Title of Rule: In-home services, WAC 246-335-015 Definitions and 246-335-060 Delivery of services.

     Purpose: To implement changes to chapter 70.127 RCW enacted by the 2003 legislature and signed by the governor on May 7, 2003.

     Statutory Authority for Adoption: RCW 70.127.120.

     Statute Being Implemented: Chapter 70.127 RCW.

     Summary: The 2003 legislature passed HB 1753 which authorized the practice of nurse delegation in the in-home setting, including home care, home health, hospice and hospice care centers. At the request of the interested parties, the department made very minor changes to chapter 246-335 WAC to enable nurse delegation in these licensed agencies. Expedited rule making is authorized under RCW 34.05.353 (1)(d).

     Reasons Supporting Proposal: Interested parties requested and are in support of the proposed changes. The department expects no opposition to these rule changes.

     Name of Agency Personnel Responsible for Drafting and Implementation: Michael Johnson, Shoreline, (206) 355-2638; and Enforcement: Byron Plan, Tumwater, (360) 236-2916.

     Name of Proponent: Department of Health, Facilities, Services and Licensing, governmental.

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

     Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule authorizes nurse delegation in the in-home care settings, which include home care, home health, hospice and hospice care center agencies. The proposed rules are in response to changes to chapter 70.127 RCW which governs in-home service agencies.

     Proposal Changes the Following Existing Rules: The proposed rule changes to chapter 246-335 WAC, In-home service agencies, authorizes nurse delegation and other legislatively mandated changes to chapter 70.127 RCW.

September 16, 2003

Mary C. Selecky

Secretary

OTS-6559.1

AMENDATORY SECTION(Amending WSR 02-18-026, filed 8/23/02, effective 10/1/02)

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. A home care agency that provides delegated tasks of nursing under RCW 18.79.260 (3)(e) and rules adopted thereunder is not considered a home health agency for purposes of this chapter.

     (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 or delegated tasks of nursing under RCW 18.79.260 (3)(e) and rules adopted thereunder.

     (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)), that includes the application, instillation or insertion of medications under a plan of care, for 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 the Nurse Practice Act as defined in chapter 18.79 RCW and rules adopted thereunder and the 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.

[Statutory Authority: Chapter 70.127 RCW. 02-18-026, § 246-335-015, filed 8/23/02, effective 10/1/02.]

     (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.

     (15) Nurse delegation as defined in RCW 18.79.260 (3)(e) and rules adopted thereunder, if applicable.

[Statutory Authority: Chapter 70.127 RCW. 02-18-026, § 246-335-060, filed 8/23/02, effective 10/1/02.]

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