency planning, communication plan, subsistence needs, evacuation plans, sheltering in place, care of casualties, tracking patients and staff during an emergency, and staff training and drills to test emergency plan; and

(3) Develop a fire protection plan to include:

(a) Instruction for all personnel, contractors or volunteers in use of alarms, firefighting equipment, methods of fire containment, evacuation routes and procedures for calling the fire department and the assignment of specific tasks to all personnel, contractors and volunteers in response to an alarm; and

(b) Fire drills for each shift of personnel.

NEW SECTION

WAC 246-335-722 Pharmaceutical services.

The licensee must ensure that all pharmaceutical services are provided consistent with chapter 246-865 WAC and the following requirements:

(1) Pharmaceutical services must be available twenty-four hours per day to provide medications and supplies through a licensed pharmacy;

(2) A licensed pharmacist must provide sufficient on-site consultation to ensure that medications are ordered, prepared, disposed, secured, stored, accounted for and administered in accordance with the policies of the center and chapter 246-865 WAC;

(3) Medications must be administered only by individuals authorized to administer medications;

(4) Medications may be self-administered in accordance with WAC 246-865-060 (7)(f);

(5) Drugs for external use must be stored apart from drugs for internal use;

(6) Poisonous or caustic medications and materials including housekeeping and personal grooming supplies must show proper warning or poison labels and must be stored safely and separately from other medications and food supplies;

(7) The hospice care center must maintain an emergency medication kit appropriate to the needs of the center;

(8) Medications brought into the hospice care center by patients to be administered by an appropriate health care professional while in the center must be specifically ordered by an authorizing practitioner and must be identified by a pharmacist or licensed nurse with pharmacist consultation prior to administration;

(9) Drugs requiring refrigeration must be kept in a separate refrigeration unit;

(10) Schedule II-IV controlled substances must be:

(a) Kept in a separate keyed storage unit;

(b) When heat sensitive, be kept in a locked refrigeration unit; and

(11) In addition to the requirements in subsection (10) of this section, schedule III and IV controlled substances must be:

(a) Stored apart from other drugs; or

(b) Stored on a separate shelf, drawer, or compartment with schedule II controlled substances;

(12) The hospice care center must provide for continuation of drug therapy for patients when temporarily leaving the center in accordance with WAC 246-865-070;

(13) If planning to use an automated drug distribution device, the hospice care center must first receive pharmacy quality assurance commission approval; and

(14) If planning to provide pharmacy services beyond the scope of services defined in this section, the hospice care center must comply with the requirements for a licensed pharmacy in chapter 246-869 WAC.

NEW SECTION

WAC 246-335-724 Exemptions and alternative methods.

Hospice care centers applying for an exemption to any of the requirements in WAC 246-335-705 through 246-335-724 must comply with the requirements in WAC 246-335-355.

Part 6 – Physical Environment Requirements

NEW SECTION

WAC 246-335-726 Applicability.

The purpose of the following construction regulations in WAC 246-335-726 through 246-335-768 is to provide minimum standards for a safe, homelike, and effective patient care environment in hospice care centers consistent with other applicable rules without redundancy and contradictory requirements. Rules allow flexibility in achieving desired outcomes and enable hospice care centers to respond to changes in technologies and health care innovations. Compliance with these rules do not relieve the hospice of the need to comply with applicable state and local building and zoning codes. Where differences in interpretations occur, the hospice will follow the most stringent requirement.

(1) These rules apply to all construction as defined in WAC 246-335-710.

(2) The requirements in WAC 246-335-726 through 246-335-768 in effect at the time the application, fee, and construction documents are submitted to the department for review will apply for the duration of the construction project.

NEW SECTION

WAC 246-335-728 Construction and design codes.

A hospice care center applicant must, through its design, construction, and necessary permits demonstrate compliance with the following codes and local jurisdiction standards:

(1) The state building code as adopted by the state building code council under the authority of chapter 19.27 RCW;

(2) The National Fire Protection Association, Life Safety Code, NFPA 101, as adopted by the Centers for Medicare and Medicaid Services;

(3) The National Fire Protection Association, Health Care Facilities Code, NFPA 99, as adopted by the Centers for Medicare and Medicaid Services; and

(4) Ventilation of health care facilities, American National Standards Institute; American Society of Heating, Refrigerating and Air-conditioning Engineers; American Society for Healthcare Engineering Standard 170-2013.

NEW SECTION

WAC 246-335-730 Design, construction review and approval of plans.

(1) Drawings and specifications for new construction, excluding minor alterations, must be prepared by or under the direction of, an architect registered under chapter 18.08 RCW. The services of a consulting engineer registered under chapter 18.43 RCW may be used for the various branches of work where appropriate. The services of a registered engineer may be used in lieu of the services of an architect if the scope of work is primarily engineering in nature.

(2) A hospice care center applicant or licensee will meet the following requirements:

(a) Preconstruction. Request and attend a presubmission conference with the department for projects with a construction value of two hundred fifty thousand dollars or more. The presubmission conference must be scheduled to occur for the review of construction documents that are no less than fifty percent complete;

(b) Construction document review. Submit construction documents for proposed new construction to the department for review within ten days of submission to the local authorities. Compliance with these standards and regulations does not relieve the hospice care center of the need to comply with applicable state and local building and zoning codes. The construction documents must include:

(i) A written program containing the following:

(A) Information concerning services to be provided and operational methods to be used;

(B) An interim life safety measures plan to ensure the health and safety of occupants during construction and installation of finishes; and

(C) An infection control risk assessment indicating appropriate infection control measures, keeping the surrounding area free of dust and fumes, and ensuring rooms or areas are well ventilated, unoccupied, and unavailable for use until free of volatile fumes and odors;

(ii) Drawings and specifications to include coordinated architectural, mechanical, and electrical work. Each room, area, and item of fixed equipment and major movable equipment must be identified on all drawings to demonstrate that the required facilities for each function are provided;

(iii) A floor plan of the existing building showing the alterations and additions, and indicating location of any service or support areas;

(iv) Required paths of exit serving the alterations or additions; and

(v) Verification that the capacities and loads of infrastructure systems will accommodate planned load.

(c) Resubmittals. The hospice will respond in writing when the department requests additional or corrected construction documents;

(d) Construction. Comply with the following requirements during the construction phase:

(i) The hospice care center applicant or licensee will not begin construction until all of the following items are complete:

(A) The department has approved the construction documents or granted authorization to begin construction;

(B) The local jurisdictions have issued a building permit; and

(C) The hospice care center applicant or licensee has notified the department in writing when construction will commence;

(ii) The department will issue an "authorization to begin construction" when the construction documents have been conditionally approved or when all of the following items have been reviewed and approved:

(A) A signed form acknowledging the risks if starting construction before the plan review has been completed. The acknowledgment of risks form shall be signed by the:

(I) Architect;

(II) Hospice chief executive officer, chief operations officer, or designee; and

(III) Hospice facilities director.

(B) The infection control risk assessment;

(D) A presubmission conference has occurred;

(iii) Submit to the department for review any addenda or modifications to the construction documents;

(iv) Ensure construction is completed in compliance with the final department approved documents;

(v) The hospice care center applicant or licensee will allow any necessary inspections for the verification of compliance with the construction documents, addenda, and modifications.

(e) Project closeout. The hospice will not use any new or remodeled areas until:

(i) The department has approved construction documents;

(ii) The local jurisdictions have completed all required inspections and approvals, when applicable or given approval to occupy; and

(iii) The facility notifies the department in writing when construction is completed and includes a copy of the local jurisdiction's approval for occupancy.

NEW SECTION

WAC 246-335-732 Site and site development.

A hospice care center applicant or licensee must provide a site with utilities that meet state building code and local regulations including:

(1) Potable water supply meeting requirements in chapters 246-270, 246-290, and 246-291 WAC;

(2) Natural drainage or properly designed/engineered drainage system;

(3) An approved public sewer system or on-site sanitary sewage system meeting requirements in chapter 246-272A or 246-272B WAC;

(4) Physical access to community emergency services;

(5) Parking area, drives, and walkways:

(a) Convenient for patients, personnel, contractors, volunteers, and visitors, while avoiding interference with patient privacy and comfort;

(b) With surfaces useable in all weather and traffic conditions; and

Part 7 – General Design Requirements

NEW SECTION

WAC 246-335-734 General requirements.

A hospice care center applicant or licensee must meet the following general design elements for patient and family care and support areas as described in this chapter.

(1) Design of the hospice care center must take into account:

(a) The number of patient rooms planned which must not include more than twenty patient beds;

(b) The requirements for patient rooms as specified in WAC 246-335-756; and

(c) The family, personnel and public area requirements for space, which may include multiuse areas, as specified in WAC 246-335-760.

(2) A hospice care center may either be freestanding or a separate portion of another building.

(3) The hospice care center must have a separate external entrance, clearly identifiable to the public.

(4) If patient rooms are located above grade level, the hospice care center must have at least one elevator or lift designed for patient transport by gurney or equivalent.

(5) Doors must be designed with:

(a) Provisions for personnel, contractors, and volunteers to gain immediate emergency access to patient occupied rooms or areas;

(b) The ability to swing outward from patient toilet and bathing rooms or equipped with double acting or rescue door hardware; and

(6) Stairways must be designed with slip-resistant floor surfaces and ramps with slip-resistant or carpeted floor surfaces are required.

(7) Design and construction must address the prevention of entrance and infestation by pests.

(8) Interior finishes must be suitable to the function of an area including:

(a) Floors must be finished with:

(i) Easily cleanable or maintainable surfaces;

(ii) Slip-resistant surfaces at entrances and other areas;

(iii) Edges covered and top set base with toe at all wall junctures;

(b) Carpets are not permitted in toilets, bathrooms, kitchens, utility rooms, janitor closets, and other areas where flooding or infection control is an issue;

(d) Walls must be:

(i) Protected from impact in high traffic areas;

(ii) Finished with easily cleanable surfaces; and

(iii) Finished with water-resistant paint, glaze, or similar water-resistant finish extending above the splash line in all rooms or areas subject to splash or spray.

(9) The design must include space and adequate storage for facility drawings, records, and operation manuals.

NEW SECTION

WAC 246-335-736 Furnishings.

Furnishings of the hospice care center must be homelike and include lounge furniture in addition to furnishings in patient rooms. Accessories such as wallpaper, bedspreads, carpets and lamps must be:

(1) Selected to create a homelike atmosphere; and

(2) Installed per manufacturer installation standards.

NEW SECTION

WAC 246-335-738 Pharmaceutical services area.

(1) Pharmaceutical services area(s) must be accessible only to authorized personnel.

(2) A hospice care center must provide pharmacy services area(s) consistent with WAC 246-865-050 which include adequate space for:

(a) A work counter;

(b) A handwash sink;

(d) Drug storage units constructed of metal, solid wood, or plywood which provide:

(i) Locked storage for all drugs;

(ii) Separate keyed storage for Schedule II-IV controlled substances;

(iii) Segregated storage for each patient's drugs;

(e) A lockable refrigerator for storage of heat sensitive drugs; and

(f) Other storage needed according to the hospice care center's functional program.

NEW SECTION

WAC 246-335-740 Food preparation.

(1) A hospice care center applicant or licensee must:

(a) Locate food preparation areas to prevent objectionable heat, noise and odors to patient rooms;

(b) Provide a nourishment center for use by patients and family with:

(i) A refrigerator capable of maintaining 45°F or less;

(ii) A two-compartment sink;

(iii) A range with exhaust hood and/or microwave;

(iv) Work surfaces;

(v) Storage for single service utensils and food items;

(vi) Soap and paper towel dispensers or equivalent;

(vii) Space for waste containers; and

(viii) A self-dispensing ice machine if not provided elsewhere in the hospice care center.

(2) The following requirements only apply if the hospice care center is planning to prepare meals and snacks for patients on-site:

(a) When primarily preparing individual meals or snacks for patients, in addition to the requirements in subsection (1) of this section, the nourishment center must include:

(i) A separate refrigerator for patients' food items capable of maintaining 45°F or less;

(ii) Separate storage for patient food items, cooking and eating utensils;

(iii) A handwash sink; and

(iv) A domestic dishwasher with a continuous supply of 155°F of water.

(b) When primarily preparing meals for fifteen or fewer patients at a time, the kitchen and equipment for preparation of patient meals and snacks must comply with chapter 246-215 WAC, Food sanitation, except, the hospice care center may use domestic or home type kitchen appliances including mechanical dishwashers; and

(c) When primarily preparing meals for sixteen or more patients at a time, the kitchen for preparation of patient meals and snacks must comply with chapter 246-215 WAC, Food sanitation.

NEW SECTION

WAC 246-335-742 Linen handling facilities.

A hospice care center applicant or licensee must provide linen handling facilities with the capacity for receiving, holding, sorting, and separating soiled and clean linens either in:

(1) Clean and soiled utility rooms meeting the requirements of WAC 246-335-732; or

(2) In a separate linen handling facility meeting the following requirements:

(a) Floor drain(s) located in the soiled linen area;

(b) Handwash sink in soiled and clean processing areas;

(d) A folding area on clean side of room; and

(e) Separate clean linen storage located to avoid sources of moist or contaminated air with:

(i) Storage for reserve supply of linens, blankets, and pillows; and

(ii) Space for carts or shelves.

NEW SECTION

WAC 246-335-744 Laundry facilities.

A hospice care center applicant or licensee must provide laundry service through the use of:

(1) A commercial laundry service; or

(2) On-site laundry facilities with:

(a) A system to avoid through traffic or excessive heat, noise or odors to travel to patient rooms;

(b) Equipment capacity for processing laundry;

(d) Washing machine(s);

(e) Floor drains as required for equipment;

(f) Dryer(s);

(g) Dryer exhaust to the exterior and make-up air; and

(h) A handwash sink.

NEW SECTION

WAC 246-335-746 Utility rooms.

(1) A hospice care center applicant or licensee must provide a clean utility room with no direct connection to soiled utility services, including:

(a) Sufficient clean storage and handling area(s);

(b) Closed storage for clean and sterile supplies and equipment;

(d) A handwash sink;

(e) Soap and towel dispenser; and

(f) A self-closing door.

(2) The hospice care center must provide a soiled utility room on each floor of the center with no direct connection to clean utility services, including:

(a) A clinic service sink, siphon jet or equivalent with bedpan flushing attachment unless bedpan flushing devices are furnished in all patient toilets;

(b) A counter top, two-compartment sink, and gooseneck spout or equivalent;

(d) Soap and towel dispenser;

(e) Locked storage for chemicals; and

(f) A self-closing door.

Part 8 – Specific Design Requirements

NEW SECTION

WAC 246-335-748 Plumbing.

An applicant must design and install plumbing, including:

(1) Backflow prevention. Devices on plumbing fixtures, equipment, facilities, buildings, premises, or areas which may cause actual or potential cross-connections of systems in order to prevent the backflow of water or other liquids, gases, mixtures, or substances into a water distribution system or other fixtures, equipment, facilities, buildings, or areas;

(2) Trap primers in floor drains and stand pipes subject to infrequent use;

(3) Wrist, knee or foot faucet controls or equivalent and gooseneck spouts on handwash sinks;

(4) Insulation on:

(a) Hot water piping systems;

(b) Cold water and drainage piping; and

(5) Equipment to deliver hot water at point of use as follows:

(a) 120°F or less for handwash sinks and bathing fixtures;

(b) 160°F or more for laundry washers;

NEW SECTION

WAC 246-335-750 Medical gases.

If oxygen is stored or used on the premises, the following must apply in addition to other codes and regulations:

(1) Electrical equipment used in oxygen-enriched environments must be properly designed for use with oxygen and should be labeled for use with oxygen; and

(2) "No smoking" signs must be posted where oxygen is being administered.

NEW SECTION

WAC 246-335-752 Heating, ventilating and air conditioning.

(1) Hospice care centers must have systems to provide individual temperature control for patient rooms to ensure patient preference and comfort. The hospice care center must have the capacity to maintain:

(a) Patient rooms at 70°F in summer and 80°F in winter; and

(b) Nonpatient care areas at 75°F in summer and 70°F in winter.

(2) Provide air pressurization differentials within the facility to promote the movement air from clean areas into dirty areas per American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE) 170.

(3) Provide air changes in areas per ASHRAE 170.

NEW SECTION

WAC 246-335-754 Electrical and communication systems.

A hospice care center applicant or licensee must provide general electrical service including:

(1) Tamper proof receptacles in patient rooms, toilets, and bathing facilities, and family and public areas;

(2) Ground fault circuit interrupter (GFCI) receptacle when located within five feet of water source and above counters that contain sinks;

(3) Emergency electrical service with:

(a) Adequate emergency lighting in patient rooms;

(b) At a minimum, provisions must be made for emergency lighting for means of egress; and

(4) Lighting fixtures with:

(a) Number, type, and location to provide illumination for the functions of each area;

(b) A reading light and control, conveniently located for patient use at each bed in the patient rooms; and

(i) Over patient beds;

(ii) In areas where patient care equipment and supplies are processed; and

(iii) In nourishment centers or kitchen areas.

(d) A night light or equivalent low level illumination; and

(e) Night light switches and general illumination switches located adjacent to the opening side of patient room doors.

(5) An electronic means of communication that notifies on-duty personnel, contractors, or volunteers and that must:

(a) Be located at the head of the bed in patient rooms and in all common areas accessible by the patients;

(b) Be physically or verbally accessible by patients slumped forward on the floors of either the toilet, bathing facility, or dressing room; and

Part 9 – Patient Areas

NEW SECTION

WAC 246-335-756 Patient rooms.

(1) A hospice care center applicant or licensee must locate patient rooms to exclude through traffic and minimize the penetration of objectionable odors and noise from other areas of the center.

(2) Hospice care centers must ensure each patient room is:

(a) Directly accessible from a corridor; and

(b) A minimum of one hundred square feet for private rooms and one hundred sixty square feet for rooms allowing a roommate.

(3) All operable windows or openings that serve for ventilation must be provided with screening.

(4) Patient room must be located above grade level.

(5) Patient beds must be placed so they do not interfere with entrance, exit or traffic flow within the room.

(6) Patient rooms must be safe, private, clean and comfortable, allowing the patient to use personal belongings to the extent possible and include:

(a) Seating for several family members, with provision for at least one sleeping accommodation in patient rooms;

(b) A window with a view of landscaping to the exterior;

(d) A space suitable for hanging full-length garments and secure storage of personal belongings within the patient room.

NEW SECTION

WAC 246-335-758 Patient toilets and bathing facilities.

(1) Each patient toilet must adjoin the patient room and include:

(a) Bedpan flushing equipment if bedpan flushing equipment is not located in a soiled utility room;

(b) A handwash sink;

(d) Slip resistant floor surfaces;

(e) A toilet paper holder;

(f) Backing to support mounting of all accessories; and

(g) Mirror and shelving or equivalent at each handwash sink.

(2) There must be at least one patient toilet in the hospice care center meeting the accessibility requirements in chapter 51-50 WAC for every four patient beds. A minimum of one patient toilet meeting the accessibility requirements is required for each hospice care center.

(3) Bathing facilities, which may be separate from patient toilet rooms, must include:

(a) Slip resistant floors;

(b) An adequate supply of hot water available at all times;

(d) A robe hook; and

(e) Grab bars that are easily cleanable and resistant to corrosion.

Part 10 – Family, Personnel, Volunteer, Contractor, and Public Areas

NEW SECTION

WAC 246-335-760 Family, personnel, volunteer, contractor, and public areas.

(1) A hospice care center applicant or licensee must provide family use areas with:

(a) A minimum of two hundred square feet;

(b) Comfortable seating for several family members;

(d) Drinking water;

(e) A public telephone;

(f) Information desk or directory signage; and

(g) Exterior, clear glass windows with a maximum sill height of thirty-six inches.

(2) Hospice care centers must provide a private space at least one hundred fifty square feet in size for every ten beds and an additional seventy-five square feet for every additional five beds. The private space should be designed for:

(a) Private group, family, and individual interviews and counseling;

(b) Interdisciplinary weekly conferences and personnel, contractor, and volunteer breaks; and

(3) Hospice care centers must provide additional space for personnel, contractors and volunteers. This space must be designed to accommodate:

(a) Secure storage for medical records;

(b) Personnel, contractor, and volunteer break areas;

(d) General storage; and

(e) At least one personnel, contractor, and volunteer toilet room with handwash sink.

(4) Hospice care centers must provide one visitor toilet room with handwash sink for every ten beds.

Part 11 – Facility Support

NEW SECTION

WAC 246-335-762 Environmental services facilities.

(1) The hospice care center must provide a waste handling area including storage area in a separate area designed to maintain pest control, or in an outside, enclosed space with:

(a) A handwash sink located adjacent to the path of travel back into patient care areas;

(b) If planned, an interior waste container wash area with floor drain connected to a sanitary sewage system and hose bibs with hot and cold water;

(2) The hospice care center must provide a locked housekeeping supply room on each floor with:

(a) A service sink or equivalent;

(b) Soap and towel dispenser;

(d) Storage for chemicals.

NEW SECTION

WAC 246-335-764 Maintenance facilities.

A hospice care center applicant or licensee must:

(1) If planning a maintenance shop, ensure it is located and designed for easy delivery and removal of equipment and to minimize noise and dust to the rest of the hospice care center with:

(a) Storage for solvents, flammable and combustible liquids; and

(b) Storage for supplies and equipment.

(2) Provide a separate room or area specifically for repair, and testing of electronic or other medical equipment according to the functional program.

NEW SECTION

WAC 246-335-766 Receiving, storage and distribution facilities.

A hospice care center applicant or licensee must:

(1) Provide bulk and general supply storage constructed to control pests and prevent spoilage, contamination, damage, and corrosion of goods including:

(a) Protection against inclement weather;

(b) Secured spaces with appropriate environmental conditions in accordance with federal and state laws and rules on supplies and medication storage if pharmaceuticals are stored; and

(2) Provide receiving and unloading area with:

(a) Administrative work space;

(b) Security and protection for supplies; and

(3) Provide storage if needed for:

(a) Flammable and combustible liquid storage;

(b) Laboratory chemicals;

(d) Gaseous oxidizing materials;

(e) Pesticides, cleaning compounds, and toxic substances; and

(f) Mobile housekeeping equipment.

Part 12 – Exemptions and Alternative Methods

NEW SECTION

WAC 246-335-768 Exemptions and alternative methods.

Hospice care centers applying for an exemption to any of the requirements in WAC 246-335-726 through 246-335-766 must comply with the requirements in WAC 246-335-355.

Part ((3)) 13 - Fees

AMENDATORY SECTION (Amending WSR 12-11-063, filed 5/15/12, effective 6/30/12)

WAC 246-335-990 Fees.

(((1) A licensee or applicant shall submit to the department:

(a) An initial twelve-month license fee of two thousand four hundred thirty-two dollars for each service category for new persons not currently licensed in that category to provide in-home services in Washington state, or currently licensed businesses which have had statement of charges filed against them;

(b) A twenty-four month renewal fee for home care, home health and hospice agencies, based on the number of full-time equivalents (FTEs), which is a measurement based on a forty-hour week and is applicable to paid agency personnel or contractors, according to the following table. A twenty-four month renewal fee for hospice care centers, based on the number of beds, according to the following table:

(i) For single service category licenses:


# of FTEs	Home Health	Hospice	Home Care	# of Beds	Hospice Care Center
5 or less	$2,432.00	$1,216.00	$730.00	5 or less	$810.00
6 to 15	$3,421.00	$1,280.00	$1,321.00	6 to 10	$1,622.00
16 to 50	$3,893.00	$1,906.00	$1,419.00	11 to 15	$2,432.00
51 to 100	$4,906.00	$3,052.00	$1,662.00	16 to 20	$3,243.00
101 or more	$5,052.00	$3,211.00	$1,784.00

(ii) For multiple service category licenses:

(A) One hundred percent of the home health category fee and seventy-five percent of the appropriate service category fee for each additional service category (hospice, home care, hospice care center); or

(B) One hundred percent of the hospice category fee and seventy-five percent of the appropriate service category fee for each additional service category (home care, hospice care center); and

(c) A change of ownership fee of two hundred fifty dollars for each licensed service category. A new license will be issued and valid for the remainder of the current license period.

(2) The department may charge and collect from a licensee a fee of one thousand two hundred ninety-seven dollars for:

(a) A second on-site visit resulting from failure of the licensee to adequately respond to a statement of deficiencies;

(b) A complete on-site survey resulting from a substantiated complaint; or

(3) A licensee with deemed status shall pay fees according to this section.

(4) A licensee shall submit an additional late fee in the amount of fifty dollars per day, not to exceed six hundred fifty dollars, from the renewal date (which is thirty days before the current license expiration date) until the date of mailing the fee, as evidenced by the postmark.

(5) Refunds. The department shall refund fees paid by the applicant for initial licensure as follows:

(a) If an application has been received but no on-site survey or technical assistance has been performed by the department, two-thirds of the fees paid, less a fifty dollar processing fee; or

(b) If an application has been received and an on-site survey or technical assistance has been performed by the department, one-third of the fees paid, less a fifty dollar processing fee.

(6) The department may not refund applicant fees if:

(a) The department has performed more than one on-site visit for any purpose;

(b) One year has elapsed since an initial licensure application is received by the department, but no license is issued because applicant failed to complete requirements for licensure; or

(c) The amount to be refunded as calculated by subsection (5)(a) or (b) of this section is ten dollars or less.)) (1) Initial license. An applicant shall submit to the department an initial twelve-month license fee of three thousand two hundred eighty-three dollars for each service category (home care, home health, hospice) for persons not currently licensed to provide in-home services in Washington state.

(2) Adding new service categories to existing license. A licensee shall submit to the department an initial twelve-month license fee of three thousand two hundred eighty-three dollars for each new service category (home care, home health, hospice, hospice care center) for licensees not currently licensed in that category to provide in-home services in Washington state, or currently licensed businesses which have had enforcement action filed against them.

(3) Renewal license. A licensee shall submit to the department a twenty-four month renewal fee for home care, home health and hospice agencies, based on the number of full-time equivalents (FTEs), which is a measurement based on a forty hour week and is applicable to paid agency personnel or contractors, according to Table 1 of this section. The department will assume a minimum of 1 FTE for each approved service area per service category. The licensee shall submit to the department a twenty-four month renewal fee for hospice care centers, based on the number of beds, according to Table 1 of this section:

(a) For licenses with a single service category:

Table 1 - Renewal Fees


# of FTEs	Home Care	Home Health	Hospice	# of Beds	Hospice Care Center
5 or less	$1,530.00	$3,283.00	$1,642.00	5 or less	$1,642.00
6 to 15	$1,783.00	$4,618.00	$1,856.00	6 to 10	$2,190.00
16 to 50	$1,916.00	$5,256.00	$2,383.00	11 to 15	$3,283.00
51 to 100	$2,244.00	$6,623.00	$4,120.00	16 to 20	$4,378.00
101 or more	$2,408.00	$6,820.00	$4,335.00

(b) For licenses with multiple service categories:

(i) One hundred percent of the home health category fee and seventy-five percent of the appropriate service category fee for each additional service category (home care, hospice, hospice care center); or

(ii) One hundred percent of the hospice category fee and seventy-five percent of the appropriate service category fee for each additional service category (home care, hospice care center).

(4) Change of ownership. A change of ownership fee of three hundred fifty dollars for each licensed service category (home care, home health, hospice, hospice care center). A new license will be issued and valid for the remainder of the current license period.

(5) The department may charge and collect from a licensee a fee of one thousand five hundred thirty dollars for:

(a) An on-site follow-up compliance survey deemed necessary in order to complete the survey process;

(b) An on-site compliance survey deemed necessary due to failure of the licensee to adequately respond to a statement of deficiencies or a directed plan of correction;

(d) State licensing surveys conducted during renewal periods that require on-site survey time beyond two days.

(6) A licensee that is not subject to the state survey requirement according to WAC 246-335-350 shall pay fees according to this section.

(7) A licensee shall submit an additional late fee in the amount of fifty dollars per day, not to exceed six hundred fifty dollars, from the renewal date, which is thirty days before the current license expiration date, until the date of mailing the fee, as evidenced by the postmark.

(8) Refunds. The department shall refund fees paid by the applicant for initial licensure as follows:

(a) If an application has been received but no on-site survey or technical assistance has been performed or provided by the department, two-thirds of the fees paid, less a fifty dollar processing fee; or

(b) If an application has been received and an on-site survey or technical assistance has been performed or provided by the department, one-third of the fees paid, less a fifty dollar processing fee.

(9) The department may not refund applicant fees if:

(a) The department has performed more than one on-site visit for any purpose;

(b) Nine months has elapsed since an initial licensure application is received by the department, but no license has been issued due to applicant's failure to complete the requirements for licensure; or

REPEALER

The following sections of the Washington Administrative Code are repealed:


WAC 246-335-001	Scope and purpose.
WAC 246-335-010	Applicability.
WAC 246-335-015	Definitions.
WAC 246-335-020	License required.
WAC 246-335-025	Initial application.
WAC 246-335-030	Renewal.
WAC 246-335-035	Change of ownership.
WAC 246-335-040	Applicant or licensee rights and responsibilities.
WAC 246-335-045	Department responsibilities.
WAC 246-335-050	Deemed status.
WAC 246-335-055	Plan of operation.
WAC 246-335-060	Delivery of services.
WAC 246-335-065	Personnel, contractor, and volunteer policies.
WAC 246-335-070	Personnel, contractor and volunteer records.
WAC 246-335-075	Bill of rights.
WAC 246-335-080	Home health plan of care.
WAC 246-335-085	Hospice plan of care.
WAC 246-335-090	Home care plan of care.
WAC 246-335-095	Supervision of home health care.
WAC 246-335-100	Supervision of hospice care.
WAC 246-335-105	Supervision of home care.
WAC 246-335-110	Patient/client records.
WAC 246-335-115	Quality improvement.
WAC 246-335-120	Home medical supplies and equipment.
WAC 246-335-125	Exemptions and alternative methods.
WAC 246-335-130	Applicability.
WAC 246-335-135	Definitions.
WAC 246-335-140	License required.
WAC 246-335-145	Initial application.
WAC 246-335-150	Renewal.
WAC 246-335-155	Other general hospice care center licensing requirements.
WAC 246-335-160	Nutritional services.
WAC 246-335-165	Infection control.
WAC 246-335-170	Emergency preparedness.
WAC 246-335-175	Pharmaceutical services.
WAC 246-335-180	Applicability.
WAC 246-335-185	Application and approval.
WAC 246-335-190	Construction and design codes.
WAC 246-335-195	Construction documents.
WAC 246-335-200	Site and site development.
WAC 246-335-205	General requirements.
WAC 246-335-210	Furnishings.
WAC 246-335-220	Pharmaceutical services area.
WAC 246-335-225	Food preparation.
WAC 246-335-230	Linen handling facilities.
WAC 246-335-235	Laundry facilities.
WAC 246-335-240	Utility rooms.
WAC 246-335-245	Plumbing.
WAC 246-335-250	Medical gases.
WAC 246-335-255	Heating, ventilating and air conditioning.
WAC 246-335-260	Electrical service and distribution.
WAC 246-335-265	Patient rooms.
WAC 246-335-270	Patient toilets and bathing facilities.
WAC 246-335-275	Family, personnel, volunteer, contractor, and public areas.
WAC 246-335-280	Environmental services facilities.
WAC 246-335-285	Maintenance facilities.
WAC 246-335-290	Receiving, storage and distribution facilities.
WAC 246-335-295	Exemptions and alternative methods.