SOCIAL AND HEALTH SERVICES

(Aging and Long-Term Support Administration)

[Filed March 13, 2023, 12:01 p.m.]

Preproposal statement of inquiry was filed as WSR 22-14-034.

Title of Rule and Other Identifying Information: New chapter 388-112B WAC, Behavioral health workers—Facility based workers—Geriatric behavioral health worker training and curriculum requirements. The department of social and health services (DSHS) is planning to add new chapter 388-112B WAC relating to curricula for persons in long-term care facilities with behavioral health needs.

Hearing Location(s): On April 25, 2023, at 10:00 a.m., at Office Building 2, DSHS Headquarters, 1115 Washington [Street S.E.], Olympia, WA 98504. Public parking at 11th and Jefferson. A map is available at https://www.dshs.wa.gov/office-of-the-secretary/driving-directions-office-bldg-2; or virtually. Hearings are currently held virtually, see the DSHS website https://www.dshs.wa.gov/office-of-the-secretary/filings-and-rules for the most current information.

Date of Intended Adoption: Not earlier than April 26, 2023.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, email DSHSRPAURulesCoordinator@dshs.wa.gov, fax 360-664-6185, by 5:00 p.m., April 25, 2023.

Assistance for Persons with Disabilities: Contact DSHS rules consultant, phone 360-664-6036, fax 360-664-6185, TTY 711 relay service, email shelley.tencza@dshs.wa.gov, by 5:00 p.m., April 11, 2023.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: This new rule will set competencies and standards to be used by nursing home facilities to create the curriculum required by RCW 74.39A.078 and set rules for approval of the curriculum by DSHS.

Reasons Supporting Proposal: During the 2017 legislative session, HB [ESHB] 1548 was codified as RCW 74.39A.078. This law requires DSHS to adopt rules to establish minimum competencies and standards for the approval of curricula for facility-based workers serving persons with behavioral health needs and geriatric behavioral health workers. The curricula must include at least 30 hours of training specific to the diagnosis, care, and crisis management of residents with a mental health disorder, traumatic brain injury, or dementia. The curricula must be outcome-based and the effectiveness must be measured by demonstrated competency in the core specialty areas through the use of a competency test. By eliminating the requirement for a social work degree through this training, the number of individuals who fall within the definition of geriatric behavioral health worker can be expanded, which consequently allows the work performed by these individuals to be used to satisfy the nursing home's direct care service minimum requirements.

Statutory Authority for Adoption: RCW 18.20.270, 74.39A.020, and 74.42.360.

Statute Being Implemented: RCW 74.39A.078.

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

Name of Proponent: DSHS, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: David Chappell, P.O. Box 45600, Lacey, WA 98504-5600, 360-725-2516.

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 David Chappell, P.O. Box 45600, Lacey, WA 98504-5600, phone 360-725-2516, email david.chappell@dshs.wa.gov.

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. While the proposed rules spell out the requirements of what the behavioral health curriculum must contain and the process for its approval, they do not require businesses to create or implement the curriculum. In consultation with stakeholders representing affected skilled nursing facilities, it was estimated that the cost for those that choose to create and implement the curriculum would not impose more-than-minor costs.

These proposed rules impact nursing facilities that may choose to create and offer this training. Some of these businesses may fall under the following North American Industry Classification System (NAICS) designation:

DSHS's aging and long-term support administration (ALTSA) has analyzed the proposed rule amendments and has determined that only those listed small businesses choosing to develop and offer geriatric behavioral health worker training will be impacted by these changes.


•	Residential mental health facilities - NAICS code 6232.
•	Nursing and residential care facilities - NAICS code 623110.

INVOLVEMENT OF STAKEHOLDERS: The following stakeholders were involved in reaching agreement on the final language of the proposed changes:


•	Leading Age, Washington.
•	Washington Healthcare Association.
•	Residential care services.

SMALL BUSINESS ECONOMIC IMPACT STATEMENT (SBEIS)—DETERMINATION OF NEED: Chapter 19.85 RCW, The Regulatory Fairness Act, requires that the economic impact of proposed regulations be analyzed in relation to small businesses. The statute defines small businesses as those businesses that employ 50 or fewer people and are independently owned and operated.

Preparation of an SBEIS is required when a proposed rule has the potential of placing a disproportionate economic impact on small businesses. The statute outlines information that must be included in an SBEIS.

Offering geriatric behavioral health training is optional for facilities, and those that do will benefit by expanding the number of individuals who fall within the definition of geriatric behavioral health worker, allowing the work performed by these individuals to be used to satisfy the nursing home's direct care service minimum requirements. The proposed rules strike a balance between holding a high standard for the required competencies of the curriculum and flexibility in application.

DSHS's ALTSA has analyzed the proposed rules and amendments and concludes that they will impose moderate costs to programs that choose to develop and offer geriatric behavioral health training, and no new costs on small businesses that do not. The preparation of a comprehensive SBEIS is not required.

Katherine I. Vasquez

Chapter 388-112B WAC

BEHAVIORAL HEALTH WORKERS-FACILITY BASED WORKERS-GERIATRIC BEHAVIORAL HEALTH WORKER TRAINING AND CURRICULUM REQUIREMENTS

WAC 388-112B-0010What definitions apply to this chapter?

The following definitions apply to this chapter:

(1) "Challenge test" means a competency test without first taking the class for which the test is designed.

(2) "Competency" means the integrated knowledge, skills, or behavior expected of a worker after completing the training in a required topic area. Learning objectives are associated with each competency.

(3) "Competency testing" means evaluating a student to determine if they can demonstrate the required level of skill, knowledge, and behavior with respect to the identified learning objectives of a particular course.

(4) "DSHS" or "Department" means the department of social and health services and the department's employees.

(5) "Facility" means a nursing home as defined in RCW 18.51.010.

(6) "Geriatric behavioral health worker" means a person who has received specialized training devoted to diagnoses, care, and crisis management of residents with a mental health disorder, traumatic brain injury, or dementia.

(7) "Geriatric behavioral health worker training" means department-approved curricula for facility-based geriatric behavioral health workers serving persons with behavioral health needs as described in RCW 74.42.360 (2)(c)(i)(B).

(8) "Learning objectives" means measurable, written statements that clearly describe what a worker must minimally learn to meet each competency. Learning objectives are identified for each competency. Learning objectives provide consistent, common language and a framework for curriculum designers, the curriculum approval process, and testing.

WAC 388-112B-0020What are the purposes of this chapter?

The purposes of this chapter are to describe the following:

(1) The standards and minimum competencies of the geriatric health worker training curriculum;

(2) The approval process for the behavioral health worker training curriculum; and

(3) The documentation required for the proof of completion of the behavioral health worker training curriculum.

WAC 388-112B-0030What must geriatric behavioral health worker training include?

(1) The geriatric behavioral health worker training curricula must include at least 30 hours of training specific to the diagnoses, care, and crisis management of residents. The curricula must include:

(a) Training related to mental health disorders;

(b) Training related to traumatic brain injury;

(d) Training related to person-centered care or other additional, relevant information to be identified by the facility.

(2) The curricula must be outcome-based, and the effectiveness measured by demonstrated competency in the areas using one or more competency tests.

(3) The curricula must be balanced regarding time allowance and content to provide quality training in all topics listed in (1)(a)(b)(c)(d) of this section.

(4) Curricula delivery can be flexible in arrangement of content and format.

(5) Competencies within the individual components of (1)(a)(b)(c)(d) of this section that are repetitive, such as trauma informed care and person-centered language, may be combined into a single portion of the curriculum.

WAC 388-112B-0040What are the competencies and learning objectives for the dementia portion of geriatric behavioral health worker training?

Curricula developed and approved for the dementia portion of geriatric behavioral health worker training must include, at a minimum, all the knowledge, skills, topics, competencies, and learning objectives described in this section.

(1) Defining dementia.

(a) Introduction to dementia. The worker will review and identify common signs, symptoms, and types of dementia and identify the difference between dementia and conditions that might look like dementia.

(i) What is dementia: Symptoms, causes, parts of the brain, types of dementia; and

(ii) Forgetfulness, depression, delirium, urinary tract infection, mild cognitive impairment, and other conditions that might be mistaken for dementia.

(b) Hallucinations and delusions. The worker will identify common hallucinations and delusions a person with dementia may exhibit and identify physical, emotional, and environmental causes of hallucinations and delusions.

(c) Interactions with residents living with dementia: The worker will distinguish between positive and negative interactions and identify ways to enhance quality of life for the individual.

(i) The role and characteristics of the worker, such as empathy, dependability, patience, strength, flexibility, creativity;

(ii) Tools for self-care, such as reducing personal stress, setting goals, communicating effectively, asking for help, exercise, nutrition;

(iii) Learning from emotions;

(iv) Support.

(d) Environmental influences on residents' behaviors. The worker will adapt the environment to promote resident independence and minimize challenges, including:

(i) Physical environment such as adjusting the lighting, controlling sounds/noise, adjusting the temperature, rearranging the furniture, and identifying wayfinding methods;

(ii) Emotional environment such as staff interactions and approaches.

(e) Working with families. The worker will recognize common emotions family members experience with a loved one who has dementia, and identify difficulties family members may experience or express about their loved one's care by:

(i) Understanding the family unit;

(ii) Working with and supporting family members and friends by providing resources; and

(iii) Building trust.

(2) Sexuality and intimacy. The worker will identify safe and unsafe expressions of sexuality by demonstrating knowledge in:

(a) Sexuality and intimacy;

(b) Sexualized behavior;

(d) Individual attitudes about sexuality and intimacy;

(e) Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ);

(f) Changes in sexual behavior, such as reduced interest, increased interest, sexual aggression, inhibitions, coping, and frustrations;

(g) Resident rights related to sexuality;

(h) Consent and appropriate reporting of nonconsensual sexual contact, including alleged and suspected sexual abuse;

(i) Talking to families about sex.

(3) Treatment of dementia. The worker will demonstrate an understand of:

(a) Conventional medicines used in the treatment of dementia and other drugs used with people who have dementia;

(b) Prohibition of chemical restraints; and

(4) Fostering communication and understanding.

(a) The worker will demonstrate the ability to communicate effectively with people living with dementia, and demonstrate an ability to recognize communication styles and ways to communicate effectively, such as:

(i) Verbal and nonverbal communication used by the resident;

(ii) Progression of dementia and ways communication changes over time;

(iii) Communication changes and common themes of communication seen in early, middle, and late phase dementia;

(iv) Successful methods to approach a resident who has dementia, such as starting a conversation or listening and interpreting information, being respectful, avoiding the use of reality orientation, and using nonverbal gestures; and

(v) The impact of culture and generational differences on resident behaviors.

(b) Trauma-informed care. The worker will recognize that past traumas can affect current thinking, behaviors, and actions, and will identify strategies to provide trauma informed care, including:

(i) Individual various common coping mechanisms following traumatic events;

(ii) Impacts culture and generation have on trauma;

(iii) Principles of trauma informed care, such as safety, trustworthiness, choice, collaboration, empowerment; and

(iv) Strategies for working with residents who have experienced trauma.

(5) Challenging behaviors. The worker will note common causes of resident's challenging behaviors, such as physical, environmental, and emotional triggers:

(a) Explore how the challenging resident behaviors might be a form of communication, and

(b) Approaching and addressing the challenging behaviors with methods such as:

(i) A standardized problem-solving method such as Plan-Do-Study-Act (PDSA), five why's, or similar;

(ii) Safe ways to approach a resident expressing a challenging behavior; and

(iii) Calming techniques;

(6) Person centered approach. The worker will demonstrate the ability to use person-centered language in the work they do.

WAC 388-112B-0043What are the competencies and learning objectives for the mental health portion of geriatric behavioral health worker training?

Curricula developed and approved for the mental health portion of geriatric behavioral health worker training will include all knowledge, skills, topics, competencies, and learning objectives described in this section.

(1) Introduction to mental disorders. The worker will review definitions, common signs, and symptoms and identify types of mental illness.

(a) Stigma and mental disorders;

(b) Common myths about mental illness;

(d) Common mental health conditions seen in the skilled nursing facility, such as:

(i) Anxiety Disorder;

(ii) Bipolar disorder;

(iii) Borderline personality disorder;

(iv) Depression;

(v) Dissociative disorder;

(vi) Neurodevelopmental disorders, such as:

(A) Intellectual disability;

(B) Autism spectrum disorder; and

(vii) Obsessive-compulsive disorder;

(viii) Posttraumatic stress disorder;

(ix) Schizoaffective disorder;

(x) Schizophrenia; and

(xi) Related conditions including but not limited to:

(A) Anosognosia;

(B) Dual diagnoses;

(D) Risk of suicide;

(E) Self-harm;

(F) Sleep disorders; and

(G) Substance use and/or abuse.

(2) Compassionate and trauma-informed mental health. The worker will recognize and identify the following strategies to provide informed care and support resilience:

(a) Impact of culture and ethnicity;

(b) Impact of generation on resident experience;

(d) Co-occurring disorders;

(e) Trauma informed care;

(f) Trauma informed approach; and

(g) Resilience.

(3) Supports for wellness. The worker will identify and understand the following:

(a) How to determine if a resident is at baseline;

(b) Steps to take if the resident's mental or emotional status seems to be deteriorating;

(d) Common types of treatments and therapies including:

(i) Medication;

(ii) Chemical restraints;

(iii) Nondrug therapies including:

(A) Natural medicine;

(B) Cannabis;

(D) Nutrition.

(4) Getting help and self-care. The worker will recognize the importance of wellness and identify strategies to prevent burnout, and know how to seek help, if needed.

(5) Respectful communication and communication dynamics. The worker will demonstrate an ability to recognize communication styles and ways to communicate effectively including skills in the areas of:

(a) Communication and privacy;

(b) Listening;

(d) Nonverbal vs verbal communication;

(e) Seeking clarification;

(f) Identifying behaviors impacting communication and their triggers; and

(g) The impact of culture and generational differences.

(6) Boundaries. The worker will demonstrate an understanding of creating healthy professional boundaries.

(a) Importance of boundaries for mental health;

(b) Personal and professional boundaries;

(d) Assertiveness.

(7) Creative approaches to challenging behaviors. The worker will demonstrate the sequence of steps to approach challenging behaviors by setting limits and providing consistency in response.

(8) Crisis management. The worker will identify potential stressors to prevent crisis and demonstrate steps for de-escalation considering the following topics:

(a) Definition of crisis;

(b) When a crisis occurs;

(d) Decompensation of the resident; and

(e) Aggression and violence of a resident leading to a crisis.

(9) Suicide prevention. The worker will identify current facts about suicide, recognize warning signs for suicidal behavior, and communicate about suicide using a person-centered approach including:

(a) Definition and history around suicide including medically assisted suicide;

(b) Risk factors to suicide;

(d) Talking about suicide and asking questions;

(e) Resources on suicide prevention;

(f) Stigma around suicide;

(g) History of the worker;

(h) Grief support resources.

WAC 388-112B-0045What are the competencies and learning objectives for the traumatic brain injury portion of geriatric behavioral health worker training?

The competencies and learning objectives for the traumatic brain injury portion of geriatric behavioral health worker curriculum will include all knowledge, skills, topics, competencies, and learning objectives described in this section.

(1) Anatomy of the brain and brain injury basics. The worker will identify parts of the brain and have an understanding of how injuries may affect a Traumatic Brain Injury survivor. The worker will also identify possible signs, symptoms, severity levels, types of brain injury, and describe the regions of the brain and functions associated with each region.

(a) Anatomy of the brain including parts and functions; and

(b) Types of brain injury:

(i) Acquired brain injury;

(ii) Traumatic brain injury;

(iii) Concussion;

(iv) Brain cell damage;

(v) Secondary Events.

(i) Mild;

(ii) Moderate;

(iii) Severe.

(d) Possible effects of the injury:

(i) Apraxia;

(ii) Attention and memory;

(iii) Behavioral and emotional changes;

(iv) Bladder and bowel changes;

(v) Dizziness and balance;

(vi) Fatigue;

(vii) Headaches;

(viii) Muscle weakness/immobility;

(ix) Pain;

(x) Post-Traumatic Stress Disorder (PTSD);

(xi) Seizures;

(xii) Sensory changes;

(xiii) Sleep;

(xiv) Spasticity;

(xv) Swallowing, appetite, and weight;

(xvi) Visual problems.

(2) Brain injury management. The worker will recognize and identify strategies to provide individualized quality care and management of symptoms for individuals with brain injury including:

(a) Trauma informed care;

(b) Approach;

(d) Enhancing recovery and healing process:

(i) Physical;

(ii) Short term (6-9 month) / Recovery or stabilize;

(iii) Long-term potential;

(iv) Sensory hypersensitivity;

(v) Additional considerations.

(e) Dual diagnoses (pre or post injury);

(i) Substance use disorder;

(ii) Mental health diagnoses;

(iii) Developmental disabilities;

(iv) Suicide.

(f) Quality of life therapies:

(i) Occupational;

(ii) Speech;

(iii) Physical;

(iv) Music;

(v) Art;

(vi) Yoga and meditation;

(vii) Laughter yoga.

(g) Prevention:

(i) Falls prevention;

(ii) Re-injury.

(h) Activities of daily living and functional independence.

(3) Behavior, mood, and cognition intervention and resolution. The worker will demonstrate an approach to challenging behaviors to recognize and resolve changes in behavior, mood, and cognition.

(a) Exploring behaviors;

(b) De-escalation strategies;

(4) Communication. The worker will demonstrate the ability to recognize communication styles and methods to communicate effectively with brain injury survivors, families of survivors, and other professionals.

(a) Social Communication;

(b) Communication tips for workers:

(i) Communicate clearly;

(ii) Provide support and opportunities for practice;

(iii) Be kind when giving constructive feedback;

(iv) Have realistic expectations.

(i) Initiating conversation;

(ii) Following conversation;

(iii) Taking turns in conversation;

(iv) Difficulty with annunciating;

(v) Nonverbal communication.

(d) Cultural diversity and communication;

(e) Communicating with the family:

(i) Involve the family;

(ii) Supporting families;

(iii) When there is no family.

(f) Communicating with professionals;

(g) Reporting.

(5) Self-care:

(a) Worker health and well-being;

(b) Take responsibility for your own care;

WAC 388-112B-0050What is the curriculum approval process for geriatric behavioral health curriculum?

A facility or other curriculum developer seeking approval for a geriatric behavioral health curriculum under this chapter will meet the following requirements:

(1) Submit the required curriculum application form; and

(a) A department-approved crosswalk linked to the competencies and learning objectives in this chapter; or

(b) A copy of the test(s) that will be used to determine student competency.

(2) Attest that the curriculum at a minimum includes:

(a) Student materials that support the curriculum and learning resource materials such as learning activities, audio-visual materials, handouts, and books; and

(b) The methods or approaches to be used for different sections of the course, including for each lesson:

(i) Learning activities that incorporate adult learning principles;

(ii) Practice of communication strategies to increase competency;

(iii) Feedback to the student; and

(iv) An emphasis on facilitation by the instructor.

(d) Methods of facilitation and student evaluation; and

(e) A plan for updating material.

WAC 388-112B-0060What components must competency testing include?

Competency testing must include the following components:

(1) Written evaluation to show the level of comprehension and knowledge of the training's learning objectives; and

(2) A scoring guide for the tester with clearly stated criteria and minimum proficiency standards.

WAC 388-112B-0070Is there a challenge test for geriatric behavioral health worker training?

There is no challenge test for geriatric behavioral health worker training.

WAC 388-112B-0080What documentation is required for successful completion of geriatric behavioral health worker training?

Geriatric behavioral health worker training must be documented by a certificate, transcript, or proof of successful completion of training issued by a qualified instructor that includes:

(1) The name of the student;

(2) The title of the training as approved by the department;

(3) The number of hours of the training;

(4) The name of the facility providing the training;

(5) The instructor's name;

(6) The instructor's signature or other authorized signature from the training entity; and

(7) The completion date of the training.