WSR 03-06-024

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)

[ Filed February 24, 2003, 3:27 p.m. , effective July 1, 2003 ]

Date of Adoption: February 20, 2003.

Purpose: Adopting new WAC 388-71-0702 through 388-71-0776, Adult day services, and repealing WAC 388-15-650 through 388-15-662, effective July 1, 2003. These rules were revised to ensure that adult day services are provided within available funding as required by law. Rules are needed to clarify the purpose of adult day care/day health programs; to clarify or amend adult day care/day health services and eligibility requirements; to transfer adult day health eligibility determinations to department/area agency on aging (AAA) case managers; to clarify the status of adult day health centers as contracted providers; to clarify the hearing rights of clients and providers; to adopt program cost controls; to amend administrative requirements for contracting with the department/AAA; and to adopt or clarify such other rules as are necessary or appropriate to accomplish these purposes.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-15-650, 388-15-651, 388-15-652, 388-15-653, 388-15-654, 388-15-655, 388-15-656, 388-15-657, 388-15-658, 388-15-659, 388-15-660, 388-15-661, and 388-15-662.

Statutory Authority for Adoption: RCW 74.04.050, 74.04.057, 74.04.200, 74.08.090, 74.09.520, and 74.39A.030.

Adopted under notice filed as WSR 03-01-010 on December 5, 2003 [2002].

Changes Other than Editing from Proposed to Adopted Version: Changes were made as a result of comments received, including: Text was added to WAC 388-71-0710 (1)(b) to allow additional methods for providers and department staff to verify Medicaid eligibility; and WAC 388-71-0776 amended to clarify that "WAC 388-71-0702 through 388-71-0776" are effective July 1, 2003.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 38, Amended 0, Repealed 13.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 38, Amended 0, Repealed 13.
Effective Date of Rule: July 1, 2003.

February 22, 2003

Bonita H. Jacques

for Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3106.5ADULT DAY SERVICES
NEW SECTION
WAC 388-71-0702   Purposes and definitions.   (1) WAC 388-71-0702 through 388-71-0776 contain the eligibility requirements for Medicaid-funded adult day care and adult day health services. These rules also contain the requirements that apply to adult day care or day health centers that contract with the department, an area agency on aging, or other department designee to provide Medicaid services to department clients. Nothing in these rules may be construed as requiring the department, area agency on aging, or other designee to contract with an adult day care or day health center.

(2) An adult day services program is a community-based program designed to meet the needs of adults with impairments through individual plans of care. This type of structured, comprehensive, nonresidential program provides a variety of health, social, and related support services in a protective setting. By supporting families and caregivers, an adult day services program enables the person to live in the community. An adult day services program assesses the needs of the persons served and offers services to meet those needs. The persons served attend on a planned basis. Nothing in this generic description of adult day services may be construed to modify the specific services or eligibility requirements referenced in the definition of adult day care and adult day health.

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

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

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

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

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

(e) "Client" means an applicant for or recipient of Medicaid-reimbursed adult day services.

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

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NEW SECTION
WAC 388-71-0704   Adult day care -- Services.   (1) Adult day care is a supervised daytime program providing core services as defined under subsection (2) of this section. Core services are appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's physician.

(2) The adult day care center must offer and provide on site the following core services:

(a) The following personal care services as defined in WAC 388-71-0202, "personal care services," or its successor:

(i) Ambulation;

(ii) Body care;

(iii) Eating;

(iv) Positioning;

(v) Self-medication;

(vi) Transfer;

(vii) Toileting;

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

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

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

(i) Referrals to other providers for services not within the scope of Medicaid reimbursed adult day care services;

(ii) Caregiver support and education; or

(iii) Assistance with coping skills.

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

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

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

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

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

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

(d) General therapeutic activities that an unlicensed person can provide or that a licensed person can provide with or without a physician's order. These services are planned and provided as an integral part of the client's plan of care and are based on the client's abilities, interests and goals. Examples include:

(i) Recreational activities;

(ii) Diversionary activities;

(iii) Relaxation therapy;

(iv) Cognitive stimulation;

(v) Group range of motion or conditioning exercises.

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

(i) Nutrition;

(ii) Stress management;

(iii) Disease management skills;

(iv) Preventive care.

(f) A nutritional meal and snacks provided each four-hour period at regular times comparable to normal meal times, including modified diet if needed and within the scope of the program, as provided under WAC 388-71-0768;

(g) Supervision and/or protection for clients who require supervision or protection for their safety;

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

(i) First aid and provisions for obtaining or providing care in an emergency.

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NEW SECTION
WAC 388-71-0706   Adult day health -- Services.   (1) Adult day health is a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services outlined in WAC 388-71-0704. Adult day health services are only appropriate for adults with medical or disabling conditions that require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's physician.

(2) The adult day health center must offer and provide on site the following services:

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

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

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

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

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NEW SECTION
WAC 388-71-0708   Adult day care -- Eligibility.   (1) COPES clients may be eligible for adult day care as a COPES service if they are assessed as having an unmet need for one or more of the following core services identified in WAC 388-71-0704:

(a) Personal care services;

(b) Routine health monitoring with consultation from a registered nurse;

(c) General therapeutic activities; or

(d) Supervision and/or protection for clients who require supervision or protection for their safety.

(2) COPES clients are not eligible for adult day care if they:

(a) Can independently perform or obtain the services provided at an adult day care center;

(b) Have unmet needs that can be met through the COPES program more cost effectively without authorizing day care services;

(c) Have referred care needs that:

(i) Exceed the scope of authorized services that the adult day care center is able to provide;

(ii) Can be met in a less structured care setting; or

(iii) Are being met by paid or unpaid caregivers.

(d) Live in a nursing home, boarding home, adult family home, or other licensed institutional or residential facility; or

(e) Are not capable of participating safely in a group care setting.

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NEW SECTION
WAC 388-71-0710   Adult day health -- Eligibility.   (1) Clients are eligible for adult day health services if they meet all of the following criteria:

(a) Age eighteen years or older; and

(b) Identified on their medical assistance identification (MAID) card, or through other methods of eligibility verification, as enrolled in one of the following medical assistance programs:

(i) Categorically needy (CNP);

(ii) Categorically needy qualified Medicare beneficiaries (CNP-QMB);

(iii) General assistance -- Expedited Medicaid Disability (GA-X); or

(iv) Alcohol and Drug Abuse Treatment and Support Act (ADATSA).

(c) Assessed as having an unmet need for skilled nursing under WAC 388-71-0712 or skilled rehabilitative therapy under WAC 388-71-0714, and:

(i) There is a reasonable expectation that these services will improve, restore or maintain the client's health status, or in the case of a progressive disabling condition, will either restore or slow the decline of the client's health and functional status or ease related pain or suffering; and

(ii) The client is at risk for deteriorating health, deteriorating functional ability, or institutionalization; and

(iii) The client has a chronic or acute health condition that he or she is not able to safely manage due to a cognitive, physical, or other functional impairment.

(d) Assessed as having needs for personal care or other core services under WAC 388-71-0708, whether or not those needs are otherwise met.

(2) Clients are not eligible for adult day health if they:

(a) Can independently perform or obtain the services provided at an adult day health center;

(b) Have referred care needs that:

(i) Exceed the scope of authorized services that the adult day health center is able to provide;

(ii) Do not need to be provided or supervised by a licensed nurse or therapist;

(iii) Can be met in a less structured care setting; or

(iv) In the case of skilled care needs, are being met by paid or unpaid caregivers.

(c) Live in a nursing home or other institutional facility; or

(d) Are not capable of participating safely in a group care setting.

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NEW SECTION
WAC 388-71-0712   Adult day health -- Skilled nursing.   (1) Skilled nursing services are medically necessary services provided directly or indirectly by a registered nurse under physician supervision, or by a licensed practical nurse under physician or registered nurse supervision, that a licensed nurse acting within the scope of practice can provide or supervise. Physician orders must be obtained when required by applicable state practice laws for licensed nurses.

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

(a) Specific to a client diagnosis;

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

(c) Evaluated every ninety days for effect on improvement of health status or prevention of decline.

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

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

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

(a) Care and assessment of an unstable or unpredictable medical condition, with time limited measurable treatment goals, requiring frequent intervention by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse according to WAC 246-840-705;

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

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

(i) Self administration of an injection;

(ii) Prefilling insulin syringes;

(iii) Irrigating a catheter;

(iv) Caring for a colostomy or urostomy;

(v) Wound dressing changes or aseptic technique; or

(vi) Disease self-management.

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

(i) Inserting or irrigating a catheter;

(ii) Administering medications or oxygen;

(iii) Administering and managing infusion therapy; or

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

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

(a) Reminding or coaching the client;

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

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

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

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

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

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

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

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NEW SECTION
WAC 388-71-0714   Adult day health -- Rehabilitative therapy.   (1) Skilled rehabilitative therapy services are medically necessary services provided by or under the supervision of a licensed physical, occupational, or speech-language pathology or audiology therapist that the therapist acting within the scope of practice can provide or supervise directly or indirectly. Physician orders must be obtained when required by applicable state practice laws for licensed therapists.

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

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

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

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

(i) Specific to a client diagnosis;

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

(iii) Evaluated every ninety days for effect on improvement of health status or prevention of decline.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(c) Massage therapy;

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

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

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

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

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

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

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

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NEW SECTION
WAC 388-71-0716   Adult day care -- Assessment and service plan.   (1) The department or an authorized case manager must assess a client's need for adult day care in accordance with WAC 388-71-0203 and 388-71-0716. Based on the assessment, the case manager determines whether the client should be referred for day care services or whether the client's needs can be met in other ways.

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

(3) Clients receiving adult day care services must be reassessed at least annually in accordance with WAC 388-71-0203 and 388-71-0716.

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NEW SECTION
WAC 388-71-0718   Adult day care -- Negotiated care plan.   (1) Upon referral of a COPES eligible client by the case manager, the day care center must conduct an intake evaluation based on an interview with the client and/or the client's representative to assess the center's ability to meet the client's needs as identified in the department service plan. The case manager will provide the client's service plan to the adult day care provider within five working days after the client or client's representative has signed it.

(2) Within two working days of the referral, the day care center must respond to the referral and notify the case manager of its ability to process and evaluate the referral.

(3) Within ten working days of the initial date of client attendance at the day care center, the center must determine whether it can meet the client's needs, how those needs will be met, and whether to accept the client to the program. The center must not accept a client whose needs the center cannot meet.

(4) Within thirty days of acceptance into the program, the day care center must develop a negotiated care plan signed by the client or the client's representative and the day care center. The care plan must:

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

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

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

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

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

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

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

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

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

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NEW SECTION
WAC 388-71-0720   Adult day health -- Assessment and service plan.   (1) The department or an authorized case manager must assess a client's potential need for adult day health in accordance with WAC 388-71-0203 and 388-71-0720.

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

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

(4) Based on the assessment, the department or area agency on aging case manager determines whether the client should be referred for a day health service evaluation or whether the client's needs can be met in other ways. The case manager may consult with the client's practitioner, department or area agency on aging nursing services staff, or other pertinent collateral contacts, concerning the client's need for skilled nursing or rehabilitative therapy.

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

(6) The department or area agency on aging case manager must reassess adult day health clients at least annually in accordance with WAC 388-71-0203 and 388-71-0720 or its successor. Clients must also be reassessed if they have a break in service of more than thirty days. The adult day center must inform the case manager of the break in service so payment authorization can be discontinued.

(7) Effective upon the adoption of these rules, recipients of adult day health services must be assessed by the department or an authorized case manager for continued or initial eligibility in accordance with this section. The assessment from the department will occur in conjunction with the:

(a) Annual reassessment for department clients;

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

(c) New referrals for adult day health services are to be forwarded to local department offices for intake and assessment for eligibility.

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

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NEW SECTION
WAC 388-71-0722   Adult day health -- Negotiated care plan.   (1) Upon referral of a client by the department or an authorized case manager, the day health center must conduct an intake evaluation and multidisciplinary assessment based on an interview with the client or the client's representative to determine the center's ability to meet the client's core service needs and potential adult day health needs as identified in the preliminary department service plan. The case manager will provide the client's service plan to the day health center within five working days after the client or client's representative has signed it. The day health center must evaluate the client's skilled and core service needs, and may provide up to ten days of paid service to complete the evaluation and develop a preliminary or negotiated plan of care to be provided to the client and the case manager.

(2) Within two working days of the referral, the day health center must respond to the referral and notify the case manager of its ability to process and evaluate the referral.

(3) Within ten paid days of service, the day health center must determine whether it can meet the client's needs, how those needs will be met, and whether to accept the client to the program. The center must not accept a client whose needs the center cannot meet. The center will be reimbursed under WAC 388-71-0724 for any service days provided from the start of the evaluation if the case manager has authorized services. The evaluation includes acceptance of the client to the center, the development of the initial assessment, and the preliminary negotiated plan of care.

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

(5) Within thirty days of the client's acceptance into the program, the day health multidisciplinary team must work with the client to develop a negotiated care plan signed by the client or the client's representative and the day health center. The care plan must:

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

(b) Include an authorized practitioner's order(s) for skilled nursing and/or skilled rehabilitative therapy according to applicable state practice laws for licensed nurses or therapists;

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

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

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

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

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

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

(i) Be approved by the case manager.

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

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

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

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NEW SECTION
WAC 388-71-0724   Adult day services -- Contracting and rates.   (1) The department, or an area agency on aging (or other department designee) as authorized by the department, must determine that the adult day care or day health center meets the applicable adult day care or day health requirements and any additional requirements for contracting with the area agency on aging through a COPES contract or with the department through a Medicaid provider contract. If a center is contracting for both day care and day health, requirements of both adult day services must be met.

(a) A prospective provider desiring to provide adult day services shall be provided an application form from the department or the area agency on aging.

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

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

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

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

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

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

(a) Mission statement, articles of incorporation, and bylaws, as applicable;

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

(c) Organizational chart;

(d) Total program operating budget including all anticipated revenue sources and any fees generated;

(e) Program policies and operating procedure manual;

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

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

(h) Audited financial statement;

(i) Floor plan of the facility;

(j) Local building inspection, fire department, and health department reports;

(k) Updated TB test for each staff member according to local public health requirements;

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

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

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

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

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

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

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

(6) Rates as of July 1, 2002, are as follows:


Counties COPES Adult Day Care
Daily Rate Hourly Rate
King $36.48 $9.10
Benton, Clark, Franklin, Island, Kitsap, Pierce, Snohomish, Spokane, Thurston, Whatcom, & Yakima $32.45 $8.11
All other counties $30.75 $7.69

(7) Payment rates are established on a daily basis for adult day health centers as may be adopted in rule. Rate adjustments are determined by the state legislature. Providers seeking current reimbursement rates can refer to MAA billing instructions or http://maa.dshs.wa.gov.

(8) Rates as of July 1, 2002, are as follows:


Counties Day Health Daily
King $47.48
Benton, Clark, Franklin, Island, Kitsap, Pierce, Snohomish, Spokane, Thurston, Whatcom, & Yakima $43.06
All other counties $40.68

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

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

(10) Transportation to and from the program site is not reimbursed under the adult day health rate. Transportation arrangements for eligible Medicaid clients are made with local Medicaid transportation brokers, informal providers, or other available resources per chapter 388-546 WAC.

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NEW SECTION
WAC 388-71-0726   Adult day health transportation.   The following rules apply if Medicaid transportation services are requested:

(1) The day health center must refer the client to a local Medicaid transportation broker. The broker may consult with the client, the client's physician, family, case manager, or day health center as needed in making any transportation arrangements.

(2) In referring the client to a day health center, the case manager may consider: the frailty and endurance of the client, the client's skilled nursing or rehabilitative therapy needs, and a reasonable round-trip travel time that may not exceed two hours, unless there is no closer center that can meet the client's skilled care needs. Documentation of language barriers may be considered on an exception to rule basis by the case manager.

(3) All brokered transportation under this subsection is subject to the requirements of chapter 388-546 WAC or its successors. In the case of any conflicts, the provisions of chapter 388-546 WAC take precedence.

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NEW SECTION
WAC 388-71-0728   Coordination of services.   (1) A COPES-eligible client may receive adult day care services on some days and adult day health services on different days if the service plan documents which level of service is to be provided on which days. However, core services must be provided on all days that adult day health skilled services are provided, and reimbursement is limited to the day health rate on days that day health services are provided.

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

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

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NEW SECTION
WAC 388-71-0730   Senior Citizens Services Act/Respite care.   (1) Except as provided under this section, the adult day services rules under this chapter do not apply to adult day care or day health services funded under chapters 74.38 and 74.41 RCW.

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

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

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

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

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NEW SECTION
WAC 388-71-0732   Hearing rights.   (1) If the department or area agency on aging denies, terminates, or reduces an individual client's adult day care or day health services, the client has the right to a fair hearing as provided under chapter 388-02 WAC.

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

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

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NEW SECTION
WAC 388-71-0734   Limiting expenditures.   (1) In order to provide adult day services within the limits of available funding, the department may limit services when program expenditures exceed the budget appropriation or when limiting services is required to prevent expenditures from exceeding the appropriation.

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

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

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

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

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

(4) Effective upon the adoption of these rules, and until this subsection is repealed, a moratorium is imposed on contracting with new adult day health centers, including but not limited to additional sites operated by currently contracted providers, except in an area where no existing program is available, funding is available, and prior departmental approval has been obtained.

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NEW SECTION
WAC 388-71-0736   Adult day centers -- Administrative policies and procedures.   (1) Adult day centers must have written policies, procedures, and documentation of the organizational structure and administration of the program.

(2) Administrative policies and procedures must include:

(a) Mission statement;

(b) Articles of incorporation and bylaws, as applicable;

(c) Current business license;

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

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

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

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

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

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

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

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

(l) Quality improvement plans and results.

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NEW SECTION
WAC 388-71-0738   Adult day centers -- Operating policies and procedures.   (1) All policies and procedures must be reviewed on a regular basis, at least annually by the advisory committee, and conform to the requirements outlined in WAC 388-71-0702 through 388-71-0774, as applicable.

(2) Policies and procedures must include:

(a) Core values and mission of the organization;

(b) Ethical standards of the center and professional standards of conduct;

(c) Short- and long-range program goals;

(d) Definition of the target population, including number, age, and needs of participants;

(e) Geographical definition of the service area;

(f) Hours and days of operation (Centers or a combination of centers under single ownership must operate at least three days a week for four consecutive hours, with each center providing at least four hours of programming a day.);

(g) Description of basic services and any optional services;

(h) Description of service delivery;

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

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

(k) Staffing pattern;

(l) A plan for utilizing community resources;

(m) Gift policy;

(n) Marketing plan;

(o) Contracting for services; and

(p) Grievance and complaint processes for staff and participants.

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NEW SECTION
WAC 388-71-0740   Adult day centers -- Fiscal operations.   (1) Adult day centers must demonstrate fiscal responsibility by using generally accepted accounting principles. Fiscal policies, procedures, and records must be developed to enable the administrator to meet the fiscal reporting needs of the governing body.

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

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

(4) A financial statement or the latest audit report of the organization by a certified public accountant must be available.

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

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NEW SECTION
WAC 388-71-0742   Adult day centers -- Client policies and procedures.   (1) Center policies must define admission criteria, discharge criteria, Health Insurance Portability and Accountability Act (HIPAA) policies, medication policy, participant rights and responsibilities, fee schedule, confidentiality, and grievance procedures.

(2) The center must comply with all applicable nondiscrimination laws, including but not limited to age, race, color, gender, religion, national origin, creed, marital status, Vietnam era or disabled veteran's status, or sensory, physical, or mental handicap.

(3) A participant bill of rights describing the client's rights and responsibilities must be developed, posted, distributed to, and explained to participants, families, staff, and volunteers. Participants will be provided the bill of rights in the language understood by the individual upon request.

(4) The center must have an advance directive policy as required by the Patient Self Determination Act of 1990 (see 42 C.F.R. 489.102 and chapter 70.122 RCW).

(5) Discharge policies must include specific criteria that establish when the participant is no longer eligible for services and under what circumstances the participant may be discharged for other factors, unless the discharge is initiated by the client's department or authorized case manager, the center must notify the client, client representative if applicable, and case manager in writing of the specific reasons for the discharge. The center must also provide the client with adequate information about appeal and hearing rights. Discharge may occur due to client choice, other criteria as defined in the center's policy such as standards of conduct or inappropriate behavior, or changes in circumstances making the client ineligible for services under WAC 388-71-0708 or 388-71-0710.

(6) Incident report policies must include investigation and reporting of any neglect, abuse, exploitation, accident, or incident jeopardizing or affecting a participant's health or safety. The policy must include how the center will determine the circumstances of the event, restrictions on staff or clients during the investigation, how similar future situations will be prevented or decreased, and the location of incident reports. The center must keep a log of all reported incidents, participant grievances, complaints, and outcomes.

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NEW SECTION
WAC 388-71-0744   Adult day center -- Client records.   (1) The adult day center must have policies and procedures to ensure that the client's record/chart is appropriately organized and that confidentiality of information is maintained.

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

(3) Individual client files must include:

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

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

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

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

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

(f) Client photograph, with client or client representative permission, updated as needed;

(g) Transportation plans;

(h) Fee determination forms;

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

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

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

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NEW SECTION
WAC 388-71-0746   Adult day center -- Documentation.   (1) Entries in the client's record must be typewritten or legibly written in ink, dated, and signed by the recording person with his/her title. Identification of the author may be a signature, initials, or other unique identifier within the requirements of applicable licensing standards and center policy.

(2) Progress notes must be chronological, timely, and recorded at least weekly by adult day health centers and at least monthly by adult day care center. Client dates of attendance are to be kept daily.

(3) Consultation and/or care plan reviews must be dated and initialed by the physician or other authorizing practitioner who reviewed them. If the reports are presented electronically, there must be representation of review by the ordering practitioner.

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

(5) The record must be legible to someone other than the writer.

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

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NEW SECTION
WAC 388-71-0748   Adult day centers -- Record retention.   (1) The adult day center must maintain a secure client record system to ensure confidentiality for all records, whether paper or electronic, in accordance with state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA).

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

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

(a) Confidentiality and the protection of records that define procedures governing the use and removal, and conditions for release of information contained in the records;

(b) The release of client information and circumstances under which a signed authorization from the client or client representative is required; and

(c) The retention and storage of records for at least six years from the last date of service to the client, including contingency plans in the event the center discontinues operation.

(4) Client records maintained on the center's premises must be in a secure storage area that includes locking cabinets or storage. Computerized records must be backed up weekly and stored off-site.

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NEW SECTION
WAC 388-71-0750   Adult day centers -- Personnel policies and procedures.   (1) Personnel policies and procedures must be in place to ensure that staff are trained and knowledgeable to provide quality services in a safe environment. Policies must include at least the following:

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

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

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

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

(e) Each staff person is to have a tuberculin test within thirty days of employment. If a test has been performed within twelve months of employment, the results of that test may be accepted. Tuberculin tests will be repeated according to local public health requirements.

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

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

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

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

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

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

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

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

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NEW SECTION
WAC 388-71-0752   Adult day center -- Staffing requirements.   (1) Staff selection is dependent on participant needs, program design, and contracting requirements. The center must have the proper balance of professionals and paraprofessionals or nonprofessionals to adequately meet the needs of participants. Services must be delivered by those with adequate professional training. A staff person can have multiple functions, such as an administrator who is also responsible for providing nursing services or social services.

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

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

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

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

(6) A nurse or personnel trained in first aid and CPR must be on hand whenever participants are present.

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

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

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

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

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

(b) The nurse must be a registered nurse (RN) with valid state credentials and have at least one-year applicable experience (full-time equivalent). In addition to a registered nurse, an adult day center can utilize a licensed practical nurse (LPN), but the LPN must be supervised in compliance with all applicable nurse practice acts and standards. The LPN must have valid state credentials and at least one-year applicable experience (full-time equivalent).

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

(d) Program assistant/aides or personal care aides must have one or more years of experience (full-time equivalent) in working with adults in a health care or social service setting.

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

(f) Consultants, with appropriate, valid state credentials may be utilized as needed to meet the requirements outlined in this chapter.

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

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

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

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

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NEW SECTION
WAC 388-71-0754   Staffing ratios.   (1) Staffing levels in adult day centers will vary based upon the number of participants and the care provided.

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

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

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

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

(6) All centers must have written policies regarding staff-participant ratios. The ratio must be a minimum of one staff to six participants. The provider must ensure that appropriate professionals provide needed services to the participants based upon the participants' service and care plans. The center is also required to employ sufficient staff to meet the needs of the participants.

(7) Staff counted in the staff-participant ratio are those who provide direct service to participants. When there is more than one participant present, there must be at least two staff members on the premises, one of whom is directly supervising the participants.

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NEW SECTION
WAC 388-71-0756   Adult day care -- Staffing requirements.   (1) Minimum staffing requirements for adult day care centers include an administrator/program director, activity coordinator, a consulting registered nurse, and a consulting social worker.

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

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NEW SECTION
WAC 388-71-0758   Adult day health -- Staffing requirements.   (1) Minimum staffing requirements for adult day health centers include an administrator, program director, registered nurse, activity coordinator, a PT/OT or speech therapist, and a social worker. The administrator and program director may be the same person.

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

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

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

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

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

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NEW SECTION
WAC 388-71-0760   Adult day centers -- Employee records.   (1) Each employee must have an individual file containing the employee's application, verification of references, TB status, signed job description, and all performance evaluations. Copies of current license or certificate and verification of current good standing, and certification of CPR and first aid training, if applicable, must also be in the file.

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

(3) Employee records must contain all records of training, such as staff orientation and training pertinent to duties or regulatory compliance, including CPR, first aid, and universal precautions training.

(4) Employee records must contain criminal history disclosure and background checks.

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NEW SECTION
WAC 388-71-0762   Adult day centers -- Education and training.   (1) Provision must be made for orientation of new employees, contractors, and volunteers.

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

(3) Staff, contractors, and volunteers must receive training about documentation, reporting requirements, and universal precautions.

(4) At a minimum, one staff person per shift must be trained and certified in CPR.

(5) Staff and volunteers must receive training on all applicable policies and procedures.

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NEW SECTION
WAC 388-71-0764   Adult day centers -- Medication.   (1) The center must develop written medication policies that are explained and accessible to all staff, contractors, volunteers, and participants that have responsibility in this area. At a minimum, policies must meet the following requirements:

(a) Medications must be kept in locked storage. If medications need to be refrigerated, they should be in a locked box, if not in a separate refrigerator dedicated to medication refrigeration.

(b) Medication policies must describe:

(i) Under what conditions licensed program staff will administer medications;

(ii) How medications brought to the program by a client must be labeled;

(iii) How nonprescription medications such as aspirin or laxatives are to be used;

(iv) How the administration of medications will be entered in participant case records as described in WAC 388-71-0744(4); and

(v) Medication policies must be consistent with laws governing medication administration under RCW 69.41.010 and chapter 246-888 WAC.

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

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

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

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NEW SECTION
WAC 388-71-0766   Adult day centers -- Facility.   (1) Selection of a location for a center must be based on information about potential participants in the service area and be made in consultation with other agencies, organizations, and institutions serving older individuals and those with functional impairments, as well as considering the availability of a suitable location.

(2) Centers must have available a current floor plan of the facility indicating usage of space with interior measurements, building inspection report, fire department inspection report, and the local health department inspection report if operating a kitchen.

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

(4) When possible, the facility should be located at street level. If the facility is not located at street level, it is essential to have a ramp and/or elevators. An evacuation plan for relocation of participants must also be in place in the event of an emergency.

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

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

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

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NEW SECTION
WAC 388-71-0768   Adult day centers -- Physical environment requirements.   (1) The facility must have sufficient space to accommodate the full range of program activities and services. The facility must be adaptable to accommodate variations of activities (group and/or individual) and services. The program must provide and maintain essential space necessary to provide services and to protect the privacy of the participants receiving services. There must be sufficient private space to permit staff to work effectively and without interruption. There must be sufficient space available for private discussions.

(2) The facility must provide at least sixty square feet of program space for multi-purpose use for each day center participant. In determining adequate square footage, only those activity areas commonly used by participants are to be included. Dining and kitchen areas are to be included only if these areas are used by clients for activities other than meals. Reception areas, storage areas, offices, restrooms, passageways, treatment rooms, service areas, or specialized spaces used only for therapies are not to be included when calculating square footage.

(3) Storage space.

(a) There must be adequate storage space for program and operating supplies.

(b) Toxic substances, whether for activities or cleaning, must be stored in an area not accessible to participants. Substances must be clearly marked, the contents identified, and stored in original containers.

(4) Restrooms.

(a) The facility's restrooms must be located as near the activity area as possible, preferably no more than forty feet away. The facility must include at least one toilet for every ten participants.

(b) Programs that have a large number of participants who require more scheduled toileting or assistance with toileting must have at least one toilet for every eight participants.

(c) The toilets shall be equipped for use by mobility-limited persons and easily accessible from all program areas. One toilet area should be designed to allow assistance from one or two staff. More accessible units may be required based upon the needs of the participants.

(d) Each restroom must contain an adequate supply of soap, toilet tissues, and paper towels.

(e) Showers are to be accessible to those who require bathing as a core service.

(5) Rest area.

(a) In addition to space for program activities, the facility must have a rest area and designated areas to permit privacy and to isolate participants who become ill or disruptive, or who may require rest.

(b) The rest area must be located away from activity areas and near a restroom and the nurse's office. There must be at least one bed, couch, or recliner for every ten participants that can be used for resting or the isolation of a participant who is ill or suspected of coming down with a communicable disease.

(c) If beds are used, the mattresses must be protected and linens changed after each use by different participants.

(6) Loading zones/parking/entrances/exits.

(a) A loading zone with sufficient space for getting in and out of a vehicle must be available for the safe arrival and departure of participants and the use of emergency personnel.

(b) There must be sufficient parking available to accommodate family caregivers, visitors, and staff.

(c) When necessary, arrangements must be made with local authorities to provide safety zones for those arriving by motor vehicle and adequate traffic signals for people entering and exiting the facility.

(d) Adequate lighting must be provided in all loading and parking zones, entrances, and exits.

(e) An adult day center must be visible and recognizable as a part of the community. The entrance to the facility must be clearly identified. The center must also be appealing and protective to participants and others.

(f) At least two well-identified exits must be accessible from the building.

(7) Atmosphere and design.

(a) The center's design must facilitate the participants movement throughout the facility and encourage involvement in activities and services.

(b) The environment must reinforce orientation and awareness of the surroundings by providing cues and information about specific rooms, locations, and functions that help the participant to get his/her orientation to time and space.

(c) A facility must be architecturally designed in conformance with the requirements of section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act to accommodate individuals with a disability and meet any state and local barrier-free requirements.

(d) Illumination levels in all areas must be adequate, and careful attention must be given to avoiding glare. Attention must be paid to lighting in transitional areas, such as outside to inside and between different areas of the facility.

(e) Sound transmission must be controlled. Excessive noise, such as fan noise, must be avoided.

(f) Comfortable conditions must be maintained within a comfortable temperature range. Excessive drafts must be avoided uniformly throughout the facility.

(g) Sufficient furniture must be available for the entire population present. Furnishings must accommodate the needs of participants and be attractive, comfortable, sturdy, and safe. Straight-backed chairs with arms must be used during activities and meals.

(h) A telephone must be available for participant use. Local calls are to be available at no cost to the participant.

(8) Safety and sanitation.

(a) The facility and grounds must be safe, clean, and accessible to all participants, and must be designed, constructed, and maintained in compliance with all applicable local, state, and federal health and safety regulations.

(b) Nonslip surfaces or bacteria-resistant carpets must be provided on stairs, ramps, and interior floors.

(c) Alarm/warning systems are necessary to ensure the safety of the participants in the facility in order to alert staff to potentially dangerous situations. It is recommended that call bells be installed or placed in the rest areas, restroom stalls, and showers.

(d) An evacuation plan/disaster plan must be strategically posted in each facility.

(e) The facility must be free of hazards, such as high steps, steep grades, and exposed electrical cords. Steps and curbs must be painted and the edges of stairs marked appropriately to highlight them. All stairs, ramps, and bathrooms accessible to those with disabilities must be equipped with securely anchored handrails.

(f) Emergency first-aid kits must be visible and accessible to staff. Contents of the kits must be replenished after use and reviewed as needed.

(g) Maintenance and housekeeping must be carried out on a regular schedule and in conformity with generally accepted sanitation standards, without interfering with the program.

(h) If smoking is permitted, an adequately ventilated area away from the main program area must be provided and supervised.

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NEW SECTION
WAC 388-71-0770   Adult day center -- Food and nutrition services.   Centers must provide meal service to all participants as outlined in WAC 388-71-0704 and 388-71-0706

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

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

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

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

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

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

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

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

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

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

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NEW SECTION
WAC 388-71-0772   Adult day centers -- Emergency procedures.   (1) A written emergency/disaster/earthquake plan must be posted at each program site and in all program owned vehicles. Staff must be trained to ensure smooth implementation of the emergency plan.

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

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

(4) Procedures for fire safety as approved by the local fire authority must be adopted and posted, including provisions for fire drills, inspection and maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. The center must conduct and document quarterly fire drills and document the center's ability to meet procedures. Improvements must be based on the fire drill evaluation. Smoke detectors must also be used.

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

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

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

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NEW SECTION
WAC 388-71-0774   Adult day centers -- Quality assurance and improvement.   (1) Every adult day center must develop a quality improvement plan, with specific measurable objectives, designed to meet requirements of any licensing, funding sources, professional standards, or regulatory compliance.

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

(3) Quality assurance and improvement plans may include but are not limited to annual evaluations, utilization reviews, participant satisfaction surveys, and participant improvement and/or care plan audits.

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NEW SECTION
WAC 388-71-0776   Effective date.   WAC 388-71-0702 through 388-71-0776 are effective July 1, 2003.

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3108.1
REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-15-650 Purpose.
WAC 388-15-651 Definitions.
WAC 388-15-652 Adult day care (COPES level I).
WAC 388-15-653 Adult day health (level II).
WAC 388-15-654 Plan of care.
WAC 388-15-655 Title XIX adult day health certification and monitoring.
WAC 388-15-656 Administration and organization.
WAC 388-15-657 Staffing.
WAC 388-15-658 Personnel requirements.
WAC 388-15-659 Facility.
WAC 388-15-660 Coordination of services.
WAC 388-15-661 Clients in residential care or nursing facility care settings.
WAC 388-15-662 Expenditures not to exceed.

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