Background:

Neonatal abstinence syndrome (NAS) can occur in an infant who has been exposed to addictive opiate drugs during the mother's pregnancy. Babies born with NAS may experience a variety of withdrawal symptoms shortly after birth. These symptoms can include tremors, high-pitched crying, gastrointestinal dysfunction, and temperature instability. According to the Centers for Disease Control and Prevention, the incidence rate of NAS in the State of Washington increased from a rate of 1.5 for every 1,000 hospital births in 1999 to a rate of 7.9 for every 1,000 hospital births in 2013.

The Department of Social and Health Services (DSHS) Children's Administration (CA) contracts with the Pediatric Interim Care Center (PICC) to provide residential care for children from birth to age 2 who have been exposed to and are exhibiting withdrawal symptoms from alcohol and other drugs. Seventy-five percent of the children served by the PICC must be in need of special care due to substance abuse by their mothers. This specialized care can include the medically supervised administration of morphine or methadone to assist the withdrawal process, swaddling and rocking, and feeding in a low-stimulus environment.

The CA licenses the PICC as a group care facility for up to 13 infants. The Department of Health (DOH) inspects the PICC for compliance with group care health and safety rules. In addition to infant care, the PICC provides on-site training to biological parents, relative caregivers, and foster and adoptive parents.

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Summary of Substitute Bill:

Requires establishments providing pediatric transitional care services to be licensed by the DOH beginning January 1, 2019. Existing facilities providing these services are not subject to construction review by the DOH for initial licensure. To become licensed, an establishment must demonstrate that it is capable of providing service to children who:

are 1 year old or younger;
have been exposed to drugs before birth;
require 24-hour residential care and skilled nursing services as a result of prenatal substance exposure; and
are referred to the establishment by the DSHS, regional hospitals, and private parties.

Establishments may train a noncredentialed, unlicensed person to be an on-site caregiver for drug-exposed infants. A caregiver may not provide medical care and must work under the supervision of a health care professional.

If the DSHS refers a child for services, the DSHS retains case management responsibility and must provide consultation to the establishment regarding placement and permanency planning, including the development of a parent-child visitation plan. The DSHS must work with the establishment and the DOH to:

identify and implement evidence-based practices that address current and best medical practices and parent participation; and
work with the establishment to ensure that Medicaid-eligible services are billed accordingly.

The DOH must adopt rules in coordination with the DSHS regarding the operation of establishments providing pediatric transitional care services. Among other criteria, the rules must include requirements for:

the provision of services, including 24-hour medical supervision;
staffing ratios that consider the number of nurses employed at the establishment and the number of trained caregivers on duty. Staffing ratios may not require more than one registered nurse to be on duty at all times, one registered nurse or licensed practical nurse for every eight infants, and one trained caregiver to four infants;
the preparation of individual weekly care plans for infants;
ensuring that NAS scoring is conducted by an appropriate health care professional;
establishing drug-exposed infant developmental screening tests;
the establishment to collaborate with the DSHS to develop an individualized safety plan for each child and meet other contractual requirements of the DSHS to identify strategies to meet supervision needs, medical concerns, and family support needs;
the maximum number of days an infant may be placed at an establishment;
development of timelines for initial and ongoing parent-infant visits to nurture and help develop attachment and bonding between the child and parent, if such visits are possible;
transportation for the infant;
on-site training requirements for caregivers, volunteers, parents, foster parents, and relatives;
background check requirements for anyone with unsupervised access to infants in care; and
other elements necessary to support the infant and the infant's family.

Substitute Bill Compared to Original Bill:

The substitute bill removes references to the establishment of, application for, and the issuance of a pediatric transitional care center license and instead provides for pediatric transitional care services to be regulated by the DOH under current regulations for facilities for the treatment of chemically dependent and mentally ill persons. Establishments providing pediatric transitional care services are not considered a new DSHS category for the purposes of rulemaking. The substitute bill provides a definition for "trained caregiver" to mean a person trained by the establishment offering services to provide hands-on care to drug-exposed infants and requires trained caregivers to work under the supervision of a health care professional. The substitute bill changes the ages of children eligible for pediatric transitional care services from birth to 2 years of age to birth to 1 year of age. The substitute bill changes the date by which an establishment providing pediatric transitional care services must be operating under a license from the DOH from July 1, 2018, to January 1, 2019. The substitute bill allows facilities currently providing these services to be exempt from construction review by the DOH.

Staff Summary of Public Testimony:

(In support) Babies exposed to drugs while in the womb experience various withdrawal symptoms. The PICC facility provides care to these babies in a nonhospital setting and provide services to the families. The PICC is currently licensed as a group home facility, which is not a good fit. The structure that the DOH can provide is the right oversight for this unique type of facility that cares for the neediest residents of our state. The substitute bill before the committee will cut down on cost since the substitute moves this under an existing license structure instead of creating a new one. Many of the infants served by the PICC have been exposed to heroin and methamphetamines. Eighty percent of these infants are visited by family members. It would be helpful to expand the types of providers who can do the NAS scoring to evaluate an infant's level of withdrawal.

(Opposed) None.