WSR 02-18-026

PERMANENT RULES

DEPARTMENT OF HEALTH


[ Filed August 23, 2002, 9:17 a.m. , effective October 1, 2002 ]

Date of Adoption: July 17, 2002.

Purpose: Chapter 246-335 WAC implements legislation enacted in March 2000, revising chapter 70.127 RCW, which establishes a single license for all in-home services providers, including home health, hospice and home care agencies. It also establishes a new category of in-home services provider, hospice care centers. The rules merge the existing requirements for home health, hospice and home care agencies, and create requirements to implement the new category of hospice care centers.

Citation of Existing Rules Affected by this Order: Repealing chapters 246-331, 246-327 and 246-336 WAC; and amending chapter 246-335 WAC.

Statutory Authority for Adoption: Chapter 70.127 RCW.

Adopted under notice filed as WSR 02-12-103 on June 5, 2002.

Changes Other than Editing from Proposed to Adopted Version: Minor technical changes.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 58, Repealed 48.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
Effective Date of Rule: October 1, 2002.

August 21, 2002

M. C. Selecky

Secretary

OTS-5571.7

PART 1

REQUIREMENTS FOR IN-HOME SERVICES AGENCIES LICENSED TO PROVIDE HOME HEALTH, HOME CARE, HOSPICE, AND HOSPICE CARE CENTER SERVICES
NEW SECTION
WAC 246-335-001   Scope and purpose.   (1) These rules implement chapter 70.127 RCW which requires the department of health to set minimum health and safety standards for in-home services agencies licensed to provide home health, home care, hospice, and hospice care center services.

(2) Applicants and licensees must meet the requirements of this chapter and other applicable state and local laws.

(3) This chapter does not apply to services provided by persons exempt from requirements of chapter 70.127 RCW as provided for in RCW 70.127.040 and 70.127.050.

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NEW SECTION
WAC 246-335-010   Applicability.   The requirements in Part 1 of this chapter apply to all in-home services agencies licensed to provide home health, home care, and hospice services unless otherwise noted in the specific sections. The requirements in Part 1 of this chapter also apply to hospice care centers as identified in Part 2. The fee requirements in Part 3 of this chapter apply to all in-home services agencies licensed to provide home health, home care, hospice and hospice care center services.

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NEW SECTION
WAC 246-335-015   Definitions.   For the purposes of this chapter, the following words and phrases will have the following meanings unless the context clearly indicates otherwise:

(1) "AAA" means the area agency on aging designated by the aging and adult services administration to contract for home care services with the department of social and health services.

(2) "Acute care" means care provided by an in-home services agency licensed to provide home health services for patients who are not medically stable or have not attained a satisfactory level of rehabilitation. These patients require frequent monitoring by a licensed nurse, therapist, dietician, or social worker to assess health status and progress.

(3) "Administrator" means an individual responsible for managing the operation of an in-home services agency.

(4) "Agency" means an in-home services agency licensed to provide home health, home care, hospice or hospice care center services.

(5) "Assessment" means:

(a) For home health and hospice agencies and hospice care centers, an evaluation of patient needs by an appropriate health care professional; or

(b) For home care agencies, an on-site visit by appropriate agency personnel to determine services requested or recommended to meet client needs.

(6) "Authenticated" means a written signature or unique identifier verifying accuracy of information.

(7) "Authorizing practitioner" means an individual authorized to approve a home health, hospice or hospice care center plan of care.

(a) For home health services:

(i) A physician licensed under chapter 18.57 or 18.71 RCW;

(ii) A podiatric physician and surgeon licensed under chapter 18.22 RCW; or

(iii) An advanced registered nurse practitioner (ARNP), as authorized under chapter 18.79 RCW;

(b) For hospice and hospice care center services:

(i) A physician licensed under chapter 18.57 or 18.71 RCW; or

(ii) An advanced registered nurse practitioner (ARNP), as authorized under chapter 18.79 RCW;

(8) "Bereavement" means care provided to the patient's family with the goal of alleviating the emotional and spiritual discomfort associated with the patient's death.

(9) "Client" means an individual receiving home care services.

(10) "Construction" for the purposes of hospice care centers means:

(a) New building(s) to be used as a hospice care center;

(b) Addition(s) to or conversion(s), either in whole or in part, of an existing building or buildings to be used as a hospice care center or a portion thereof; or

(c) Alteration or modification to a hospice care center.

(11) "Contractor" means an individual, person, or licensee who has a written contract with a licensee to provide patient or client care services or equipment.

(12) "Deemed status" means a designation assigned by the department for an in-home services agency licensed to provide home health, home care, or hospice services meeting the provisions of WAC 246-335-050, certified or accredited by organizations recognized by RCW 70.127.085, or monitored under contract with the department of social and health services under RCW 70.127.085 to provide home care services.

(13) "Department" means the Washington state department of health.

(14) "Dietician" means a person certified under chapter 18.138 RCW or registered by the American Dietetic Association.

(15) "Director of clinical services" means an individual responsible for nursing, therapy, nutritional, social, or related services that support the plan of care provided by in-home services agencies licensed to provide home health, hospice or hospice care center services.

(16) "Document" means the process of recording information relating to patient or client care verified by signature or unique identifier, title, and date.

(17) "Family" means an individual or individuals who are important to, and designated in writing by, the patient or client and need not be relatives, or who are legally authorized to represent the patient or client.

(18) "Health care professional" means an individual who provides health or health-related services within the individual's authorized scope of practice and who is licensed, registered or certified under Title 18 RCW, Business and professions.

(19) "Home care agency" or "in-home services agency licensed to provide home care services" means a person administering or providing home care services directly or through a contract arrangement to clients in places of permanent or temporary residence.

(20) "Home care aide" means an individual providing home care services.

(21) "Home care services" means nonmedical services and assistance provided to ill, disabled, infirm or vulnerable clients that enables them to remain in their residences. Home care services include, but are not limited to: Personal care such as assistance with dressing, feeding and personal hygiene to facilitate self-care; homemaker assistance with household tasks, such as housekeeping, shopping, meal planning and preparation, and transportation; respite care assistance and support provided to the family; or other nonmedical tasks, as defined in this section.

(22) "Home health agency" or "in-home services agency licensed to provide home health services" means a person administering or providing two or more home health services directly or through a contract arrangement to patients in places of permanent or temporary residence. A person administering or providing only nursing services may elect to be an in-home services agency licensed to provide home health services.

(23) "Home health aide" means an individual registered or certified as a nursing assistant under chapter 18.88A RCW.

(24) "Home health aide services" means services provided by home health aides in an in-home services agency licensed to provide home health, hospice, or hospice care center services under the supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist. Such care may include ambulation and exercise, medication assistance level 1 and level 2, reporting changes in patients' conditions and needs, completing appropriate records, and personal care or homemaker services, and other nonmedical tasks, as defined in this section.

(25) "Home health services" means services provided to ill, disabled, infirm, or vulnerable patients. These services include, but are not limited to, nursing services, home health aide services, physical therapy services, occupational therapy services, speech therapy services, respiratory therapy services, nutritional services, medical social services, home medical supplies or equipment services, and professional medical equipment assessment services.

(26) "Home medical supplies or equipment services" means providing diagnostic, treatment, and monitoring equipment and supplies used in the direct care of patients or clients as stated in a plan of care.

(27) "Homelike" for the purposes of a hospice care center means an environment having the qualities of a home, including privacy, comfortable surroundings, opportunities for patient self-expression, and supporting interaction with the family, friends, and community.

(28) "Hospice agency" or "in-home services agency licensed to provide hospice services" means a person administering or providing hospice services directly or through a contract arrangement to patients in places of permanent or temporary residence under the direction of an interdisciplinary team.

(29) "Hospice care center" or "in-home services agency licensed to provide hospice care center services" means a homelike, noninstitutional facility where hospice services are provided, and that meet the requirements for operation under RCW 70.127.280 and applicable rules.

(30) "Hospice care center service category" means the different levels of care provided in a hospice care center, including continuous care, general inpatient care, inpatient respite care, and routine home care.

(a) "Continuous care" means care for patients requiring a minimum of eight hours of one-to-one services in a calendar day, with assessment and supervision by an RN. An RN, LPN or home health aide may provide the care or treatment, according to practice acts and the rules adopted thereunder, of acute or chronic symptoms, including a crisis in their caregiving.

(b) "General inpatient care" means care for patients requiring an RN on-site twenty-four hours a day, for assessment and supervision. An RN, LPN or home health aide may provide the care or treatment, according to practice acts and the rules adopted thereunder, of acute or chronic symptoms, including a crisis in their caregiving.

(c) "Inpatient respite care" means care for patients whose caregivers require short-term relief of their caregiving duties.

(d) "Routine home care" means the core level of service for patients not receiving continuous care, general inpatient care, or inpatient respite care.

(31) "Hospice care center services" means hospice services provided in a hospice care center and may include any of the levels of care defined as hospice care center service categories.

(32) "Hospice services" means symptom and pain management provided to a terminally ill patient, and emotional, spiritual and bereavement support for the patient and family in a place of temporary or permanent residence, including hospice care centers, and may include the provision of home health and home care services for the terminally ill patient through an in-home services agency licensed to provide hospice or hospice care center services.

(33) "In-home services agency" or "in-home services licensee" means a person licensed to administer or provide home health, home care, hospice or hospice care center services directly or through a contract arrangement to patients or clients in a place of temporary or permanent residence.

(34) "In-home services category" means home health, home care, hospice, or hospice care center services.

(35) "Interdisciplinary team" means the group of individuals involved in patient care providing hospice services or hospice care center services including, at a minimum, a physician, registered nurse, social worker, spiritual counselor and volunteer.

(36) "Licensed practical nurse" or "LPN" means an individual licensed as a practical nurse under chapter 18.79 RCW.

(37) "Licensed nurse" means a licensed practical nurse or registered nurse.

(38) "Licensee" means the person to whom the department issues the in-home services license.

(39) "Maintenance care" means care provided by in-home services agencies licensed to provide home health services that are necessary to support an existing level of health, to preserve a patient from further failure or decline, or to manage expected deterioration of disease. These patients require periodic monitoring by a licensed nurse, therapist, dietician, or social worker to assess health status and progress.

(40) "Managed care plan" means a plan controlled by the terms of the reimbursement source.

(41) "Medical director" means a physician licensed under chapter 18.57 or 18.71 RCW responsible for the medical component of patient care provided in an in-home services agency licensed to provide hospice and hospice care center services according to WAC 246-335-055 (4)(a).

(42) "Medication assistance level 1" means home health aide assistance with medications that are ordinarily self-administered by the patients of an in-home services agency licensed to provide home health, hospice or hospice care center services and are under the direction of appropriate agency health care personnel. The assistance must be provided in accordance with nursing assistant scope of practice as defined in chapter 18.88A RCW and the rules adopted thereunder.

(43) "Medication assistance level 2" means assistance with medications as defined by the board of pharmacy in chapter 246-888 WAC.

(44) "Nonmedical tasks" means those tasks which do not require clinical judgment and which can be performed by unlicensed individuals. These tasks are ordinarily performed by the patient or client, which if not for the patient or client's cognitive or physical limitation(s), would be completed independently by the patient, client, or family. These tasks may be completed by home health aides or home care aides. These nonmedical tasks include, but are not limited to:

(a) "Ambulation" which means assisting the patient or client to move around. Ambulation includes supervising or guiding the patient or client when walking alone or with the help of a mechanical device such as a walker, assisting with difficult parts of walking such as climbing stairs, supervising or guiding the patient or client if the patient or client is able to propel a wheelchair, pushing of the wheelchair, and providing constant or standby physical assistance to the patient or client if totally unable to walk alone or with a mechanical device.

(b) "Bathing" which means assisting the patient or client to wash. Bathing includes supervising or guiding the patient or client to bathe, assisting the patient or client with difficult tasks such as getting in or out of the tub or washing the back, and completely bathing the patient or client if totally unable to wash self.

(c) "Body care" which means skin care including the application of over the counter ointments or lotions. "Body care" excludes foot care for patients or clients who are diabetic or have poor circulation.

(d) "Feeding" which means assistance with eating. Feeding includes supervising or guiding the patient or client when able to feed self, assisting with difficult tasks such as cutting food or buttering bread, and orally feeding the patient or client when unable to feed self.

(e) "Medication assistance level 2" which means assistance with medications as defined in the board of pharmacy rules, chapter 246-888 WAC, and consistent with nursing assistant rules under chapter 18.88A RCW.

(f) "Positioning" which means assisting the patient or client to assume a desired position, and with turning and exercises to prevent complications, such as contractures and pressure sores. Range of motion ordered as part of a physical therapy treatment is not included, unless such activity is authorized in agency policies and procedures and is supervised by a licensed physical therapist in a home health or hospice agency or hospice care center.

(g) "Protective supervision" which means being available to provide safety guidance protection to the patient or client who cannot be left alone due to impaired judgment.

(h) "Toileting" which means helping the patient or client to and from the bathroom, assisting with bedpan routines, using incontinent briefs, cleaning the patient or client after elimination, and assisting the patient or client on and off the toilet.

(i) "Transfer" which means assistance with getting in and out of a bed or wheelchair or on and off the toilet or in and out of the bathtub. Transfer includes supervising or guiding the patient or client when able to transfer, providing steadying, and helping the patient or client when the patient or client assists in own transfer. This does not include transfers when the patient or client is unable to assist in their own transfer or needs assistive devices unless specific training or skills verification has occurred consistent with agency policies and procedures.

(45) "One-time visit" means a single visit by one individual to provide home health, hospice or home care services with no predictable need for continuing visits, not to exceed twenty-four hours.

(46) "On-site" means the location where services are provided.

(47) "Patient" means an individual receiving home health, hospice, or hospice care center services.

(48) "Person" means any individual, business, firm, partnership, corporation, company, association, joint stock association, public or private organization, or the legal successor thereof that employs or contracts with two or more individuals.

(49) "Personnel" means individuals employed and compensated by the licensee.

(50) "Plan of care" means a written document based on assessment of patient or client needs that identifies services to meet these needs.

(51) "Pressure relationships" of air to adjacent areas means:

(a) Positive (P) pressure is present in a room when the:

(i) Room sustains a minimum of 0.001 inches of H2O pressure differential with the adjacent area, the room doors are closed, and air is flowing out of the room; or

(ii) Sum of the air flow at the supply air outlets (in CFM) exceeds the sum of the air flow at the exhaust/return air outlets by at least 70 CFM with the room doors and windows closed;

(b) Negative (N) pressure is present in a room when the:

(i) Room sustains a minimum of 0.001 inches of H2O pressure differential with the adjacent area, the room doors are closed, and air is flowing into the room; or

(ii) Sum of the air flow at the exhaust/return air outlets (in CFM) exceeds the sum of the air flow at the supply air outlets by at least 70 CFM with the room doors and windows closed;

(c) Equal (E) pressure is present in a room when the:

(i) Room sustains a pressure differential range of plus or minus 0.0002 inches of H2O with the adjacent area, and the room doors are closed; or

(ii) Sum of the air flow at the supply air outlets (in CFM) is within ten percent of the sum of the air flow at the exhaust/return air outlets with the room doors and windows closed.

(52) "Professional medical equipment assessment services" means periodic care provided by a licensed nurse, therapist or dietician, within their scope of practice, for patients who are medically stable, for the purpose of assessing the patient's medical response to prescribed professional medical equipment, including, but not limited to, measurement of vital signs, oximetry testing, and assessment of breath sounds and lung function (spirometry).

(53) "Quality improvement" means reviewing and evaluating appropriateness and effectiveness of services provided under this chapter.

(54) "Registered nurse" or "RN" means an individual licensed under chapter 18.79 RCW.

(55) "Service area" means the geographic area in which the department has given approval to a licensee to provide in-home services based on criteria in WAC 246-335-055 (1)(a)(vi). Service areas do not apply to hospice care centers.

(56) "Sink" means one of the following:

(a) "Clinic service sink (siphon jet)" means a plumbing fixture of adequate size and proper design for waste disposal with siphon jet or similar action sufficient to flush solid matter of at least two and one-eighth inch diameter.

(b) "Service sink" means a plumbing fixture of adequate size and proper design for filling and emptying mop buckets.

(c) "Hand wash sink" means a plumbing fixture of adequate size and proper design to minimize splash and splatter and permit hand washing without touching fixtures with hands, with adjacent soap dispenser with foot control or equivalent and single service hand drying device.

(57) "Social worker" means an individual regulated under chapter 18.19 or 18.225 RCW.

(58) "Spiritual counseling" means services provided or coordinated by an individual with knowledge of theology, pastoral counseling or an allied field.

(59) "Statement of deficiencies" means a written notice of any violation of chapter 70.127 RCW or the rules adopted thereunder which describes the reasons for noncompliance.

(60) "Statement of charges" means a document which initiates enforcement action against a licensee or applicant and which creates the right to an adjudicative proceeding. The department shall prepare a statement of charges in accordance with WAC 246-10-201.

(61) "Supervisor of direct care services" means an individual responsible for services that support the plan of care provided by an in-home services agency licensed to provide home care services.

(62) "Survey" means an inspection or investigation, announced or unannounced, conducted by the department to evaluate and monitor a licensee's compliance with this chapter.

(63) "Therapist" means an individual who is:

(a) A physical therapist, licensed under chapter 18.74 RCW;

(b) A respiratory therapist, licensed under chapter 18.89 RCW;

(c) An occupational therapist, licensed under chapter 18.59 RCW; or

(d) A speech therapist licensed under chapter 18.35 RCW.

(64) "Therapy assistant" means a licensed occupational therapy assistant defined under chapter 18.59 RCW or physical therapist assistant defined under chapter 18.74 RCW.

(65) "Volunteer" means an individual who provides direct care to a patient or client and who:

(a) Is not compensated by the in-home services licensee; and

(b) May be reimbursed for personal mileage incurred to deliver services.

(66) "WISHA" means the Washington Industrial Safety and Health Act, chapter 49.17 RCW.

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NEW SECTION
WAC 246-335-020   License required.   A person must possess a current license issued by the department before advertising, operating, managing, conducting, opening or maintaining an in-home services agency unless exempt under RCW 70.127.040 or 70.127.050.

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NEW SECTION
WAC 246-335-025   Initial application.   An applicant for initial licensure or additional in-home service category must:

(1) Submit to the department:

(a) A completed application on forms provided by the department;

(b) Evidence of current professional liability insurance in the amount of one hundred thousand dollars per occurrence and public liability and property damage insurance in the amount of two hundred thousand dollars per occurrence as a minimum. This subsection does not apply to hospice applicants that provide in-home hospice care without receiving compensation for delivery of services;

(c) Disclosure statements and criminal history background checks obtained within three months of the application date for the administrator and director of clinical services or supervisor of direct care services in accordance with RCW 43.43.830 through 43.43.845;

(d) The following information:

(i) Name of managing personnel, officers, administrator, director of clinical services or supervisor of direct care services, and partners or individuals owning ten percent or more of the applicant's assets;

(ii) A description of the organizational structure;

(iii) A description of the in-home services categories to be offered directly or under contract;

(iv) Name, address, and phone numbers of all office locations that provide services within the state;

(v) A copy of the current business license(s);

(vi) A description of the service area for which the applicant is requesting to provide services;

(vii) Other information as required by the department;

(viii) Fees specified in WAC 246-335-990; and

(2) Develop and approve policies and procedures addressing the content of this chapter; and

(3) Meet the requirements of this chapter as determined by an initial survey conducted by the department.

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NEW SECTION
WAC 246-335-030   Renewal.   At least thirty days before the expiration date of the current license, the licensee must submit the following to the department:

(1) A completed application on forms provided by the department;

(2) Evidence of continuing insurance coverage according to WAC 246-335-025 (1)(b);

(3) Disclosure statements and criminal history background checks obtained within three months of the renewal date for the administrator and director of clinical services or supervisor of direct care services when these individuals are new to the agency since initial licensure or the last renewal, in accordance with RCW 43.43.830 through 43.43.845;

(4) Documentation required under WAC 246-335-050, if initially applying or reapplying for deemed status;

(5) A written request for continuation of deemed status, when applicable, including:

(a) The most recent decisions and findings; and

(b) Any changes in accreditation status, from the accrediting organization; and

(6) Information listed in WAC 246-335-025 (1)(d).

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NEW SECTION
WAC 246-335-035   Change of ownership.   At least thirty days prior to changing ownership of an in-home services agency:

(1) The licensee must submit in writing to the department:

(a) The full name, address and phone number of the current and prospective owner;

(b) The name, address, and phone number of the currently licensed in-home services agency and the name under which the prospective agency will operate;

(c) Date of the proposed change of ownership; and

(d) Any change in office location and service area, if relevant;

(2) The prospective new owner must submit:

(a) Information listed in WAC 246-335-025 (1)(b) through (d); and

(b) The change of ownership fee specified in WAC 246-335-990.

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NEW SECTION
WAC 246-335-040   Applicant or licensee rights and responsibilities.   (1) An applicant or licensee must:

(a) Comply with the provisions of chapter 70.127 RCW and this chapter;

(b) Display the license issued by the department in an area accessible to the public;

(c) Notify the department in writing:

(i) When there are changes of administrator, director of clinical services, or supervisor of direct care services;

(ii) Within thirty days of beginning or ceasing operation of any office location(s);

(iii) Thirty or more days before ceasing operation of any in-home services category licensed by the department;

(iv) To request approval to expand home health, hospice or home care service areas. An agency must submit information based on the criteria in WAC 246-335-055 (1)(a)(vi) and receive approval for service area expansion prior to providing services in the proposed expanded service area;

(v) When decreasing home health, hospice or home care service areas; and

(vi) Within thirty days of receipt, for deemed agencies only, of all decisions and findings from an accrediting entity, including any changes in accreditation or monitored status;

(d) Cooperate with the department during surveys which may include reviewing licensee records and conducting on-site visits with patient or client consent;

(e) Respond to a statement of deficiencies by submitting to the department:

(i) Within ten working days of receipt, a written plan of correction for each deficiency. All corrections must be completed within sixty days after the survey exit date, unless otherwise specified by the department; and

(ii) No longer than ninety days after the survey exit date, a progress report describing corrections made and ongoing monitoring actions, unless otherwise specified by the department.

(2) An applicant or licensee will:

(a) Receive a written statement of deficiencies found during a survey; and

(b) Receive written service area approval or denial;

(3) An applicant or licensee may:

(a) Discuss findings observed during a survey with the surveyor; and

(b) Discuss the statement of deficiencies, denial of service area under WAC 246-335-045 (2)(f), or denial of an exemption under WAC 246-335-125 or 246-335-295 with the department's manager;

(4) An applicant or licensee has the right to respond to and contest a statement of charges according to the following provisions:

(a) RCW 43.70.115, department of health authority for license approval, denial, restriction, conditioning, modification, suspension and revocation;

(b) Chapter 34.05 RCW, the Administrative Procedure Act; and

(c) Chapter 246-10 WAC, Adjudicative proceedings.

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NEW SECTION
WAC 246-335-045   Department responsibilities.   (1) The department may, in accordance with chapter 70.127 RCW:

(a) Issue an initial license including the in-home services category(ies) and department approved service area(s), if applicable, for twelve months following submission of a completed application and appropriate fee, and following a survey that documents the applicant meets all the requirements of this chapter;

(b) Issue a renewal license including the in-home services category(ies) and department approved service area(s), if applicable, for a twenty-four month period following submission of a completed application and appropriate fee;

(c) Issue a license for change of ownership including the in-home services category(ies) and department approved service area(s), if applicable, to the new licensee for the remainder of the current license period following submission of the required information and appropriate fee, under WAC 246-335-035.

(2) The department may:

(a) Conduct surveys at any time and at least once during a licensure period to determine compliance with chapter 70.127 RCW and this chapter, except for agencies with deemed status under WAC 246-335-050 (2) and (3);

(b) Conduct one licensing survey inclusive of all in-home services categories;

(c) Investigate any person suspected of:

(i) Advertising, operating, managing, conducting, opening or maintaining an in-home services agency or providing in-home services, including hospice care center services, without a license unless exempt from licensure under RCW 70.127.040 and 70.127.050; or

(ii) Survey a licensee at anytime if the department has reason to believe the licensee is providing unsafe, insufficient, inadequate or inappropriate care;

(d) Investigate allegations of noncompliance with RCW 43.43.830 through 43.43.845, when necessary, in consultation with law enforcement personnel;

(e) Require licensees to complete additional disclosure statements and background inquiries for an individual associated with the licensee or having direct contact with children under sixteen years of age, people with developmental disabilities, or vulnerable adults if the department has reason to believe that offenses specified under RCW 43.43.830 have occurred since completion of the previous disclosure statement and criminal background inquiry;

(f) Approve, deny or revoke requests by home health, hospice or home care agencies for initial service area or service area expansion based on:

(i) The licensee's demonstrated ability or inability to comply with this chapter as illustrated by substantiated complaint history, survey outcomes or enforcement action; and

(ii) Evidence of the licensee's ability or inability to manage and supervise services throughout the approved service area under criteria listed in WAC 246-335-055 (1)(a)(vi);

(g) Approve, deny, restrict, condition, modify, suspend, or revoke a license under this chapter under RCW 70.127.170 and 70.127.180(3);

(h) Issue a statement of deficiencies following a survey which identifies noncompliance with chapter 70.127 RCW and this chapter; and

(i) Prepare and serve upon the licensee or applicant at the earliest practical time a statement of charges following a survey which identifies noncompliance with chapter 70.127 RCW and this chapter. The statement of charges shall be accompanied by a notice that the licensee or applicant may request a hearing to contest the charges.

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NEW SECTION
WAC 246-335-050   Deemed status.   (1) A home health or hospice licensee that is certified by the federal Medicare program, or accredited by the community health accreditation program, or the joint commission on accreditation of healthcare organizations is not subject to a state licensure survey when exempt under subsection (3) of this section or the department has granted deemed status under subsection (6) of this section.

(2) An in-home services licensee under contract with and monitored by the department of social and health services or AAA to provide home care services must notify the department when the contract is initiated. The licensee is not required to submit the information noted in subsection (4) of this section and is not subject to a state licensure survey when the department has granted deemed status under subsection (6) of this section.

(3) An agency certified by the federal Medicare program is automatically granted deemed status for state licensure survey and is not required to submit the information noted in subsection (4) of this section.

(4) An agency accredited by the community health accreditation program or the joint commission on accreditation of healthcare organizations requesting deemed status, except as provided in subsection (5) of this section, must submit to the department:

(a) A written request to be considered for deemed status;

(b) Verification of accreditation; and

(c) A copy of the decisions and findings of the accrediting organization based on an on-site survey within the twenty-four month period preceding the request for deemed status.

(5) A licensee may not request deemed status for an initial license or the survey conducted during the initial licensure period.

(6) The department shall grant deemed status to an in-home services category when:

(a) The department determines, using a liberal interpretation, the survey standards used at the time of certification, accreditation, or monitoring are substantially equivalent to chapter 70.127 RCW; and

(b) The licensee meets the requirements of this chapter and otherwise qualifies for licensure.

(7) If the department determines that the survey standards are not substantially equivalent to those required by this chapter, the department will notify the affected licensees with:

(a) A detailed description of the deficiencies in the alternate survey process; and

(b) An explanation concerning the risk to the consumer.

(8) The department may conduct validation surveys of agencies with deemed status according to RCW 70.127.085.

(9) The department retains authority to:

(a) Survey those in-home services categories not accredited, certified or monitored by the organizations specified in this section; and

(b) Investigate complaints against a deemed agency.

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NEW SECTION
WAC 246-335-055   Plan of operation.   (1) The applicant or licensee must establish and implement policies and procedures which include:

(a) A written plan of operation identifying:

(i) A description of the organizational structure;

(ii) Personnel job descriptions;

(iii) Responsibilities of contractors and volunteers;

(iv) Services to be provided;

(v) The days and hours of agency operation; and

(vi) Criteria for management and supervision of services throughout the service area(s) or hospice care center which include:

(A) For home health, hospice or hospice care center applicants or licensees:

(I) How the initial assessment and development of the plan of care will be completed per WAC 246-335-080 and 246-335-085;

(II) How patient needs will be met when assigned personnel, volunteers, or contractors are unable to serve the patient;

(III) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-095 and 246-335-100;

(IV) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-065 (10) and (11); and

(V) How the quality improvement program required in WAC 246-335-115 will be applied throughout the entire service area;

(B) For home care applicants or licensees:

(I) How the initial intake and development of the plan of care will be completed per WAC 246-335-090;

(II) How client needs will be met when assigned personnel, volunteers or contractors are unable to serve the client;

(III) How supervision of personnel and volunteers and monitoring of services provided by contractors will occur which meet the requirements of WAC 246-335-105;

(IV) How performance evaluations for personnel and volunteers and evaluation of services provided by contractors will be conducted per WAC 246-335-065 (10) and (11); and

(V) How the quality improvement program required in WAC 246-335-115 will be applied throughout the entire service area;

(b) A process to inform patients or clients of alternative services prior to ceasing operation or when the licensee is unable to meet the patient's or client's needs;

(c) A plan for preserving records, including the process to preserve or dispose of records prior to ceasing operation; and

(d) Time frames for filing documents in the patient or client records.

(2) The licensee must continue to update policies and procedures to reflect current practice, services provided by the agency, and state and local laws.

(3) The applicant or licensee must identify an administrator who is responsible to:

(a) Oversee the management and fiscal affairs of the licensee;

(b) Implement the provisions of this section;

(c) Designate in writing an alternate to act in the administrator's absence;

(d) Provide management and supervision of services throughout the approved service area or in the hospice care center;

(e) Arrange for necessary services;

(f) Keep contracts current;

(g) Serve as a liaison between the licensee, personnel, contractors and volunteers;

(h) Assure personnel, contractors and volunteers are currently credentialed by the state of Washington, when appropriate, according to applicable practice acts;

(i) Assure personnel, contractors and volunteers comply with the licensee's policies and procedures;

(j) Implement a quality improvement process;

(k) Manage recordkeeping according to this chapter;

(l) Assure supplies and equipment are available and maintained in working order;

(m) Assure the accuracy of public information materials; and

(n) Assure current written policies and procedures are accessible to personnel, contractors and volunteers during hours of operation.

(4) Hospice and hospice care center applicants or licensees must include in the plan of operation:

(a) Responsibilities and availability of the medical director to include:

(i) Advising the licensee on policies and procedures;

(ii) Serving as liaison with a patient's authorizing practitioner;

(iii) Providing patient care and family support;

(iv) Approving modifications in individual plans of care; and

(v) Participating in interdisciplinary team conferences as required by WAC 246-335-085, hospice plan of care and WAC 246-335-155 (9)(a), hospice care center plan of care;

(b) Availability of a bereavement program for up to one year after a patient's death;

(c) Availability of social services, spiritual counseling, volunteer services, and respite care; and

(d) Assuring direct care personnel, contractors and volunteers have training specific to the needs of the terminally ill and their families.

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NEW SECTION
WAC 246-335-060   Delivery of services.   The applicant or licensee must establish and implement policies and procedures that describe:

(1) Admission, transfer, discharge and referral processes;

(2) Specific services, including nonmedical tasks, available to meet patient or client, or family needs as identified in plans of care;

(3) Agency personnel, contractor, and volunteer roles and responsibilities related to medication assistance level 1 and level 2;

(4) Coordination of care, including:

(a) Coordination among services being provided by the in-home services agency; and

(b) Coordination with other agencies when care being provided impacts patient or client health;

(5) Actions to address patient or client, or family communication needs;

(6) Infection control practices for direct care personnel, contractors, and volunteers consistent with local health authorities;

(7) Actions to take when personnel, volunteers, contractors, or patients or clients exhibit or report symptoms of a communicable disease in an infectious stage in accordance with chapter 246-100 WAC, Communicable and certain other diseases and chapter 246-101 WAC, Notifiable conditions;

(8) Management of patient or client medications and treatments in accordance with appropriate practice acts;

(9) Food storage, preparation and handling;

(10) Reporting of patient/client abuse and neglect according to chapter 74.34 RCW;

(11) Emergency care of patient or client;

(12) Actions to be taken upon death of a patient or client;

(13) Implementation of advanced directives in accordance with the Natural Death Act; and

(14) Plans for service delivery when natural or man-made emergencies occur that prevent normal agency operation.

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NEW SECTION
WAC 246-335-065   Personnel, contractor, and volunteer policies.   The applicant or licensee must establish and implement policies and procedures regarding the following:

(1) Employment criteria consistent with chapter 49.60 RCW, Discrimination -- Human rights commission;

(2) Job descriptions commensurate with responsibilities and consistent with health care professional credentialing and scope of practice as defined in relevant practice acts and rules adopted thereunder;

(3) References for personnel, contractors and volunteers;

(4) Credentials of health care professionals that are current and in good standing;

(5) In-person contact with personnel, contractors and volunteers prior to service provision;

(6) Orientation to current agency policies and procedures and verification of skills or training specific to the care needs of patients or clients;

(7) Ongoing training pertinent to patient or client care needs;

(8) Current cardiopulmonary resuscitation training consistent with agency policies and procedures for direct care personnel and contractors in home health and hospice agencies, and hospice care centers;

(9) Infection control practices including communicable disease testing, immunization, and vaccination according to current local health authorities and availability of equipment necessary to implement plans of care and infection control policies and procedures;

(10) Annual performance evaluations of all personnel and volunteers providing direct patient or client care, including on-site observation of care and skills specific to the care needs of patients or clients;

(11) Annual evaluations of services provided by contractors providing direct patient or client care; and

(12) Washington state patrol criminal background inquiries and disclosure statements under RCW 43.43.830 through 43.43.845 for the administrator, director of clinical services or supervisor of direct care services per WAC 246-335-025 (1)(c), 246-335-030(3), and 246-335-035 and personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable adults.

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NEW SECTION
WAC 246-335-070   Personnel, contractor and volunteer records.   The applicant or licensee must maintain records on all personnel and volunteers and have access to records on all contractors to include:

(1) Current practice certification, credential or licensure, as applicable;

(2) Documentation of references;

(3) Evidence of orientation to current agency policies and procedures;

(4) Verification of personnel, contractor, and volunteer skills or training specific to meeting the care needs of patients or clients;

(5) Evidence of disclosure statement and Washington state patrol criminal background inquiry according to RCW 43.43.830 through 43.43.845;

(6) Training on current and revised agency policies and procedures, including patient or client care issues;

(7) Current CPR training for direct care personnel and contractors in home health and hospice agencies, and hospice care centers;

(8) Communicable disease testing, immunization, and vaccination according to current local health authorities; and

(9) Documentation of evaluations of personnel and volunteers providing direct patient or client care and evaluations of services provided by contractors providing direct patient or client care as required in WAC 246-335-065 (10) and (11).

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NEW SECTION
WAC 246-335-075   Bill of rights.   (1) An in-home services licensee at the time of admission must provide each patient or client, or designated family member with a written bill of rights affirming each individual's right to:

(a) A listing of the services offered by the in-home services licensee and those being provided;

(b) The name of the individual supervising the care and the manner in which that individual may be contacted;

(c) A description of the process for submitting and addressing complaints;

(d) Submit complaints without retaliation and to have the complaint addressed by the licensee;

(e) Be informed of the state complaint hotline number;

(f) A statement advising the patient or client, or designated family member of the right to ongoing participation in the development of the plan of care;

(g) A statement providing that the patient or client, or designated family member is entitled to information regarding access to the department's listing of providers and to select any licensee to provide care, subject to the individual's reimbursement mechanism or other relevant contractual obligations;

(h) Be treated with courtesy, respect, privacy, and freedom from abuse and discrimination;

(i) Refuse treatment or services;

(j) Have property treated with respect;

(k) Privacy of personal information and confidentiality of health care records;

(l) Be cared for by properly trained personnel, contractors and volunteers with coordination of services;

(m) A fully itemized billing statement upon request, including the date of each service and the charge. Licensees providing services through a managed care plan are not required to provide itemized billing statements; and

(n) Be informed about advanced directives and the licensee's responsibility to implement them.

(2) An in-home services licensee must ensure that the rights under this section are implemented and updated as appropriate.

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NEW SECTION
WAC 246-335-080   Home health plan of care.   (1) Home health licensees must, except as provided in subsections (2) and (3) of this section:

(a) Develop and implement a written home health plan of care for each patient with input from the patient or designated family member and authorizing practitioner;

(b) Assure each plan of care is developed by appropriate agency personnel and is based on a patient assessment, except when providing one-time visits under subsection (3) of this section;

(c) Assure the home health plan of care includes:

(i) Current diagnoses and information on health status;

(ii) Goals or outcome measures;

(iii) Types and frequency of services to be provided;

(iv) Home medical equipment and supplies used by the patient;

(v) Orders for treatments and their frequency to be provided and monitored by the licensee;

(vi) Special nutritional needs and food allergies;

(vii) Orders for medications to be administered and monitored by the licensee including name, dose, route, and frequency;

(viii) Medication allergies;

(ix) The patient's physical, cognitive and functional limitations;

(x) Discharge and referral plan;

(xi) Patient and family education needs pertinent to the care being provided by the licensee;

(xii) Resuscitation status of the patient according to documentation consistent with the Natural Death Act and advance directives, chapter 70.122 RCW; and

(xiii) The level of medication assistance to be provided.

(d) Develop and implement a system to:

(i) Assure the plan of care is reviewed and updated by appropriate agency personnel according to the following time frames:

(A) For patients requiring acute care services, every two months;

(B) For patients requiring maintenance services, every six months; and

(C) For patients requiring only professional medical equipment assessment services or home health aide only services, every twelve months.

(ii) Assure the plan of care is signed or authenticated and dated by appropriate agency personnel and the authorizing practitioner, according to the time frames in (d)(i)(A), (B) or (C) of this subsection;

(iii) Assure the plan care is returned to the agency within sixty days of the initial date of service or date of review and update;

(iv) Inform the authorizing practitioner regarding changes in the patient's condition that indicate a need to change the plan of care;

(v) Obtain approval from the authorizing practitioner for additions and modifications;

(vi) Assure all verbal orders for modification to the plan of care are immediately documented in writing and signed or authenticated and dated by an agency individual authorized within the scope of practice to receive the order and signed or authenticated by the authorizing practitioner and returned to the agency within sixty days of the date the verbal orders were received.

(2) Home health agencies providing home health aide only services to a patient may develop a modified plan of care by providing only the following information on the plan of care:

(a) Types and frequency of services to be provided;

(b) Home medical equipment and supplies used by the patient;

(c) Special nutritional needs and food allergies;

(d) The patient's physical, cognitive and functional limitations; and

(e) The level of medication assistance to be provided.

(3) Home health agencies providing a one-time visit for a patient may provide the following written documentation in lieu of the home health plan of care and patient record requirements in WAC 246-335-110 (1)(c):

(a) Patient name, age, current address, and phone number;

(b) Confirmation that the patient was provided a written bill of rights under WAC 246-335-075;

(c) Patient consent for services to be provided;

(d) Authorizing practitioner orders; and

(e) Documentation of services provided.

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NEW SECTION
WAC 246-335-085   Hospice plan of care.   (1) Hospice licensees must, except as provided in subsection (2) of this section:

(a) Develop and implement a written hospice plan of care for each patient with input from the authorizing practitioner, appropriate interdisciplinary team members, and the patient or designated family member;

(b) Assure each plan of care is developed by appropriate agency personnel and is based on a patient and family assessment;

(c) Assure the hospice plan of care includes:

(i) Current diagnoses and information on health status;

(ii) Goals or outcome measures;

(iii) Symptom and pain management;

(iv) Types and frequency of services to be provided;

(v) Home medical equipment and supplies used by the patient;

(vi) Orders for treatments and their frequency to be provided and monitored by the licensee;

(vii) Special nutritional needs and food allergies;

(viii) Orders for medications to be administered and monitored by the licensee including name, dose, route, and frequency;

(ix) Medication allergies;

(x) The patient's physical, cognitive and functional limitations;

(xi) Patient and family education needs pertinent to the care being provided by the licensee;

(xii) Resuscitation status of the patient according to documentation consistent with the Natural Death Act and advance directives, chapter 70.122 RCW; and

(xiii) The level of medication assistance to be provided;

(d) Develop and implement a system to:

(i) Assure and document the plan of care is reviewed by the appropriate interdisciplinary team members within the first week of admission and every two weeks thereafter;

(ii) Assure the plan of care is signed or authenticated and dated by appropriate agency personnel and the authorizing practitioner;

(iii) Assure the plan of care is returned to the agency within sixty days from the initial date of service;

(iv) Inform the authorizing practitioner regarding changes in the patient's condition that indicates a need to change the plan of care;

(v) Obtain approval from the authorizing practitioner for additions and modifications; and

(vi) Assure all verbal orders for modification to the plan of care are immediately documented in writing and signed or authenticated and dated by an agency individual authorized within the scope of practice to receive the order and signed or authenticated by the authorizing practitioner and returned to the agency within sixty days from the date the verbal orders were received.

(2) Hospice agencies providing a one-time visit for a patient may provide the following written documentation in lieu of the hospice plan of care and patient record requirements in WAC 246-335-110 (1)(c):

(a) Patient's name, age, current address, and phone number;

(b) Confirmation that the patient was provided a written bill of rights under WAC 246-335-075;

(c) Patient consent for services to be provided;

(d) Authorizing practitioner orders; and

(e) Documentation of services provided.

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NEW SECTION
WAC 246-335-090   Home care plan of care.   (1) Home care licensees must, except as provided in subsection (2) of this section:

(a) Develop and implement a written home care plan of care for each client with input and written approval by the client or designated family member;

(b) Assure each plan of care is developed by appropriate agency personnel, lists services requested or recommended to meet client needs, and is based on an on-site visit, under agency policies and procedures;

(c) Assure the home care plan of care includes:

(i) The client's functional limitations;

(ii) Nutritional needs and food allergies for meal preparation;

(iii) Home medical equipment and supplies relevant to the plan of care;

(iv) Type and schedule of services to be provided; and

(v) Nonmedical tasks requested;

(d) Assure the plan of care is reviewed on-site, updated, approved and signed by appropriate agency personnel and the client or designated family member every twelve months and as necessary based on changing client needs.

(2) Home care agencies providing a one-time visit for a client may provide the following written documentation in lieu of the home care plan of care and client record requirements in WAC 246-335-110 (1)(c):

(a) Client name, age, current address, and phone number;

(b) Confirmation that the client was provided a written bill of rights under WAC 246-335-075;

(c) Client consent for services to be provided; and

(d) Documentation of services provided.

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NEW SECTION
WAC 246-335-095   Supervision of home health care.   The following supervision requirements only apply to home health agencies:

(1) A licensee must employ a director of clinical services;

(2) The director of clinical services or designee must be available during all hours patient care is being provided;

(3) The director of clinical services must designate in writing a similarly qualified alternate to act in the director's absence;

(4) The director of clinical services or designee must assure:

(a) Coordination, development and revision of written patient care policies and procedures related to each service provided;

(b) Supervision of all patient care provided by personnel and volunteers;

(c) Evaluation of services provided by contractors;

(d) Coordination of services when one or more licensee is providing care to the patient;

(e) Compliance with the plan of care;

(f) All direct care personnel, contractors, and volunteers observe and recognize changes in the patient's conditions, and report any changes to the director or designee; and

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy;

(5) The licensee must document supervision including, but not limited to:

(a) RN supervision when using the services of a RN or LPN, in accordance with chapter 18.79 RCW;

(b) For patients receiving acute care services, supervision of the home health aide services during an on-site visit with or without the home health aide present must occur once a month to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit must be conducted by a licensed nurse or therapist in accordance with the appropriate practice acts;

(c) For patients receiving maintenance care or home health aide only services, supervision of the home health aide services during an on-site visit with or without the home health aide present must occur every six months to evaluate compliance with the plan of care and patient satisfaction with care. The supervisory visit must be conducted by a licensed nurse or licensed therapist in accordance with the appropriate practice acts; and

(d) Supervision by a licensed therapist when using the services of a therapy assistant in accordance with the appropriate practice acts; and

(6) The licensee using home health aides must assure:

(a) Each home health aide reviews the plan of care or written instructions for the care of each patient prior to providing home health aide services and whenever there is a change in the plan of care; and

(b) Each home health aide assists with medications according to WAC 246-335-015, and agency policy.

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NEW SECTION
WAC 246-335-100   Supervision of hospice care.   The following supervision requirements only apply to hospice agencies:

(1) A licensee must employ a director of clinical services;

(2) The director of clinical services or designee must be available twenty-four hours per day, seven days per week;

(3) The director of clinical services must designate in writing a similarly qualified alternate to act in the director's absence;

(4) The director of clinical services or designee must assure:

(a) Coordination, development and revision of written patient and family care policies and procedures related to each service provided;

(b) Supervision of all patient and family care provided by personnel and volunteers;

(c) Evaluation of services provided by contractors;

(d) Coordination of services when one or more licensee is providing care to the patient and family;

(e) Compliance with the plan of care;

(f) All direct care personnel, contractors, and volunteers observe and recognize changes in the patient's condition, and report any changes to the director or designee; and

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy;

(5) The licensee must document supervision including, but not limited to:

(a) RN supervision when using the services of a RN or LPN, in accordance with chapter 18.79 RCW;

(b) Licensed nurse supervision of home health aide services during an on-site visit with or without the home health aide present once a month to evaluate compliance with the plan of care and patient and family satisfaction with care;

(c) Supervision by a licensed therapist when using the services of a therapy assistant in accordance with the appropriate practice acts; and

(6) The licensee using home health aides must assure:

(a) Each home health aide reviews written instructions for the care of each patient and family prior to providing home health aide services and whenever there is a change to the plan of care; and

(b) Each home health aide assists with medications according to WAC 246-335-015, and agency policy.

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NEW SECTION
WAC 246-335-105   Supervision of home care.   The following supervision requirements only apply to home care agencies:

(1) The licensee must employ a supervisor of direct care services;

(2) The supervisor or designee must be available during all hours of client care;

(3) The supervisor of direct care services must designate in writing a similarly qualified alternate to act in the supervisor's absence;

(4) The supervisor of direct care services must assure:

(a) Supervision of all client care provided by personnel and volunteers;

(b) Evaluation of services provided by contractors;

(c) Coordination, development and revision of written client care policies;

(d) Participation in coordination of services when more than one licensee is providing care to the client;

(e) Compliance with the plan of care;

(f) All direct care personnel, contractors, and volunteers observe and recognize changes in the client's needs, and report any changes to the director or designee;

(g) All direct care personnel, contractors, and volunteers initiate emergency procedures according to agency policy;

(h) Each home care aide reviews the plan of care or written instructions for the care of each client prior to providing home care aide services and whenever there is a change in the plan of care; and

(i) Each home care aide assists with medications according to WAC 246-335-015, and agency policy; and

(5) The licensee must document supervision including, but not limited to, client contact every six months by phone or visit to evaluate compliance with the plan of care and to assess client satisfaction.

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NEW SECTION
WAC 246-335-110   Patient/client records.   (1) The licensee must:

(a) Maintain a current record for each patient or client consistent with chapter 70.02 RCW, Medical records -- Health care information access and disclosure;

(b) Assure that the record is:

(i) Accessible, in an integrated document, in the licensee's office site for review by appropriate direct care personnel, volunteers, contractors, and the department;

(ii) Written legibly in permanent ink or retrievable by electronic means;

(iii) On the licensee's standardized forms;

(iv) In a legally acceptable manner;

(v) Kept confidential;

(vi) Chronological in its entirety or by the service provided;

(vii) Fastened together to avoid loss of record contents; and

(viii) Kept current with all documents filed according to agency time frames per agency policies and procedures;

(c) Include documentation of the following in each record, unless exempted in (d) of this subsection:

(i) Patient or client's name, age, current address and phone number;

(ii) Patient's or client's consent for service, care, and treatment;

(iii) Payment source and patient or client responsibility for payment;

(iv) Initial assessment when providing home health, hospice and hospice care center services, except when providing home health aide only services under WAC 246-335-080(5);

(v) Plan of care according to WAC 246-335-080, 246-335-085, 246-335-090, and 246-335-155(9), depending upon the service provided;

(vi) Signed or authenticated and dated notes documenting and describing services provided during each patient or client contact;

(vii) Observations and changes in the patient's or client's condition or needs;

(viii) For patients receiving home health, hospice and hospice care center services, with the exception of home health aide only services per WAC 246-335-080(5), authorized practitioner orders and documentation of response to medications and treatments ordered;

(ix) Supervision of home health aide and home care aide services according to WAC 246-335-095 (5)(b) and (c), 246-335-100 (5)(b), and 246-335-105(5); and

(x) Other documentation as required by this chapter;

(d) For patients receiving a one-time visit under WAC 246-335-080(3), 246-335-085(2) or 246-335-090(2), provide the documentation required in these sections;

(e) Consider the records as property of the licensee and allow the patient or client access to his or her own record; and

(f) Upon request and according to agency policy and procedure, provide patient or client information or a summary of care when the patient or client is transferred or discharged to another agency or facility.

(2) The licensee must maintain records for:

(a) Adults -- three years following the date of termination of services; and

(b) Minors -- three years after attaining age eighteen, or five years following discharge, whichever is longer.

(3) The licensee must:

(a) Store records to prevent loss of information and to maintain the integrity of the record and protect against unauthorized use;

(b) Maintain or release records after a patient's or client's death according to chapter 70.02 RCW, Medical records -- Health care information access and disclosure; and

(c) After ceasing operation, retain or dispose of records in a confidential manner according to the time frames in subsection (2) of this section.

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NEW SECTION
WAC 246-335-115   Quality improvement.   Every in-home services licensee must maintain a quality improvement program to assure the quality of care and services provided throughout its service area or within a hospice care center thatincludes, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services provided under RCW 70.127.120(2);

(2) A method to identify, monitor, evaluate, and correct problems identified by patients or clients, families, personnel, contractors, or volunteers; and

(3) A system to assess patient or client satisfaction.

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NEW SECTION
WAC 246-335-120   Home medical supplies and equipment.   This section applies only to home health and hospice agencies and hospice care centers providing or contracting for medical supplies or equipment services. The applicant or licensee must:

(1) If the applicant or licensee provides medical supplies or equipment services, develop and implement policies and procedures to:

(a) Maintain medical supplies and equipment;

(b) Clean, inspect, repair and calibrate equipment per the manufacturers' recommendations, and document the date and name of individual conducting the activity;

(c) Assure safe handling and storage of medical supplies and equipment;

(d) Inform the patient or designated family member of the cost and method of payment for equipment, equipment repairs and equipment replacement;

(e) Document the patient or designated family member's approval;

(f) Instruct each patient or family to use and maintain supplies and equipment in a language or format the patient or family understands, using one or more of the following:

(i) Written instruction;

(ii) Verbal instruction; or

(iii) Demonstration;

(g) Document the patient or family understanding of the instructions provided;

(h) Replace supplies and equipment essential for the health or safety of the patient; and

(i) Identify and replace equipment recalled by the manufacturer.

(2) If the applicant or licensee contracts for medical supplies or equipment services, develop and implement policies and procedures to assure that contractors have policies and procedures consistent with subsection (1) of this section.

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NEW SECTION
WAC 246-335-125   Exemptions and alternative methods.   (1) To request an exemption from the minimum requirements in this chapter, the licensee must submit a written request to the department, including:

(a) A description of the requested exemption and alternatives, if appropriate;

(b) Rationale for the exemption;

(c) Impact of the exemption on public health and safety; and

(d) Any other information the department requests.

(2) The department may grant the licensee an exemption from a requirement of this chapter if:

(a) The department determines the exemption will not jeopardize public health or safety; and

(b) The exemption is not contrary to the intent of chapter 70.127 RCW and the requirements of this chapter, a specific requirement of this chapter.

(3) The licensee must retain a copy of each approved exemption and have them available at all times.

(4) An exemption is limited to a specific requirement and for the licensee who receives it. The exemption does not apply to any new applicants or other existing licensees.

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PART 2

REQUIREMENTS SPECIFIC TO HOSPICE CARE CENTERS
NEW SECTION
WAC 246-335-130   Applicability.   The requirements in Part 2 of this chapter only apply to hospice care centers.

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NEW SECTION
WAC 246-335-135   Definitions.   The definitions for Part 2 of this chapter are located in WAC 246-335-015.

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NEW SECTION
WAC 246-335-140   License required.   (1) A person must possess a current license issued by the department before advertising, operating, managing, conducting, opening or maintaining a hospice care center.

(2) Prior to being issued a license as a hospice care center, an applicant must:

(a) Be licensed as an in-home services agency licensed to provide hospice services;

(b) Obtain a certificate of need under chapter 70.38 RCW;

(c) Complete the construction review process;

(d) Receive a certificate of occupancy by local building officials;

(e) Submit a completed application and appropriate fee;

(f) Develop policies and procedures addressing the content of this chapter; and

(g) Meet the requirements of this chapter as determined by an initial survey completed by the department.

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NEW SECTION
WAC 246-335-145   Initial application.   An applicant for initial licensure must submit to the department:

(1) A completed application on forms provided by the department;

(2) Evidence of current professional liability insurance in the amount of one hundred thousand dollars per occurrence and public liability and property damage insurance in the amount of two hundred thousand dollars per occurrence as a minimum;

(3) Disclosure statements and criminal history background checks obtained within three months of the application date for the administrator and director of clinical services in accordance with RCW 43.43.830 through 43.43.845;

(4) The following information:

(a) Name of managing personnel, officers, administrator, director of clinical services and partners or individuals owning ten percent or more of the applicant's assets;

(b) A description of the organizational structure;

(c) A description of the hospice care center service categories to be offered directly or under contract;

(d) Documentation that no more than forty-nine percent of patient care days, in the aggregate on a biennial basis will be provided in a hospice care center, under RCW 70.127.280 (1)(d);

(e) Name, address, and phone numbers of the center location(s) within the state;

(f) A copy of their current business license;

(5) Other information as required by the department; and

(6) Fees specified in WAC 246-335-990.

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NEW SECTION
WAC 246-335-150   Renewal.   At least thirty days before the expiration date of the current license, a licensee must submit the following to the department:

(1) A completed application on forms provided by the department;

(2) Evidence of continuing insurance coverage according to WAC 246-335-145(2);

(3) Disclosure statements and criminal history background checks obtained within three months of renewal for the administrator and director of clinical services when these individuals are new to the hospice care center since initial licensure or the last renewal, in accordance with RCW 43.43.830 through 43.43.845; and

(4) Information and fees listed in WAC 246-335-145 (4) through (6).

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NEW SECTION
WAC 246-335-155   Other general hospice care center licensing requirements.   (1) Change of ownership. A hospice care center licensee must meet the change of ownership requirements in WAC 246-335-035.

(2) Applicant or licensee rights and responsibilities. A hospice care center applicant or licensee must meet the applicant or licensee responsibility requirements in WAC 246-335-040.

(3) Department responsibilities. The department responsibility requirements in WAC 246-335-045 apply to hospice care center licensees and applicants.

(4) Plan of operation. A hospice care center applicant or licensee must meet the plan of operation requirements in WAC 246-335-055, and assure pets or animals living on the premises:

(a) Have regular examinations and immunizations, appropriate for the species, by a veterinarian licensed in Washington state;

(b) Be veterinarian certified as free of diseases transmittable to humans;

(c) Are restricted from food preparation areas; and

(d) Include only those customarily considered domestic pets.

(5) Delivery of services. A hospice care center applicant or licensee must:

(a) Meet the delivery of services requirements in WAC 246-335-060; and

(b) Establish and implement policies and procedures that assure:

(i) Auditory and physical privacy for the patient and family during the admitting process;

(ii) Patient rooms are private, unless the patient requests a roommate. Only two patients may share a room;

(iii) Each patient is provided a bed with a mattress appropriate to the special needs and size of the patient; and

(iv) Availability of clean bed and bath linens that are in good condition and free of holes and stains.

(6) Personnel, contractor, and volunteer policies. A hospice care center applicant or licensee must:

(a) Meet the personnel, contractor and volunteer policy requirements in WAC 246-335-065; and

(b) Assure training in the safe storage and handling of oxygen containers and other equipment as necessary.

(7) Personnel, contractor, and volunteer records. A hospice care center applicant or licensee must meet the personnel, contractor, and volunteer records requirements in WAC 246-335-070.

(8) Bill of rights. A hospice care center applicant or licensee must:

(a) Meet the bill of rights requirements in WAC 246-335-075; or

(b) For patients already being served by the hospice agency operating the hospice care center, assure:

(i) The bill of rights requirements have been provided to the patient and designated family member; and

(ii) Provide any additional information needed specific to the hospice care center.

(9) Plan of care. A hospice care center applicant or licensee must:

(a) Meet the plan of care requirements in WAC 246-335-085; or

(b) For patients already being served by the hospice agency operating the hospice care center, review the plan of care for any necessary revisions, and maintain the plan of care with any revisions in the hospice care center.

(10) Supervision. A hospice care center applicant or licensee must:

(a) Meet the supervision requirements in WAC 246-335-100; and

(b) Develop any necessary supervision requirements specific to:

(i) The hospice care center service category staffing requirements; and

(ii) Supervising personnel, volunteers and evaluating contractor services who are employed by a separately licensed hospice agency.

(11) Patient records. A hospice care center applicant or licensee must meet the requirements in WAC 246-335-110.

(12) Quality improvement. A hospice care center applicant or licensee must:

(a) Meet the quality improvement requirements in WAC 246-335-115; or

(b) Assure the hospice agency operating the hospice care center has a quality improvement program that applies to the hospice care center; or

(c) Implement any needed changes or additions to the current hospice agency quality improvement program.

(13) Home medical supplies and equipment. A hospice care center applicant or licensee must meet the home medical supplies and equipment requirements in WAC 246-335-120.

(14) Staffing requirements. A hospice care center applicant or licensee must implement the following staffing requirements:

(a) There must be adequate staffing on duty at all times. Considerations for determining adequate staffing include, but are not limited to:

(i) Number of patients currently admitted and residing in the center;

(ii) Specific patient care requirements;

(iii) Family care needs; and

(iv) Availability of support from other interdisciplinary team members;

(b) Two people, who may either be personnel, contractors or volunteers, must be on duty twenty-four hours per day, seven days per week;

(c) A registered nurse must be available twenty-four hours per day for consultation and direct participation in nursing care;

(d) A registered nurse must be on-site when required to perform duties specified in chapter 18.79 RCW;

(e) When providing general inpatient services, a hospice care center must comply with the staffing requirements in (a) through (d) of this subsection, and assure:

(i) A registered nurse is present twenty-four hours per day, seven days per week, to direct nursing services; and

(ii) Care is provided by either a RN, LPN or home health aide to meet the needs of each patient in accordance with the plan of care; and

(f) When providing continuous care services, a hospice care center must, in addition to the staffing requirements in (a) through (d) of this subsection, assure:

(i) One-on-one staffing, directed by an RN, for a minimum of eight hours to a maximum of twenty-four hours per calendar day; and

(ii) Care is provided by either a RN, LPN or home health aide to meet the needs of each patient in accordance with the plan of care.

(15) A hospice care center may either be owned or leased. If the hospice agency leases space, all delivery of interdisciplinary services, including staffing and management, must be done by the hospice agency per RCW 70.127.280 (1)(g).

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NEW SECTION
WAC 246-335-160   Nutritional services.   (1) Nutritional services must be supervised by an RN or dietician.

(2) Appropriate nutritional consultation must be provided to the patient and family regarding the patient's dietary needs.

(3) Food must be prepared and served at intervals appropriate to the needs of patients, recognizing the unique dietary needs and changes of the terminally ill.

(4) Nutritional services must either be provided directly or through written agreement with a food service company.

(5) Food service sanitation must meet the requirements of chapter 246-215 WAC.

(6) Policies and procedures on nutritional services must include:

(a) Food storage;

(b) Food preparation;

(c) Food service; and

(d) Scheduled cleaning of all food service equipment and work areas.

(7) A copy of the procedures must be kept within or adjacent to the food service area and must be available for reference by nutritional service personnel and other personnel at all times.

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NEW SECTION
WAC 246-335-165   Infection control.   A hospice care center applicant or licensee must develop and implement written policies and procedures addressing infection control pertinent to the hospice care center and consistent with WAC 246-335-060 (6) and (7).

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NEW SECTION
WAC 246-335-170   Emergency preparedness.   A hospice care center applicant or licensee must:

(1) Develop and implement written policies and procedures governing emergency preparedness and fire protection;

(2) Develop an acceptable written plan, periodically rehearsed with personnel, contractors, and volunteers, to be followed in the event of an internal or external emergency, and for the care of casualties of the patient and family, personnel, contractors, and volunteers arising from such emergencies; and

(3) Develop a fire protection plan to include:

(a) Instruction for all personnel, contractors or volunteers in use of alarms, fire fighting equipment, methods of fire containment, evacuation routes and procedures for calling the fire department and the assignment of specific tasks to all personnel, contractors and volunteers in response to an alarm; and

(b) Fire drills for each shift of personnel.

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NEW SECTION
WAC 246-335-175   Pharmaceutical services.   The licensee must assure that all pharmaceutical services are provided consistent with chapter 246-865 WAC and the following requirements:

(1) Pharmaceutical services must be available twenty-four hours per day to provide medications and supplies through a licensed pharmacy;

(2) A pharmacist must provide sufficient on-site consultation to ensure that medications are ordered, prepared, disposed, secured, stored, accounted for and administered in accordance with the policies of the center and chapter 246-865 WAC;

(3) Medications must be administered only by individuals authorized to administer medications;

(4) Medications may be self-administered or administered by a designated family member in accordance with WAC 246-865-060 (7)(f);

(5) Drugs for external use must be stored apart from drugs for internal use;

(6) Poisonous or caustic medications and materials including housekeeping and personal grooming supplies must show proper warning or poison labels and must be stored safely and separately from other medications and food supplies;

(7) The hospice care center must maintain an emergency medication kit appropriate to the needs of the center;

(8) Medications brought into the hospice care center by patients to be administered by an appropriate health care professional while in the center must be specifically ordered by an authorizing practitioner and must be identified by a pharmacist or licensed nurse with pharmacist consultation prior to administration;

(9) Drugs requiring refrigeration must be kept in a separate refrigeration unit;

(10) Schedule II - IV controlled substances must be:

(a) Kept in a separate keyed storage unit; and

(b) When heat sensitive, be kept in a locked refrigeration unit;

(11) Schedule II - IV controlled substances no longer needed by the patient must be disposed in compliance with chapter 246-865 WAC;

(12) The hospice care center must provide for continuation of drug therapy for patients when temporarily leaving the center in accordance with WAC 246-865-070;

(13) If planning to use an automated drug distribution device, the hospice care center must first receive board of pharmacy approval; and

(14) If planning to provide pharmacy services beyond the scope of services defined in this section, the hospice care center must comply with the requirements for a licensed pharmacy in chapter 246-869 WAC.

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PHYSICAL ENVIRONMENT REQUIREMENTS SPECIFIC TO HOSPICE CARE CENTERS
NEW SECTION
WAC 246-335-180   Applicability.   The purpose of the following construction regulations is to provide minimum standards for a safe, homelike, and effective patient care environment in hospice care centers consistent with other applicable rules and regulations without redundancy and contradictory requirements. Rules allow flexibility in achieving desired outcomes and enable hospice care centers to respond to changes in technologies and health care innovations.

(1) These regulations apply to all construction as defined in WAC 246-335-015.

(2) The requirements in this section in effect at the time the application, fee, and construction documents are submitted to the department for review will apply for the duration of the construction project.

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NEW SECTION
WAC 246-335-185   Application and approval.   (1) A hospice care center applicant must submit an application and construction documents under WAC 246-335-195 and provide documentation of approval from local zoning commissions, fire departments, and building departments, if applicable, to the department for review and approval for all construction as defined in WAC 246-335-015.

(2) A hospice care center applicant must:

(a) Respond in writing when the department requests additional or corrected construction documents;

(b) Complete construction in accordance with the final "department approved" documents;

(c) Submit to the department for review any change orders, addenda or modifications to the construction documents for review and approval;

(d) Notify the department in writing when construction is completed;

(e) Submit to the department a copy of the local jurisdictions' certificate of occupancy; and

(f) Submit 8 1/2 by 11 inch floor plans.

(3) The department shall notify the hospice care center in writing when:

(a) The construction documents are approved; or

(b) The construction documents are not approved. If the construction documents are not approved, the department shall submit a letter to the applicant identifying sections of this chapter for which a requirement is stated and there is a deficiency.

(4) A hospice care center applicant must not begin construction until the construction documents are approved by the department and the local jurisdictions have issued the appropriate permits.

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NEW SECTION
WAC 246-335-190   Construction and design codes.   A hospice care center applicant must, through its design, construction and necessary permits demonstrate compliance with the following codes and local jurisdiction standards:

(1) As adopted by the state building code council, and the Uniform Building Code Standards, as published by the International Conference of Building Officials as amended and adopted by the Washington state building code council and published as chapter 51-40 WAC;

(2) The Uniform Mechanical Code, (as published by the International Conference of Building Officials and the International Association of Plumbing and Mechanical Officials) as amended and adopted by the Washington state building code council and published as chapter 51-42 WAC;

(3) Fire Code and Uniform Fire Code Standards, as published by the International Conference of Building Officials and the Western Fire Chiefs Association as amended and adopted by the Washington state building code council and published as chapters 51-44 and 51-45 WAC;

(4) Plumbing Code and Uniform Plumbing Code Standards, as published by the International Association of Plumbing and Mechanical Officials, as amended and adopted by the Washington state building code council and published as chapters 51-46 and 51-47 WAC;

(5) State Ventilation and Indoor Air Quality Code, as adopted by the Washington state building code council and filed as chapter 51-13 WAC;

(6) The Washington State Energy Code, as amended and adopted by the Washington state building code council and filed as chapter 51-13 WAC;

(7) Electric Code of the National Fire Protection Association (NFPA-70) as adopted by the Washington state department of labor and industries including chapter 296-46A WAC;

(8) Accepted Procedure and Practice in Cross-contamination Control, Pacific Northwest Edition, 9th Edition, American Water Works Association;

(9) If planning on caring for patients with mycobacterium tuberculosis, Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities, 1994. Morbidity and Mortality Weekly Report (MMWR), Volume 43, October 28, 1994; and

(10) National Fire Protection Association Standards 99, 1999 Edition.

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NEW SECTION
WAC 246-335-195   Construction documents.   (1) Construction documents submitted to the department for review and approval must include:

(a) A written functional program that contains information concerning services to be provided and operational methods to be used;

(b) Two sets of coordinated and dimensioned construction drawings, drawn to scale, including:

(i) Site plan showing the location of utility lines, parking, driveways, access for emergency vehicles, sufficient space for garbage storage and disposal, oxygen tank or bulk storage, and delivery areas separated from mechanical air intakes per ventilation and mechanical codes;

(ii) Floor plans identifying each room by number, designating the function of each room, and identifying fixed and moveable equipment and furnishings;

(iii) Interior and exterior elevations;

(iv) Building sections and construction details;

(v) Schedules of room finishes, doors, finish hardware, and windows;

(vi) Mechanical, including plumbing, heating, ventilation, and air conditioning;

(vii) Electrical, including lighting, power, and communication systems;

(viii) Fire and life safety showing paths of egress, rated partitions and interim life safety to the point of egress;

(ix) Two sets of the fire sprinkler shop drawings, hydraulic calculations and equipment specifications, stamped by the fire sprinkler system designer; and

(x) Two sets of the fire alarm shop drawings and equipment specifications;

(c) One copy of the specifications that fully describes the workmanship, finishes, and materials; and

(d) If the project is a remodel of an existing facility, a plan that shows how they will ensure the health and safety of occupants during construction and installation of finishes must be submitted for review and approval prior to construction. This includes taking appropriate infection control measures, keeping the surrounding area free of dust and fumes, and assuring rooms or areas are well-ventilated, unoccupied, and unavailable for use until free of volatile fumes and odors.

(2) Drawings and specifications for construction must be prepared by, or under the direction of, an architect registered under chapter 18.08 RCW. The services of a consulting engineer registered under chapter 18.43 RCW must be used for the various branches of the work where appropriate. The services of a registered professional engineer may be used in lieu of the services of an architect if work involves engineering only. All drawings submitted by a registered professional must be stamped and signed.

(3) Compliance with these standards and regulations does not relieve the hospice care center of the need to comply with applicable state and local building and zoning codes.

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NEW SECTION
WAC 246-335-200   Site and site development.   A hospice care center applicant or licensee must provide a site with utilities that meet uniform building code and local regulations including:

(1) Potable water supply meeting requirements in chapters 246-270, 246-290, and 246-291 WAC;

(2) Natural drainage or properly designed/engineered drainage system;

(3) Public or on-site sanitary sewage utilities meeting requirements in chapter 246-271 or 246-272 WAC;

(4) Physical access to community emergency services;

(5) Parking area, drives, and walkways:

(a) Convenient for patients, personnel, contractors, volunteers, and visitors, while avoiding interference with patient privacy and comfort;

(b) With surfaces useable in all weather and traffic conditions; and

(c) Illuminated at night.

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GENERAL HOSPICE CARE CENTER DESIGN REQUIREMENTS
NEW SECTION
WAC 246-335-205   General requirements.   A hospice care center applicant or licensee must meet the following general design elements for patient and family care and support areas as described in this chapter.

(1) Design of the hospice care center must take into account:

(a) The number of patient rooms planned which must not include more than twenty patient beds;

(b) The requirements for patient rooms as specified in WAC 246-335-265; and

(c) The family, personnel and public area requirements for space, which may include multiuse areas, as specified in WAC 246-335-275.

(2) A hospice care center may either be freestanding or a separate portion of another building.

(3) The hospice care center must have a separate external entrance, clearly identifiable to the public.

(4) If the hospice care center provides optional services not authorized in this chapter, those services must be physically separate from the area providing hospice care center services by a one-hour fire barrier wall.

(5) Ceiling heights in occupied areas or areas intended for patient use must be sufficiently high to meet the functional needs and equipment requirements of the space. Suspended tracks, rails, lights, or other obstructions located in path of travel can not be less than seven feet above finished floor to lowest point of obstruction.

(6) A corridor system throughout the hospice care center designed for traffic circulation must provide patient safety with:

(a) A width of six feet for hospice care centers accommodating six or more patients and restrictions of no more than seven inches for egress of patient care areas; or

(b) A width of four feet for hospice care centers accommodating five or less patients and restrictions of no more than seven inches for egress of patient care areas.

(7) If patient rooms are located above grade level, the hospice care center must have at least one elevator or lift designed for patient transport by gurney or equivalent.

(8) Doors must be designed with:

(a) Nominal four foot width for patient room doors in the path of egress designed to prevent swinging into corridor widths;

(b) Provision for personnel, contractors, and volunteers to gain immediate emergency access to patient occupied rooms or areas;

(c) Ability to swing outward from patient toilet and bathing rooms; and

(d) Vision panels in all pairs of opposite swinging doors.

(9) The hospice care center must provide a fire suppression system conforming to National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, 1999 Edition.

(10) Stairways must be designed with slip-resistant floor surfaces and ramps with slip-resistant or carpeted floor surfaces are required.

(11) Design and construction must address the prevention of entrance and infestation by pests.

(12) Interior finishes must be suitable to the function of an area including:

(a) Floors must be finished with:

(i) Easily cleanable and/or maintainable surfaces;

(ii) Slip-resistant surfaces at entrances and other areas;

(iii) Edges covered and top set base with toe at all wall junctures; and

(b) Carpets are not permitted in toilets, bathrooms, kitchens, utility rooms, janitor closets, and other areas where flooding or infection control is an issue;

(c) Ceiling finishes must be easily cleanable or maintainable;

(d) Walls must be:

(i) Protected from impact in high traffic areas;

(ii) Finished with easily cleanable surfaces; and

(iii) Finished with water-resistant paint, glaze, or similar water-resistant finish extending above the splash line in all rooms or areas subject to splash or spray.

(13) The design must include space and adequate storage for facility drawings, records, and operation manuals.

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NEW SECTION
WAC 246-335-210   Furnishings.   Furnishings of the hospice care center must be home-like and include lounge furniture in addition to furnishings in patient rooms. Accessories such as wallpaper, bedspreads, carpets and lamps must be:

(1) Selected to create a home-like atmosphere; and

(2) Installed per uniform building and fire codes and per manufacturer installation standards.

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NEW SECTION
WAC 246-335-220   Pharmaceutical services area.   (1) Pharmaceutical services area(s) must be accessible only to authorized personnel.

(2) A hospice care center must provide pharmacy services area(s) consistent with WAC 246-865-050 which include adequate space for:

(a) A work counter;

(b) A handwash sink;

(c) A soap and paper towel dispenser;

(d) Drug storage units constructed of metal, solid wood, or plywood which provide:

(i) Locked storage for all drugs;

(ii) Separate keyed storage for Schedule II - IV controlled substances;

(iii) Segregated storage for each patient's drugs;

(e) A lockable refrigerator for storage of heat sensitive drugs; and

(f) Other storage needed according to the hospice care center's functional program.

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NEW SECTION
WAC 246-335-225   Food preparation.   (1) A hospice care center applicant or licensee must:

(a) Locate food preparation areas to prevent objectionable heat, noise and odors to patient rooms;

(b) Provide a nourishment center for use by patients and family with:

(i) A refrigerator capable of maintaining 45F or less;

(ii) A two-compartment sink;

(iii) A range with exhaust hood and/or microwave;

(iv) Work surfaces;

(v) Storage for single service utensils and food items;

(vi) Soap and paper towel dispensers or equivalent;

(vii) Space for waste containers; and

(viii) A self-dispensing ice machine (if not provided elsewhere in the hospice care center);

(2) The following requirements only apply if the hospice care center is planning to prepare meals and snacks for patients on-site:

(a) When primarily preparing individual meals or snacks for patients, in addition to the requirements in subsection (1) of this section, the nourishment center must include:

(i) A separate refrigerator for patients' food items capable of maintaining 45F or less;

(ii) Separate storage for patient food items, cooking and eating utensils;

(iii) A handwash sink; and

(iv) A domestic dishwasher with a continuous supply of 155F of water;

(b) When primarily preparing meals for fifteen or fewer patients at a time, the kitchen for preparation of patient meals and snacks must comply with chapter 246-215 WAC, Food sanitation, except, the hospice care center may use domestic or home type kitchen appliances including mechanical dishwashers, provided the licensee:

(i) Operates the appliances according to manufacturer's direction; and

(ii) Provides a continuous supply of water maintained at 155F or more to the dishwasher(s); and

(c) When primarily preparing meals for sixteen or more patients at a time, the kitchen for preparation of patient meals and snacks must comply with chapter 246-215 WAC, Food sanitation.

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NEW SECTION
WAC 246-335-230   Linen handling facilities.   A hospice care center applicant or licensee must provide linen handling facilities with the capacity for receiving, holding, sorting, and separating soiled and clean linens either in clean and soiled utility rooms meeting the requirements of WAC 246-335-200 or in a separate linen handling facility meeting the following requirements:

(1) Floor drain(s) located in the soiled linen area;

(2) Handwash sink in soiled and clean processing areas;

(3) Negative air pressure gradient with direction of air flow from clean side of room to dirty side of room if room is shared;

(4) A folding area on clean side of room; and

(5) Separate clean linen storage located to avoid sources of moist or contaminated air with:

(a) Storage for reserve supply of linens, blankets, and pillows; and

(b) Space for carts and/or shelves.

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NEW SECTION
WAC 246-335-235   Laundry facilities.   A hospice care center applicant or licensee must provide laundry service through the use of:

(1) A commercial laundry service; or

(2) On-site laundry facilities with:

(a) A system to avoid through traffic or excessive heat, noise and odors to travel to patient rooms;

(b) Equipment capacity for processing laundry;

(c) Arrangement for uninterrupted work flow from soiled to clean function;

(d) Washing machine(s);

(e) Floor drains as required for equipment;

(f) Dryer(s);

(g) Dryer exhaust to the exterior and make-up air; and

(h) A handwash sink.

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NEW SECTION
WAC 246-335-240   Utility rooms.   (1) A hospice care center applicant or licensee must provide a clean utility room with no direct connection to soiled utility services, including:

(a) Sufficient clean storage and handling area(s);

(b) Closed storage for clean and sterile supplies and equipment;

(c) A work surface;

(d) Handwash sink;

(e) Soap and towel dispenser; and

(f) A self-closing door.

(2) The hospice care center must provide a soiled utility room on each floor of the center with no direct connection to clean utility services, including:

(a) A clinic service sink, siphon jet or equivalent with bedpan flushing attachment unless bedpan flushing devices are furnished in all patient toilets;

(b) Counter top, two-compartment sink, and gooseneck spout or equivalent;

(c) Storage for cleaning supplies and equipment;

(d) Soap and towel dispenser;

(e) Locked storage for chemicals; and

(f) Self-closing door.

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PHYSICAL ENVIRONMENT -- SPECIFIC DESIGN REQUIREMENTS
NEW SECTION
WAC 246-335-245   Plumbing.   An applicant must design and install plumbing, including:

(1) Backflow prevention with devices on plumbing fixtures, equipment, facilities, buildings, premises, or areas which may cause actual or potential cross-connections of systems in order to prevent the backflow of water or other liquids, gases, mixtures, or substances into a water distribution system or other fixtures, equipment, facilities, buildings, or areas;

(2) Trap primers in floor drains and stand pipes subject to infrequent use;

(3) Wrist, knee or foot faucet controls or equivalent and gooseneck spouts without aerators on handwash sinks;

(4) Insulation on:

(a) Hot water piping systems;

(b) Cold water and drainage piping; and

(c) Piping exposed to outside temperatures; and

(5) Equipment to deliver hot water at point of use as follows:

(a) 120F or less for handwash sinks and bathing fixtures;

(b) 160F or more for laundry washers;

(c) 120F or more for laundry washers using chemical sanitization;

(d) 120F or more for mechanical dishwashers using chemical sanitization;

(e) 140F or more for mechanical dishwashers using high temperature sanitization; and

(f) 180F or more for sanitization cycle in high temperature mechanical dishwashers.

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NEW SECTION
WAC 246-335-250   Medical gases.   If oxygen is stored or used on the premises, the following must apply in addition to other codes and regulations:

(1) Electrical equipment used in oxygen-enriched environments must be properly designed for use with oxygen and should be labeled for use with oxygen; and

(2) "No smoking" signs must be posted where oxygen is being administered.

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NEW SECTION
WAC 246-335-255   Heating, ventilating and air conditioning.   (1) Hospice care centers must have systems to provide individual temperature control for patient rooms to assure patient preference and comfort. The hospice care center must have the capacity to maintain:

(a) Patient rooms at 70F in summer and 80F in winter; and

(b) Nonpatient care areas at 75F in summer and 70F in winter.

(2) Total air circulation rates measured in air changes per hour (ACH) and ventilation air quantities must be provided in the following areas, if applicable, as follows:

(a) Patient rooms - 4 ACH circulated, 2 ACH outside air;

(b) Corridors - 2 ACH with 20% minimum outside air;

(c) Toilets, bathing facilities, locker rooms, housekeeping closets, soiled linen handling facilities, soiled utility rooms and laundry rooms - minimum 10 ACH total or a minimum of 70 CFM exhausted directly to the outdoors;

(d) Clean linen handling facilities, clean utility rooms, and medication distribution rooms - 4 ACH total or a minimum of 70 CFM;

(e) Food preparation areas - 10 ACH with 2 ACH outside air; and

(f) All other areas not specifically addressed above must be designed in accordance with Table 2 of ASHRAE Standard 62-1999.

(3) Heating and air conditioning system fans must continuously operate to maintain required pressure differences. Heating and air conditioning system air flows must be balanced to maintain pressure differences as follows:

(a) Provide negative pressure for any of the following areas, if applicable:

(i) Toilet rooms and showers;

(ii) Janitor rooms;

(iii) Soiled utility rooms; and

(iv) Food service areas and other areas where moisture or odors are generated;

(b) Provide positive pressure for any of the following areas, if applicable:

(i) Medication distribution rooms;

(ii) Clean utility rooms; and

(iii) Other similar areas.

(4) System outdoor air inlets must be located at least ten feet from any exhaust fan outlet, plumbing vent, combustion appliance vent, or other sources of contaminated air.

(5) A kitchen grease hood must be installed, and the applicant must provide a section drawing showing listed assembly type(s), fan discharge type and direction, curb venting, all required clearances both above and below the roof, materials, cleanouts, access doors, hood overhang of cooking equipment and other details in accordance with NFPA 96, Uniform Mechanical Code Sections 507 and 508, WAC 388-78A-070 (2)(e)(ii)(E) and 388-78A-290 (1)(a).

(6) Independent cooling system must be in place for elevator machine rooms.

(7) Combination fire smoke dampers must be in place for penetrations of corridor walls and of occupancy separations required around mechanical rooms, laundry rooms and storage rooms used in common.

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NEW SECTION
WAC 246-335-260   Electrical service and distribution.   A hospice care center applicant or licensee must provide general electrical service including:

(1) Tamperproof receptacles in patient rooms, toilets, and bathing facilities, and family, and public areas;

(2) Ground fault circuit interrupter (GFCI) receptacle when located within five feet of water source and above counters that contain sinks;

(3) Emergency electrical service with:

(a) Adequate emergency lighting in patient rooms;

(b) At a minimum, provisions must be made for emergency lighting for means of egress; and

(c) Power, appropriate to provide continuous operation of life support equipment;

(4) Lighting fixtures with:

(a) Number, type, and location to provide illumination for the functions of each area;

(b) A reading light and control, conveniently located for patient use at each bed in the patient rooms; and

(c) Protective lens or protective diffusers on overhead light fixtures:

(i) Over patient beds;

(ii) In areas where patient care equipment and supplies are processed; and

(iii) In nourishment centers or kitchen areas;

(d) A night light or equivalent low level illumination;

(e) Night light switches and general illumination switches located adjacent to the opening side of patient room doors; and

(5) An electronic means of communication that notifies on-duty personnel, contractors, or volunteers and that must:

(a) Be located at the head of the bed in patient rooms and in all common areas accessible by the patients;

(b) Be physically or verbally accessible by patients slumped forward on the floors of either the toilet, bathing facility, or dressing room; and

(c) Consider the patient's communication needs.

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PATIENT AREAS
NEW SECTION
WAC 246-335-265   Patient rooms.   (1) A hospice care center applicant or licensee must locate patient rooms to exclude through traffic and minimize the penetration of objectionable odors and noise from other areas of the center.

(2) Hospice care centers must assure each patient room is:

(a) Directly accessible from a corridor; and

(b) A minimum of one hundred square feet for private rooms and one hundred sixty square feet for rooms allowing a roommate.

(3) All operable windows or openings that serve for ventilation must be provided with screening.

(4) Patient room must be located above grade level.

(5) Patient beds must be placed so they do not interfere with entrance, exit or traffic flow within the room.

(6) Patient rooms must be safe, private, clean and comfortable, allowing the patient to use personal belongings to the extent possible and include:

(a) Seating for several family members, with provision for at least one sleeping accommodation in patient rooms;

(b) A window with a view of landscaping to the exterior;

(c) A noncoin-operated telephone readily available for the patient and family to make and receive confidential calls; and

(d) A space suitable for hanging full-length garments and secure storage of personal belongings within the patient room.

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NEW SECTION
WAC 246-335-270   Patient toilets and bathing facilities.   (1) Each patient toilet must adjoin the patient room and include:

(a) Bedpan flushing equipment if bedpan flushing equipment is not located in a soiled utility room;

(b) Grab bars located per chapter 51-40 WAC and securely mounted on both sides of the water closet, with at least one horizontal grab bar extending eighteen inches beyond the front of the water closet;

(c) A handwash sink;

(d) Single service soap and towel dispensers;

(e) Slip-resistant floor surfaces;

(f) Toilet paper holder;

(g) Backing to support mounting of all accessories; and

(h) Mirror and shelving or equivalent at each handwash sink.

(2) There must be at least one patient toilet in the hospice care center meeting the accessibility requirements in chapter 51-40 WAC for every four patient beds. A minimum of one patient toilet meeting the accessibility requirements is required for each hospice care center.

(3) Bathing facilities, which may be separate from patient toilet rooms, must include:

(a) With ten or fewer beds, one barrier free roll-in shower or accessible tub designed for ease of entry;

(b) With eleven or more beds one barrier free roll-in shower or accessible tub, and one additional shower or tub, neither of which need to be barrier free or accessible;

(c) Slip resistant floors;

(d) An adequate supply of hot water available at all times;

(e) A towel bar, hook, or ring;

(f) A robe hook; and

(g) Grab bars that are easily cleanable, resistant to corrosion, functionally designed, and securely mounted at patient bathing facilities in accordance with WAC 51-30-1100 including:

(i) One vertical bar at the faucet end; and

(ii) Bars located on two sides of each standard bathtub and shower.

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FAMILY, PERSONNEL, VOLUNTEER, CONTRACTOR AND PUBLIC AREAS
NEW SECTION
WAC 246-335-275   Family, personnel, volunteer, contractor, and public areas.   (1) A hospice care center applicant or licensee must provide family use areas with:

(a) A minimum of two hundred square feet;

(b) Comfortable seating for several family members;

(c) Provision for families and patients to share meals;

(d) Drinking water;

(e) Public telephone;

(f) Information desk or directory signage; and

(g) Exterior, clear glass windows with a maximum sill height of thirty-six inches.

(2) Hospice care centers must provide a private space at least one hundred fifty square feet in size for every ten beds and an additional seventy-five square feet for every additional five beds. The private space should be designed for:

(a) Private group, family and individual interviews and counseling;

(b) Interdisciplinary weekly conferences and personnel, contractor, and volunteer breaks; and

(c) Spiritual services.

(3) Hospice care centers must provide additional space for personnel, contractors and volunteers. This space must be designed to accommodate:

(a) Secure storage for medical records;

(b) Personnel, contractor, and volunteer break areas;

(c) Personnel, contractor, and volunteer work areas;

(d) General storage; and

(e) At least one personnel, contractor, and volunteer toilet room with handwash sink.

(4) Hospice care centers must provide one visitor toilet room with handwash sink for every ten beds.

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FACILITY SUPPORT
NEW SECTION
WAC 246-335-280   Environmental services facilities.   (1) The hospice care center must provide a waste handling area including storage area in a separate, well-ventilated area designed to maintain pest control and to preclude objectionable odors in other areas of the hospice care center, or in an outside, enclosed space with:

(a) A handwash sink located adjacent to the path of travel back into patient care areas;

(b) If planned, a waste container wash area with floor drain connected to a sanitary sewage system and hose bibs with hot and cold water;

(c) If planned, waste dumpsters and compactor storage area with drain connected to a sanitary sewage system and hose bibs with hot and cold water.

(2) The hospice care center must provide a locked housekeeping supply room on each floor with:

(a) A service sink or equivalent;

(b) Soap and towel dispenser;

(c) A mop rack storage area for mobile housekeeping equipment and supplies; and

(d) Storage for chemicals.

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NEW SECTION
WAC 246-335-285   Maintenance facilities.   A hospice care center applicant or licensee must:

(1) If planning a maintenance shop, assure it is located and designed for easy delivery and removal of equipment and to minimize noise and dust to the rest of the hospice care center with:

(a) Storage for solvents, flammable and combustible liquids; and

(b) Storage for supplies and equipment; and

(2) Provide a separate room or area specifically for repair, and testing of electronic or other medical equipment according to the functional program.

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NEW SECTION
WAC 246-335-290   Receiving, storage and distribution facilities.   A hospice care center applicant or licensee must:

(1) Provide bulk and general supply storage constructed to control pests, and prevent spoilage, contamination, damage, and corrosion of goods including:

(a) Protection against inclement weather;

(b) Secured spaces with appropriate environmental conditions in accordance with federal and state laws and rules on supplies and medication storage if pharmaceuticals are stored; and

(c) Off-floor storage when required to prevent contamination and water damage to stores;

(2) Provide receiving and unloading area with:

(a) Administrative work space;

(b) Security and protection for supplies; and

(c) Location to prevent vehicle exhaust from entering the hospice care center; and

(3) Provide storage if needed for:

(a) Flammable and combustible liquid storage;

(b) Laboratory chemicals;

(c) Medical compressed gases;

(d) Gaseous oxidizing materials;

(e) Pesticides, cleaning compounds, and toxic substances; and

(f) Mobile housekeeping equipment.

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EXEMPTIONS AND ALTERNATIVE METHODS
NEW SECTION
WAC 246-335-295   Exemptions and alternative methods.   Hospice care centers applying for an exemption to any of the requirements of this chapter must comply with the requirements in WAC 246-335-125.

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PART 3

FEES
NEW SECTION
WAC 246-335-990   Fees.   (1) A licensee or applicant shall submit to the department:

(a) An initial twelve-month license fee of one thousand five hundred dollars for each service category for new persons not currently licensed in that category to provide in-home services in Washington state, or currently licensed businesses which have had statement of charges filed against them;

(b) A twenty-four month renewal fee based on the number of full-time equivalents (FTEs), which is a measurement based on a forty-hour week and is applicable to paid agency personnel or contractors, or the number of beds, as follows:

(c) For single service category licenses:

# of FTEs Home Health Hospice Home Care # of Beds Hospice Care Center
5 or less $1,500.00 $750.00 $450.00 5 or less $500.00
6 to 15 $2,110.00 $790.00 $815.00 6 to 10 $1,000.00
16 to 50 $2,400.00 $1,174.99 $875.00 11 to 15 $1,500.00
51 to 100 $3,025.00 $1,882.29 $1,025.00 16 to 20 $2,000.00
101 or more $3,115.00 $1,980.00 $1,100.00

(d) For multiple service category licenses:

(i) One hundred percent of the home health category fee and seventy-five percent of the appropriate service category fee for each additional service category (hospice, home care, hospice care center); or

(ii) One hundred percent of the hospice category fee and seventy-five percent of the appropriate service category fee for each additional service category (home care, hospice care center); and

(e) A change of ownership fee of one hundred fifty dollars for each licensed service category. A new license will be issued and valid for the remainder of the current license period.

(2) The department may charge and collect from a licensee a fee of seven hundred fifty dollars for:

(a) A second on-site visit resulting from failure of the licensee to adequately respond to a statement of deficiencies:

(b) A complete on-site survey resulting from a substantiated complaint; or

(c) A follow-up compliance survey.

(3) A licensee with deemed status shall pay fees according to this section.

(4) A licensee shall submit an additional late fee in the amount of twenty-five dollars per day, not to exceed five hundred dollars, from the renewal date (which is thirty days before the current license expiration date) until the date of mailing the fee, as evidenced by the postmark.

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Washington State Code Reviser's Office