Original Notice.

     Preproposal statement of inquiry was filed as WSR 02-21-012.

     Title of Rule: Adopt new chapter 388-72A WAC, Comprehensive assessment reporting evaluation (CARE).

     Purpose: These rules are needed to implement the new comprehensive assessment reporting evaluation (CARE) tool, an automated system used to assess clients of long-term care.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.39A.090.

     Statute Being Implemented: RCW 74.09.520, 74.39A.090.

     Summary: Aging and Disability Services is adopting rules to support the comprehensive assessment reporting evaluation, a system used to determine needs for, develop care plan for, and support delivery of long-term care services.

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Brooke Buckingham, ADSA, 640 Woodland Square Loop, Lacey, WA 98503, (360) 725-2530.

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

     Agency Comments or Recommendations, if any, as to Statutory Language, Implementation, Enforcement, and Fiscal Matters: Once CARE implementation is completed, rules within chapter 388-72A WAC will replace comparable sections within chapter 388-71 WAC.

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

     Explanation of Rule, its Purpose, and Anticipated Effects: These rules will support the implementation of the comprehensive assessment reporting evaluation (CARE). Designated staff will use this automated system to collect demographic data, assess functional needs and abilities, health and medical information, determine eligibility for services, develop a care plan, and authorize services for clients on or requesting long-term care services.

     Proposal does not change existing rules.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. A small business economic impact statement is not required because the rules do not impact small businesses. The rules only affect client eligibility assessments and determination of need for home and community long-term care services.

     RCW 34.05.328 does not apply to this rule adoption. The proposed rules do meet the definition of "significant legislative rule," but a cost benefit analysis is not required under RCW 34.05.328 (5)(b)(vii), exempting, "rules of the department of social and health services relating only to client medical or financial eligibility and rules concerning liability for care of dependents."

     Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on February 4, 2003, at 1:00 p.m.

     Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by January 31, 2003, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

     Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., February 4, 2003.

     Date of Intended Adoption: Not earlier than February 5, 2003.

December 18, 2002

Bonita H. Jacques

for Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     (1) Initial assessment;

     (2) Annual reassessment; or

     (3) Assessment due to a significant change in condition.

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     (1) Assess your abilities and needs using a department-prescribed assessment tool, called the comprehensive assessment reporting evaluation (CARE); and

     (2) Perform the assessment based on an in-person interview with you in your own home or other place of residence, which is defined in WAC 388-71-0202. A case manager may request the assessment be conducted in private.

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     (1) Determine eligibility for department-paid home and community programs;

     (2) Identify your strengths;

     (3) Evaluate your living situation and environment;

     (4) Evaluate your physical health, functional and cognitive abilities, social resources, income and financial resources, and emotional and social functioning for service planning purposes;

     (5) Identify your values and preferences for effective service planning based on your lifestyle;

     (6) Determine availability of alternative resources including family, neighbors, friends, community programs, volunteers, and other service delivery options that will provide needed assistance;

     (7) Determine risk of and program eligibility for nursing facility placement; and

     (8) Determine need for case management activities.

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     (1) Activities of daily living consist of the following care tasks that are directly related to your disabling condition:

     (a) Bathing, how you take a full-body bath/shower, sponge bath, and transfer in/out of tub/shower;

     (b) Bed mobility, how you move to and from a lying position, turn side to side, and position your body while in bed;

     (c) Body care, how you perform with passive range of motion, applications of dressings and ointments or lotions to the body and pedicure to trim toenails and apply lotion to feet. In adult family homes or in licensed boarding homes contracting with DSHS to provide assisted living services, dressing changes using clean technique and topical ointments must be delegated by a registered nurse in accordance with chapter 246-840 WAC. Body care excludes:

     (i) Foot care for clients who are diabetic or have poor circulation; or

     (ii) Changing bandages or dressings when sterile procedures are required.

     (d) Dressing, how you put on, fasten, and take off all items of street clothing, including donning/removing prosthesis;

     (e) Eating, how you eat and drink, regardless of skill. Eating includes any method of receiving nutrition, e.g., by mouth, tube or through a vein;

     (f) Locomotion in room and immediate living environment, how you move between locations in your room and immediate living environment. If you are in a wheelchair, locomotion includes how self-sufficient you are once in your wheelchair;

     (g) Locomotion outside of immediate living environment including outdoors, how you move to and return from more distant areas. If you are living in boarding home or nursing facility (NF), this includes areas set aside for dining, activities, etc. If you are living in your own home or in an adult family home, locomotion outside immediate living environment including outdoors includes how you move to and return from a patio or porch, backyard, to the mailbox, to see the next-door neighbor, etc;

     (h) Walk in room, hallway and rest of immediate living environment, how you walk between locations in your room and immediate living environment;

     (i) Medication management, how you self-administer medications prescribed by primary care provider or administer when you are unable;

     (j) Toilet use, how you use the toilet room, commode, bedpan, or urinal, transfer on/off toilet, cleanse, change pad, manage ostomy or catheter, and adjust clothes;

     (k) Transfer, how you move between surfaces, i.e., to/from bed, chair, wheelchair, standing position. Transfer does not include how you move to/from the bath or toilet; and

     (l) Personal hygiene, how you maintain personal hygiene, including combing hair, brushing teeth, applying makeup, washing/drying face hands, menses care, and perineum. This does not include personal hygiene in baths and showers.

     (2) Instrumental activities of daily living (IADL) consist of the following routine activities performed around the home or in the community.

     (a) Meal preparation, how meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food, utensils, and cleaning up after meals). NOTE: This task may not be authorized to just plan meals or clean up after meals. You must need assistance with actual meal preparation;

     (b) Ordinary housework, how ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry);

     (c) Essential shopping, how shopping is completed to meet your health and nutritional needs (e.g., selecting items). Shopping is limited to brief, occasional trips in the local area to shop for food, medical necessities and household items required specifically for your health, maintenance or well-being. This includes shopping with or for you;

     (d) Wood supply, how wood is supplied (e.g., splitting, stacking, or carrying wood) when you use wood as the sole source of fuel for heating and/or cooking;

     (e) Travel to medical services, how you travel by vehicle to a physician's office or clinic in the local area to obtain medical diagnosis or treatment-includes driving vehicle yourself, traveling as a passenger in a car, bus, or taxi;

     (f) Managing finances, how bills are paid, checkbook is balanced, household expenses are managed. The department cannot pay for any assistance with managing finances; and

     (g) Telephone use, how telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed).

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     (2) For each ADL, except as otherwise provided for bathing, body care, and medication management, the case manager assesses the level of your ability to self-perform the ADL and the level of support provided by others.

     (a) For each ADL, the case manager measures your level of self-performance by determining what you actually did within the last seven days, not what you might be capable of doing. If you:

     (i) Received no help or oversight, or if you needed help or oversight only once or twice, you are assessed as being independent;

     (ii) Received oversight (monitoring or standby), encouragement, or cueing three or more times, or needed physical assistance in addition to supervision only once or twice, you are assessed as needing supervision;

     (iii) Were:

     (A) Highly involved in the activity,

     (B) Given physical help in guided maneuvering of limbs or other nonweight bearing assistance on three or more occasions, or

     (C) Given weight bearing assistance but only one or two times, you are assessed as needing limited assistance.

     (iv) Performed part of the activity, but on three or more occasions, you needed weight bearing support or you received full performance of the activity during part, but not all, of the activity from others, you were assessed as needing extensive assistance;

     (v) Received full caregiver performance of the activity and all subtasks during the entire seven-day period from others, you are assessed as having total dependence. Total dependence means complete nonparticipation by you in all aspects of the ADL; or

     (vi) Or others do not perform an ADL over the last seven days before your assessment, your assessment will indicate that the activity did not occur during the entire seven-day period.

     (b) For each ADL, the case manager also determines the level of support provided, which means the highest level of support provided by others over the last seven days, even if that level of support occurred only once. For each ADL, the assessment will indicate one of the following levels of support provided:

     (i) No set-up or physical help provided by others;

     (ii) Set-up help only provided, which is the type of help characterized by providing you with articles, devices, or preparation necessary for greater self-performance of the activity (such as giving or holding out an item that you take from others);

     (iii) One-person physical assist provided;

     (iv) Two- or more person physical assist provided; or

     (v) Activity did not occur during entire seven-day period.

     (3) The activity of bathing is assessed in the same way as other ADL's under subsection (2) of this section, except you are assessed as needing:

     (a) Limited assistance with bathing if physical help is limited to transfer only.

     (b) Extensive assistance with bathing if you needed physical help with part of the activity (other than transfer).

     (4) The activity of body care is assessed to determine whether you need assistance. You are assessed as needing assistance if you require:

     (a) Application of ointment or lotions;

     (b) Trimming of toenails;

     (c) Dry bandage changes; or

     (d) Passive range of motion treatment.

     (5) The activity of medication management is assessed to determine whether you need assistance managing your medications. If you:

     (a) Remember to take medications as prescribed and manage your medications without assistance, you are assessed as being independent with medical management.

     (b) Need assistance from a nonlicensed provider to facilitate your self-administration of a prescribed, over the counter, or herbal medication, you are assessed as needing assistance with medication management. Assistance required includes reminding or coaching you, handing you the medication container, opening the container, using an enabler to assist you in getting the medication into your mouth, and placing the medication in your hand. This does not include assistance with intravenous or injectable medications. You must be aware that you are taking medications.

     (c) Are a person with a functional disability who is capable of and who chooses to self-direct your medication assistance/administration, you are assessed as needing self-directed medication assistance/administration.

     (d) Must have medications placed in your mouth or applied to your skin or mucus membrane by a licensed professional or as delegated by a registered nurse (RN) to: a provider who is not a RN or a licensed practical nurse (LPN) in an adult family home or boarding home following nurse delegation protocols in chapter 246-840 WAC, or by a family member or unpaid caregiver, you are assessed as needing medications administered to you. Intravenous or injectable medications must be administered by a licensed health care professional, family member, or unpaid caregiver.

     (6) For each IADL, the case manager assesses the level of your ability to self-perform the IADL and how difficult it is (or would be) for you to perform the activity on your own.

     (a) The case manager measures the level of your ability to self-perform the activity by determining what you actually did within the last thirty days, not what you might be capable of doing. If you:

     (i) Received no help, set-up help, or supervision, you are assessed as being independent;

     (ii) Received set-up help or arrangements only, you are assessed as needing supervision;

     (iii) Sometimes performed the activity yourself and other times needed assistance, you are assessed as needing limited assistance;

     (iv) Were involved in performing the activity, but required cueing/supervision or partial assistance at all times, you are assessed as needing extensive assistance;

     (v) Needed the activity fully performed by others, you are assessed as having total dependence; or

     (vi) Others did not perform the activity within the assessment period, the assessment will indicate that the activity did not occur.

     (b) For each IADL, the case manager determines how difficult it is or would be for you to perform the activity. The assessment will determine whether you have or would have:

     (i) No difficulty in performing the activity;

     (ii) Some difficulty in performing the activity (e.g., you need some help, are very slow, or fatigue easily); or

     (iii) Great difficulty in performing the activity (e.g., little or no involvement in the activity is possible).

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     (1) Authorize services to correspond with your assessed need, per WAC 388-72A-0040;

     (2) Develop a service plan with you that identifies:

     (a) Your specific abilities and needs;

     (b) A plan for meeting each need for which you want assistance;

     (c) Ways to meet your needs with the most appropriate services, both formal and informal;

     (d) Who is responsible for carrying out each part of the plan;

     (e) Anticipated outcomes;

     (f) Dates and changes to the plan;

     (g) Dates of referral, service initiation, follow-up reviews;

     (h) Those needs that you do not want assistance with at this time; and

     (i) Agreement to the service plan by you or your representative.

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     (1) You are age:

     (a) Eighteen or older and blind or disabled, as defined in WAC 388-511-1105; or

     (b) Sixty-five or older.

     (2) You meet financial eligibility requirements. This means the department will assess your finances and determine if your income and resources fall within the limits set in WAC 388-515-1505, Community options program entry system (COPES);

     (3) You:

     (a) Are not eligible for Medicaid personal care services (MPC); or

     (b) Are eligible for MPC services, but the department determines that the amount, duration, or scope of your needs is beyond what MPC can provide.

     (4) Your comprehensive assessment shows you need the level of care provided in a nursing facility (or will likely need the level of care within thirty days unless COPES services are provided) which means one of the following applies.

     (a) You require care provided by or under the supervision of a registered nurse or a licensed practical nurse on a daily basis, or:

     (b) You have an unmet or partially met need with at least three or more of the following, as defined in WAC 388-72A-0040:

     (i) Setup in eating (e.g., cutting meat and opening containers at meals; giving one food category at a time);

     (ii) Supervision in toileting;

     (iii) Supervision in bathing;

     (iv) Supervision plus setup in transfer;

     (v) Supervision plus setup in bed mobility;

     (vi) Supervision plus set up help in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (vii) Assistance required in medication management.

     (c) You have an unmet or partially met need with at least two or more of the following, as defined in WAC 388-72A-0040:

     (i) Extensive assistance plus one person physical assistance in toileting;

     (ii) Extensive assistance plus one person physical assistance in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (iii) Extensive assistance plus one person physical assistance in transfer;

     (iv) Limited assistance plus one person physical assistance in bed mobility and need turning/repositioning;

     (v) Physical help limited to transfer plus one person physical assist in bathing;

     (vi) Supervision plus one person physical assist in eating; or

     (vii) Daily assistance required in medication management.

     (d) You have a cognitive impairment and require supervision due to one or more of the following: disorientation, memory impairment, impaired decision making, or wandering and have an unmet or partially met need with at least one or more of the following, as defined in WAC 388-72A-0040:

     (i) Extensive assistance plus one person physical assistance in toileting;

     (ii) Extensive assistance plus one person physical assistance in one of the following three tasks:

     (A) Walk in room, hallway and rest of immediate living environment;

     (B) Locomotion in room and immediate living environment;

     (C) Locomotion outside of immediate living environment including outdoors.

     (iii) Extensive assistance plus one person physical assistance in transfer;

     (iv) Limited assistance plus one person physical assistance in bed mobility;

     (v) Physical help limited to transfer plus one person physical assist in bathing;

     (vi) Supervision plus one person physical assist in eating; or

     (vii) Daily assistance required in medication management.

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     (1) Are certified as Title XIX categorically needy, as defined in WAC 388-500-0005.

     (2) Have an unmet or partially met need in at least one or more of the following, as defined in WAC 388-72A-0040:

     (a) Help/oversight one or two times during the last seven days plus setup in eating;

     (b) Supervision in toileting;

     (c) Supervision in bathing;

     (d) Supervision in dressing;

     (e) Supervision plus setup in transfer;

     (f) Supervision plus setup in bed mobility;

     (g) Supervision plus set up help in one of the following three tasks:

     (i) Walk in room, hallway and rest of immediate living environment;

     (ii) Locomotion in room and immediate living environment;

     (iii) Locomotion outside of immediate living environment including outdoors.

     (h) Assistance required in medication management;

     (i) Supervision in personal hygiene;

     (j) Assistance with body care, which means you need:

     (i) Application of ointment or lotions;

     (ii) Your toenails trimmed;

     (iii) Dry bandage changes; or

     (iv) Passive range of motion treatment.

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     (1) Be eighteen years of age or older;

     (2) Have an unmet or partially met need in at least one or more of the following, as defined in WAC 388-72A-0040:

     (a) Help/oversight one or two times during the last seven days plus setup in eating;

     (b) Supervision in toileting;

     (c) Supervision in bathing;

     (d) Supervision in dressing;

     (e) Supervision plus setup in transfer;

     (f) Supervision plus setup in bed mobility;

     (g) Supervision plus set up help in one of the following three tasks:

     (i) Walk in room, hallway and rest of immediate living environment;

     (ii) Locomotion in room and immediate living environment;

     (iii) Locomotion outside of immediate living environment including outdoors.

     (h) Assistance required in medication management;

     (i) Supervision in personal hygiene;

     (j) Assistance with body care, which means you need:

     (i) Application of ointment or lotions;

     (ii) Your toenails trimmed;

     (iii) Dry bandage changes; or

     (iv) Passive range of motion treatment.

     (3) Currently be on the Chore program and not be eligible for MPC or COPES, Medicare home health or other programs if these programs can meet your needs;

     (4) Have net household income (as described in WAC 388-450-0005, 388-450-0020, 388-450-0040, and 388-511-1130) not exceeding:

     (a) The sum of the cost of your chore services; and

     (b) One-hundred percent of the Federal Poverty Level (FPL) adjusted for family size.

     (5) Have resources, as described in chapter 388-470 WAC, which does not exceed ten thousand dollars for a one-person family or fifteen thousand dollars for a two-person family. (Note: One thousand dollars for each additional family member may be added to these limits.)

     (6) Not transfer assets on or after November 1, 1995 for less than fair market value as described in WAC 388-513-1365.

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     (1) Cognitive performance;

     (2) Clinical complexity, e.g., medical conditions;

     (3) Mood/behaviors; and

     (4) Activities of daily living (ADL).

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     (1) Cognitive performance

     (a) Short term memory;

     (b) Self-performance in eating;

     (c) Ability to make self understood;

     (d) Ability to make decisions regarding ADLs; and

     (e) Comatose or in a persistent vegetative state.

     (2) Clinical complexity

     (a) Diagnoses requiring more than average care time and/or special care;

     (b) Skin problems receiving treatment;

     (c) Unstable clinical conditions; and

     (d) Skilled nursing needs.

     (3) Mood/behaviors the assessment data evaluated may include, but is not limited to the following:

     (a) Assaulting care givers;

     (b) Resisting care;

     (c) Wandering; and

     (d) Depression.

     (4) Activities of daily living (ADLs), the amount of assistance the client needs to perform ADLs.

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     (1) Cognitive performance by using the cognitive performance scale (CPS) and assigning a score. The score assigns ranges from zero to six with six being very severely impaired;

     (2) Clinical complexity by determining whether your medical conditions take more or less time and/or require special care;

     (3) Mood/behavior by determining whether your mood/behavior symptoms take more or less time;

     (4) ADLs by scoring the assistance needed to perform ADLs.

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     (a) Assistance available to meet your needs. This is defined as:

     (i) Met;

     (ii) Unmet;

     (iii) Partially met.

     NOTE: Home and community programs (HCP) services may not replace other available resources the department identified when completing CARE. The hours will be adjusted to account for tasks that are either fully or partially met by other available resources. These resources may be unpaid or paid for by other state or community sources.

     (b) Environment, such as whether you:

     (i) Have laundry facilities out of home; and/or

     (ii) Use wood as a primary source of heat and/or;

     (iii) The time it takes to access essential shopping services.

     (c) Living arrangement. The department will adjust payments to a personal care provider who is doing household tasks at the same time (e.g., essential shopping, meal preparation, laundry, and wood supply) if:

     (i) There is more than one client living in the same household; or

     (ii) You and your paid provider live in the same household.

     (2) The CARE tool will provide a maximum number of hours that can be used to develop your care plan. The assessor must take into account cost effectiveness, client health and safety, and program limits in determining how hours can be used to meet identified client needs.

     (3) Within the limits of subsection (2) of this section, you and your case manager will work to determine what services you choose to receive if you are eligible, per WAC 388-72A-0055, 388-72A-0060, 388-72A-0065, 388-15-652 or 388-15-653. The hours may be used to authorize:

     (a) Personal care services;

     (b) Home delivered meals;

     (c) Adult day care;

     (d) Adult day health;

     (c) A home health aide.

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     (1) Environmental modifications;

     (2) Personal response system (PERS);

     (3) Skilled nursing;

     (4) Specialized medical equipment;

     (5) Training; or

     (6) Transportation services.

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