WSR 02-14-161

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Adult Services Administration)

[ Filed July 3, 2002, 11:44 a.m. ]

Supplemental Notice to WSR 02-03-117.

Preproposal statement of inquiry was filed as WSR 00-07-057.

Title of Rule: Amending WAC 388-76-535, 388-76-61510 and 388-76-710; adopting new sections WAC 388-76-64005, 388-76-64010, 388-76-64015, 388-76-64020, 388-76-64025, 388-76-64030, 388-76-64035, 388-76-64040, 388-76-64045, 388-76-64050 and 388-76-64055; and repealing WAC 388-76-640.

Purpose: Amending, adding and repealing rules on adult family homes to be consistent with current statute, and to make corrections. The subject matter in these rules was previously proposed as WSR 02-03-117.

Statutory Authority for Adoption: RCW 70.128.040, 69.41.085.

Statute Being Implemented: RCW 70.128.040, 69.41.085.

Summary: These rules on adult family homes add new statutory authority, increase the number of days allowed to prepare a negotiated care plan, and make corrections to outdated information. WAC 388-76-640 is repealed and replaced with new WAC subsections to provide greater clarity and to be consistent with chapter 246-888 WAC, Medication assistance. The subject matter in these rules was previously proposed as WSR 02-03-117. A public hearing was held on February 26, 2002. As a result of public comments, we have revised the rules and are reproposing them for public review and comment.

Reasons Supporting Proposal: The Board of Pharmacy promulgated chapter 246-888 WAC, Medication assistance in 1999 changing several medication practices allowed in community-based settings. These rules have been updated to be consistent with RCW 69.41.085 and chapter 246-888 WAC, Medication assistance, providing clarification for adult family home providers related to resident medications.

Name of Agency Personnel Responsible for Drafting: Robert Stroh, AASA, 640 Woodland Square Loop S.E., P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2587; Implementation and Enforcement: Joyce Stockwell, AASA, 640 Woodland Square Loop S.E., P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2404.

Name of Proponent: Department of Social and Health Services, governmental.

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

Explanation of Rule, its Purpose, and Anticipated Effects: Chapter 69.41 RCW has been amended and chapter 246-888 WAC, Medication assistance, has been promulgated by the Board of Pharmacy. These changes allow individuals residing in community-based, long-term care facilities to receive assistance with medications from a nonpractitioner under defined circumstances. Therefore, the department needs to update WAC 388-76-640 Resident medications (adult family home rules) to reflect these new changes. WAC 388-76-640 is repealed and replaced with eleven new WAC sections to provide clarity for providers and to be consistent with chapter 246-888 WAC, Medication assistance. Outdated information in WAC 388-76-535 and 388-76-710 is updated. WAC 388-76-61510 changes the timeline required for developing negotiated care plans for new admissions from fourteen to thirty days.

Proposal Changes the Following Existing Rules: WAC 388-76-61510 changes the timeline required for developing a negotiated care plan from fourteen to thirty days from date of a resident's admission. This change has resulted from stakeholder input (the RCW does not specify timelines).

WAC 388-76-640 is repealed and replaced by new sections on resident medications: WAC 388-76-64005, 388-76-64010, 388-76-64015, 388-76-64020, 388-76-64025, 388-76-64030, 388-76-64035, 388-76-64040, 388-76-64045, 388-76-64050, and 388-76-64055.

WAC 388-76-535 is amended to include RCW 69.41.085 as authority.

WAC 388-76-710 is amended to correct the Board of Appeals mailing address.

No small business economic impact statement has been prepared under chapter 19.85 RCW. Residential care services has analyzed its proposed rules and concluded that the rules do not impose an increase in existing costs, an imposition of a new cost, or a decrease in benefit. Amended and new sections provide clarification of existing requirements, or update existing rules to conform to changes in state law. No new costs to small businesses are incurred.

RCW 34.05.328 does not apply to this rule adoption. A cost benefit analysis (CBA) review has been completed and it has been determined that the proposed rules "do not make significant changes to a policy or regulatory program," the rules are not "significant legislative rules" as defined in RCW 34.05.328 (5)(c)(iii). Therefore, under chapter 34.05 RCW, the proposed changes in chapter 388-76 WAC, Adult family home minimum licensing requirements, are exempt from requiring a cost-benefit analysis.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on August 6, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by August 2, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., August 6, 2002.

Date of Intended Adoption: Not earlier than August 7, 2002.

June 28, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3134.1RESIDENT MEDICATIONS
NEW SECTION
WAC 388-76-64005   Definitions.   For purposes of this chapter, these definitions apply:

"Enablers" means a physical device used to facilitate a resident's self-administration of a prescribed or over-the-counter medication. Physical devices include, but are not limited to a medicine cup, glass, cup, spoons, bowl, pre-filled syringes, syringes used to measure oral liquids, specially adapted table surfaces, drinking straw, piece of cloth, and the resident's hand.

"Prescribed medication" refers to any medication (legend drug, controlled substance, and over-the-counter) that is prescribed by an authorized practitioner.

"Medication organizer" is a container with separate compartments for storing oral medications organized in daily doses.

"Over-the-counter (OTC) medication" is any medication that can be purchased without a prescriptive order, including but not limited to vitamin, mineral, or herbal preparations.

"Practitioner" includes a physician, osteopathic physician, pediatric physician, pharmacist, licensed practical nurse, registered nurse, advanced registered nurse practitioner, dentist, and physician assistant. Refer to chapter 69.42 RCW for a complete listing of practitioners.

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NEW SECTION
WAC 388-76-64010   What are the rules the provider must follow in all situations involving resident medications?   (1) The provider must ensure that all prescribed and OTC medications are kept in locked storage.

(2) The provider must ensure that all prescribed and OTC medications are stored in the original containers with legible and original labels. When medication organizers are used, refer to WAC 388-76-64050.

(3) The resident always has the right to refuse any medications.

(4) When a resident who is receiving medication assistance or administration refuses or does not receive a prescribed medication, the provider must notify the prescribing practitioner unless the provider, acting within their scope of practice, is able to make a judgment about the significance of the resident's refusal.

(5) If a provider becomes aware that a resident who is independent is refusing a prescribed medication, the provider must notify the prescribing practitioner unless the provider, acting within their scope of practice, is able to make a judgment about the significance of the resident's refusal.

(6) The provider must ensure that the negotiated care plan addresses how residents will get their medications when they absent from the adult family home or when a family member assisting with medications is not available.

(7) The provider must have a policy addressing the disposition of resident prescribed medications that are unused, leftover, or remaining after the resident leaves the adult family home.

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NEW SECTION
WAC 388-76-64015   What defines the type of help a resident may need when taking their medication?   (1) The resident assessment must identify the individual's functional level related to the management of medications as referenced in WAC 388-76-61020(9).

(2) Independent with self-administration is when the resident is independently able to directly apply prescribed and OTC medications by ingestion, inhalation, injection or other means.

(3) Self-administration with assistance as described in chapter 246-888 WAC, Medication assistance is when a resident is independent with self-administration but requires assistance from a non-practitioner when taking prescribed or OTC medications. This assistance does not include injectable or intravenous medications as defined in WAC 246-888-020.

(4) Medication administration is required when a resident cannot safely perform independent self-administration or self-administration with assistance. Medication administration must be performed by a practitioner as defined in chapter 69.41 RCW or by nurse delegation (WAC 246-840-910 through 246-840-970) unless performed by a family member or surrogate decision maker.

(5) If a resident's circumstances require a combination of independent with self-administration, self-administration with assistance, or medication administration, the reason(s) for this combination must be explained in the resident's negotiated care plan.

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NEW SECTION
WAC 388-76-64020   What must the provider's house policies address for residents who are independent with self-administration?   (1) Residents who are independent with self-administration:

(a) May administer their own prescribed and OTC medications unless otherwise stipulated in their negotiated care plan.

(b) May keep their prescribed and OTC medications securely locked in their room or in an area otherwise agreed upon and documented in their negotiated care plan.

(2) Residents who are independent with self-administration are not required to keep a daily medication log unless otherwise stipulated in their negotiated care plan.

(3) For purposes of emergency situations, the provider must maintain a current list of prescribed and OTC medications including name, dosage, frequency, and the name and phone number of the prescribing practitioner as needed. The provider must coordinate with the resident when there is a medication change or new order(s) and must document the changes in the resident's negotiated care plan.

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NEW SECTION
WAC 388-76-64025   How do a resident and provider initiate self-administration with assistance?   (1) A resident or their representative and the provider consult with a practitioner to determine the appropriateness for self-administration with assistance.

(2) The practitioner, in consultation with the resident or their representative and the provider, considers such factors as the physical and mental limitations of the resident and the setting or environment where the resident lives.

(3) While no additional separate assessment or documentation of the resident's needs is required for initiating self-administration with assistance, the provider must amend the resident's negotiated care plan to reflect this service documenting the decision making process.

(4) The provider must ensure that the practitioner re-assesses the resident if there is a change in the health status, medications, physical or mental limitations, or environment.

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NEW SECTION
WAC 388-76-64030   What must the provider monitor when implementing self-administration with assistance?   (1) The provider must ensure that self-administration with assistance is occurring when a resident needs assistance from a non-practitioner to safely facilitate self-administration of a medication.

(2) The resident must be able to put the prescribed or OTC medication into their own mouth or apply or instill the medications.

(3) The resident must be aware that they are receiving a prescribed or OTC medication, but does not necessarily need to be able to state the name of the medication, intended effects or side effects.

(4) Self-administration with assistance must occur immediately prior to the ingestion or application of a prescribed or OTC medication.

(5) Self-administration with assistance may include steadying or guiding a resident's hand while applying or instilling prescribed or OTC medications such as ointments, eye, ear and nasal preparations, but does not include the practice of "hand-over-hand" (total physical assistance) administration.

(6) Self-administration with assistance does not include direct assistance with intravenous and injectable medications, however, delivering a pre-filled syringe to the resident is allowed providing that the resident independently self-administers the injection per WAC 246-888-020.

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NEW SECTION
WAC 388-76-64035   What other situations must the provider monitor when self-administration with assistance occurs for a resident?   A nonpractitioner may assist the resident to self-administer a prescribed or OTC medication through a gastronomy or "g-tube" provided that:

(1) The resident is able to independently self-administer through the "g-tube";

(2) The prescription is written as an oral medication via "g-tube";

(3) The practitioner has determined that the prescribed or OTC medication can be altered, if necessary, for use via "g-tube."

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NEW SECTION
WAC 388-76-64040   What must the provider do when there is a need to alter medications during self-administration with assistance?   (1) If the prescribed or OTC medication is altered, the provider must have documentation for the alteration by the approving practitioner on the prescription container or in the resident's record.

(2) Alteration of a prescribed or OTC medication for self-administration with assistance includes, but is not limited to, crushing tablets, cutting tablets in half, opening capsules, mixing powdered medications with food or liquids.

(3) Residents must be aware that the prescribed or OTC medication is being altered and/or added to their food.

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NEW SECTION
WAC 388-76-64045   What other types of assistance can a nonpractitioner provide?   Prescribed or OTC medication can be transferred from one container to another for the purpose of an individual dose such as pouring a liquid medication from the medication container to a calibrated spoon or medication cup.

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NEW SECTION
WAC 388-76-64050   Who can fill medication organizers and what is required?   (1) A registered nurse (RN), licensed practical nurse (LPN), the resident, or the resident's family members may fill medication organizers.

(2) Prescribed medications being placed into an organizer for the resident must have already been dispensed by a pharmacist and are being removed from an original container that has been labeled for the resident by a pharmacist or pharmacy service.

(3) The medication organizer must allow prescribed and OTC medications to be readily identifiable by residents, caregivers, and the RN and LPN.

(4) Medication organizers must carry a label that clearly identifies the following information:

(a) Name of the resident;

(b) Name of the medication(s);

(c) Dosage and dosage frequency.

(d) Name and phone number of the prescribing practitioner when it is a prescribed medication.

(5) When a resident has a change in medications by the prescribing practitioner, the person filling the medication organizers must replace labels with required updated information immediately.

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NEW SECTION
WAC 388-76-64055   What documentation is the provider required to include in the resident's daily medication log?   (1) The provider must ensure that every resident (unless WAC 388-76-64015(2) applies) has a daily medication log that includes the following information:

(a) A listing of all prescribed and OTC medications, the frequency, and the dosage;

(b) The time the medication was taken by the resident;

(c) The time of medication refusal if the resident refused to take a prescribed medication.

(2) The provider must ensure that the person (including family members) who assisted or administered prescribed or OTC medication to the resident initials the daily medication log within one hour after the medication was taken.

(3) If a resident refuses to take prescribed medications, the requirements in subsection (2) of this section apply including a note indicating the resident's refusal.

(4) When the prescribing practitioner makes a change to any current medications, the provider must:

(a) Ensure that the change and the date of the change are immediately documented on the daily medication log;

(b) Request from the prescribing practitioner written verification of the change by mail, facsimile, other electronic means, or a new original labeled container from the pharmacy;

(c) Coordinate with the resident's pharmacy service to ensure that the changed medication is received from the pharmacy to begin the change consistent with the new order.

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REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-76-640 Resident medications.

Washington State Code Reviser's Office