This section only applies to an RTF in its licensed capacity to provide pediatric transitional care services according to this chapter.

(1) The licensee must establish and implement policies and procedures that:

(a) Describe how the licensee meets the infants' health care needs by satisfying the requirements of this section; and

(b) Are reviewed and approved by a pediatrician, a pediatric physician's assistant, or pediatric ARNP at least biennially.

(2) The licensee may only provide pediatric transitional care services to infants who:

(a) Are less than twelve months of age;

(b) Have been exposed to drugs before birth;

(c) Require twenty-four-hour continuous residential care and skilled nursing services as a result of drug exposure; and

(d) Are medically assessed by a pediatrician, physician's assistant, or pediatric ARNP and referred to the RTF by the department of children, youth, and families regional hospitals or private parties.

(3) The licensee may only admit drug exposed infants that primarily require withdrawal management services and whose condition has been determined by a pediatrician, physician's assistant, or pediatric ARNP to be otherwise medically stable and predictable.

Admissions must contain a complete discharge summary from the sending facility.

(4) The licensee shall not admit infants solely for treatment of complex medical conditions requiring specialized care, monitoring, and equipment including, but not limited to, respiratory compromise requiring assisted ventilation or continuous oxygen, conditions requiring a peripherally inserted central catheter line, or conditions requiring nasogastric tubes.

(5) The staffing and staffing ratios in this subsection apply at all times. The licensee shall provide twenty-four-hour medical supervision to infants according to the following minimum staffing requirements:

(a) One registered nurse shall be present and on duty at the facility at all times;

(b)(i) One registered nurse or licensed practical nurse shall be present and on duty for every eight infants requiring morphine or other controlled substances for treatment of condition;

(ii) One registered nurse or licensed practical nurse shall be present and on duty for every sixteen infants provided that the staffing ratio of subsection (3) of this section is not exceeded.

(c) One trained caregiver to four infants; and

(d) A pediatrician, physician's assistant, or pediatric ARNP responsible for the supervision of infant medical care and nursing services must be available by phone twenty-four hours a day for consultation and on-site for medical examinations.

(6) The licensee may provide services for an infant for up to forty-five days. Pediatric transitional care services may be extended beyond forty-five days if the pediatrician, physician's assistant, or pediatric ARNP on staff determines it to be medically necessary and with consent of the infant's parent, legal guardian, or state agency with placement and care authority. The assessment and determination must be conducted and entered into the infant's record no less than two days before the infant's forty-fifth day at the RTF and must include the medical reasons for the extended stay.

(7) The licensee shall provide trainings to parents or legal guardians, foster parents, and relatives on:

(a) Reading your infant's signs and signals;

(b) Managing feeding difficulties;

(c) Managing stimulus in a family environment;

(d) Impact of drugs in utero on developmental milestones;

(e) Managing your stress and that of your family; and

(f) Therapeutic benefits of touch, sound and light in modulating infant behavior.

(8) The licensee shall provide for medical examinations and consultations by a pediatrician, physician's assistant, or pediatric ARNP for each infant with the frequency and regularity recommended by the American Academy of Pediatrics and according to the time frames in this subsection.

Medical assessments, examinations, screenings, and other services relevant to an infant's individual service plan shall include:

(a) An initial health assessment of the infant conducted and completed by a registered nurse upon the infant's arrival;

(b) An initial medical examination of the infant conducted and completed by a pediatrician, physician's assistant or pediatric ARNP within twenty-four hours, if on morphine, otherwise seventy-two hours of the infant's arrival unless a pediatrician, physician's assistant or pediatric ARNP orders a shorter time frame;

(c) Medical examinations of infants conducted every three weeks by a pediatrician, physician's assistant, or pediatric ARNP unless a pediatrician, physician's assistant or pediatric ARNP orders a shorter time frame;

(d) A plan of management for neonatal abstinence syndrome (NAS). Licensees must use a NAS scoring tool approved by the department. NAS scoring must be conducted and completed based on the infant's condition and treatment by a trained licensed practical nurse, registered nurse, pediatrician, physician's assistant, or pediatric ARNP on staff at the RTF. A licensed practical nurse can gather NAS scoring data but cannot analyze the data to inform medication dosage and other treatment decisions;

(e) Infant developmental screening tests, approved by the department, within thirty days after the infant's arrival at the RTF; and

(f) If written consent is given by the parent or guardian, administration of all routinely recommended vaccinations to the infant at the ages and intervals according to the national immunization guidelines in the "Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger—United States, 2018"; as published in the "Morbidity and Mortality Weekly Report (MMWR) 2018; 67(5):156-157."

(9) The licensee must:

(a) Provide transportation of the infant to and from the RTF, if needed. Transportation requirements shall include the following:

(i) All vehicles used for transportation must be in good working condition and insured by the licensee;

(ii) Drivers must be at least twenty-one years of age, have proof of a valid driver's license, and be employed by the RTF;

(iii) Drivers must be accompanied by a trained caregiver or licensed health care provider employed by the RTF to attend to the infant during transport; and

(iv) Child passenger restraint requirements must be in compliance with RCW 46.61.687.

(b) Limit admission, transfer, discharge, and referral processes to infants for whom the RTF is qualified by staff, services, equipment, building design and occupancy to provide safe care;

(c) Refer infants for health care provided outside of the RTF as needed such as, but not limited to, laboratory, dental, ambulatory care, or specialty services;

(d) Follow all prescribed treatments, modified diets, activities, or activity limitations;

(e) Keep health care appointments;

(f) Provide a health assessment any time an infant exhibits signs or symptoms of an injury, illness or abnormality for which a medical diagnosis and treatment are indicated;

(g) Address serious illness, medical emergencies, or threat to life, to include:

(i) Criteria for determining the degree of medical stability of infants;

(ii) Observing infants for signs and symptoms of illness or trauma;

(iii) Reporting abnormal signs and symptoms according to an established protocol;

(iv) Criteria requiring an infant's immediate transfer to a hospital;

(v) How staff transmits the infant's medical and related data in the event of a transfer;

(vi) How to notify the parent or guardian, personal representative, or next of kin in the event of an emergency, threat to life, serious change in the infant's condition, transfer of an infant to another facility, or death; and

(vii) When to consult with internal or external resource agencies or entities such as poison control, fire department, or police.

(h) Assure provisions of each infant's personal care items and durable medical equipment including storing and labeling each resident's personal care items separately, preventing contamination, and preventing access by other residents;

(i) Develop and implement the policies and procedures explaining how nursing staff will be used including:

(i) Scheduling of hours on-site and availability by phone;

(ii) Supervision, assessment, and training of other staff;

(iii) Delegation to other staff;

(iv) Medication management;

(v) Treatment planning;

(vi) Health screenings; and

(vii) Health assessments.

(10) In satisfying the requirements of this chapter, the licensee must also collaborate with the department of children, youth, and families regarding individual safety plans and to meet family and medical needs as contractually required.

(11) The licensee shall have equipment to support infants receiving pediatric transitional care services in adequate supply to meet the medical needs of the population:

(a) Cardiac respiratory monitors for each infant receiving morphine or as medically indicated;

(b) Pediatric pulse oximeter in each infant room;

(c) Plumbed or portable oxygen tanks and suction devices in an adequate supply to meet infant needs;

(d) Digital thermometers designed for pediatric use in each infant room;

(e) Scales used for weighing infants;

(f) Warming beds in adequate supply to meet infant needs;

(g) Refrigerator with thermometer for storing infant formula;

(h) Refrigerator with thermometer, approved for storing medications and vaccinations consistent with Centers for Disease Control and Prevention "Vaccine Storage and Handling Toolkit, January 2018"; and

(i) Infant first-aid kit.

(12) The licensee must develop and implement policies and procedures that ensure unauthorized persons do not access the pediatric transitional care services unit.