WSR 04-09-094

EMERGENCY RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)

[ Filed April 20, 2004, 4:21 p.m. ]

Date of Adoption: April 20, 2004.

Purpose: The emergency rule revises chapter 388-72A WAC, Comprehensive assessment reporting evaluation (CARE) tool, to include the CARE algorithm component in rule.

A CR-101, preproposal statement of inquiry, for adoption of permanent rules on this subject has also been filed.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-72A-0040 and 388-72A-0075; and amending WAC 388-72A-0010, 388-72A-0055, 388-72A-0060, 388-72A-0065, 388-72A-0070, 388-72A-0080, 388-72A-0085, 388-72A-0090, and 388-72A-0095.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.

Other Authority: RCW 74.39A.090, 74.39A.095.

Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest.

Reasons for this Finding: Based on fair hearings, the department has determined that confusion about the new CARE assessment as described under current rules in chapter 388-72A WAC is leading to inconsistent hearing decisions and is jeopardizing the fair and equitable administration of home and community programs. Additional information about the CARE algorithm needs to be included in chapter 388-72A WAC immediately in order to allay such confusion and to ensure that clients receive benefits appropriate to their assessed needs.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 14, Amended 9, Repealed 2.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 14, Amended 9, Repealed 2.
Effective Date of Rule: Immediately.

April 20, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3389.5
AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0010   Does chapter 388-71 WAC apply to me?   Yes. Chapter 388-71 WAC applies with the exception of the following: WAC 388-72-0202 (Direct personal care services, household assistance, medically oriented tasks, personal care services, plan of care, supervision, and unscheduled tasks), 388-71-0203, 388-71-0205, 388-71-0430, 388-71-0435, 388-71-0440, 388-71-0442, and 388-71-0445.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0010, filed 2/19/03, effective 3/22/03.]


NEW SECTION
WAC 388-72A-0036   How are my needs for personal care services determined?   The assessor gathers information from you, your caregivers, family members, and other sources to determine how much assistance you need with personal care services. This is measured by your:

(1) Self-performance, what you actually did within the last seven days, not what you might be capable of doing. Coding is based on the level of performance that occurred three or more times in the seven-day period.

(2) 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.

(3) Status, which identifies whether a need is met, unmet, partially met, or declined.

(4) Assistance available.

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NEW SECTION
WAC 388-72A-0037   How are self performance and support provided for the activities of daily living (ADLs) scored?   (1) For each ADL, except as otherwise provided for bathing, body care, and medication management, the assessor determines your ability to self-perform the ADL. Your self performance is scored as:

(a) Independent if you received no help or oversight, or if you needed help or oversight only once or twice.

(b) Supervision if you received oversight (monitoring or standby), encouragement, or cueing three or more times, or needed physical assistance in addition to supervision only once or twice.

(c) Limited assistance if you were highly involved in the activity and:

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

(ii) Given weight bearing assistance but only one or two times.

(d) Extensive assistance if you 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.

(e) Total dependence if you received full caregiver performance of the activity and all subtasks during the entire seven-day period from others. Total dependence means complete nonparticipation by you in all aspects of the ADL; or

(f) Activity did not occur if you or others do not perform an ADL over the last seven days before your assessment. The activity may not have occurred because:

(i) You were not able (e.g., walking, if paralyzed); or

(ii) No provider was available to assist; or

(iii) You declined assistance with the task.

(2) The assessor also determines the level of support provided. Your support provided is scored as:

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

(b) 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);

(c) One-person physical assist provided;

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

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

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NEW SECTION
WAC 388-72A-0038   How are the ADLs bathing, body care, and medication managed scored?   (1) The activity of bathing is assessed in the same way as other ADLs in WAC 388-72A-0037, 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).

(2) The activity of body care is assessed to determine whether you need assistance. You are scored 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.

(3) The activity of medication management is assessed to determine whether you need assistance managing your medications. This assistance is scored as:

(a) Independent if you remember to take medications as prescribed and manage your medications without assistance.

(b) Assistance required if you 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) Self-directed medication assistance/administration if you are a person with a functional disability who is capable of and who chooses to self-direct your medication assistance/administration.

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

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NEW SECTION
WAC 388-72A-0039   How are self performance and difficulty for the instrumental activities of daily living (IADLs) scored?   (1) For each IADL, the assessor determines your ability to self-perform the IADL. Your self performance is scored as:

(a) Independent if you received no help, set-up help, or supervision.

(b) Supervision if you received set-up help or arrangements only.

(c) Limited assistance if you sometimes performed the activity yourself and other times needed assistance.

(d) Extensive assistance if you were involved in performing the activity, but required cueing/supervision or partial assistance at all times.

(e) Total dependence if you needed the activity fully performed by others.

(f) Activity did not occur if you or others did not perform the activity within the assessment period.

(2) For each IADL, the assessor determines how difficult it is or would be for you to perform the activity. This is scored as:

(a) No difficulty in performing the activity;

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

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

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NEW SECTION
WAC 388-72A-0041   How are status and assistance available scored for ADLs and IADLs?   (1) For each ADL and IADL, the assessor determines whether there is an informal support available. An informal support is a person or resource that is available to provide assistance without home and community program funding.

(a) Met: The ADL or IADL will be fully provided by an informal support.

(b) Unmet: An informal support will not be available to provide assistance with the identified ADL or IADL.

(c) Partially Met: An informal support will be available to provide some assistance, but not all, with the identified ADL or IADL.

(d) Client declines: Client does not want assistance with the task.

(2) If partially met is selected then the amount of the assistance available is determined using one of four categories. Table 1 below is used to determine these percentages.

(a) Less than one-fourth of the time,

(b) One-fourth to one-half of the time

(c) Over one-half of the time to three-fourths of the time

(d) Over three-fourths of the time.

Place illustration here.

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AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0055   Am I eligible for COPES-funded services?   You are eligible for COPES-funded services if you meet all of the following criteria. The department or its designee must assess your needs and determine that:

(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 or the activity did not occur (because you were unable or no provider was available) 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; or

(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; or

(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.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0055, filed 2/19/03, effective 3/22/03.]


AMENDATORY SECTION(Amending WSR 03-24-001, filed 11/19/03, effective 12/20/03)

WAC 388-72A-0060   Am I eligible for MPC-funded services?   You are eligible for MPC-funded services when the department or its designee assesses your needs and determines that you meet all of the following criteria:

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

(2) Have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) in at least three 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) You have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) with at least one or more of the following((, as defined in WAC 388-72A-0040)):

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

(b) Extensive assistance plus one person physical assistance 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.

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

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

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

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

(g) Daily assistance required in medication management; or

(h) 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.

(i) Extensive assistance plus one person physical assistance in dressing.

(j) Extensive assistance plus one person physical assistance in personal hygiene.

[Statutory Authority: RCW 74.08.090, 74.04.050, 74.04.057, 74.04.200, 74.09.520, 74.39.020, 74.39A.090, 2003 1st sp.s. c 25, 2003 c 140. 03-24-001, 388-72A-0060, filed 11/19/03, effective 12/20/03. Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0060, filed 2/19/03, effective 3/22/03.]


AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0065   Am I eligible for Chore-funded services?   To be eligible for Chore-funded services, you must:

(1) Be eighteen years of age or older;

(2) Have an unmet or partially met need or the activity did not occur (because you were unable or no provider was available) 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.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0065, filed 2/19/03, effective 3/22/03.]


NEW SECTION
WAC 388-72A-0069   How does CARE use the information the assessor gathers used?   CARE processes the information that the assessor gathers through an algorithm. An algorithm is a numerical formula utilized by the CARE assessment software that determines a classification group, payment level and referral needs based upon the information documented in the CARE assessment.

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AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0070   What are the in-home hours and residential rate based on?   The department employs a client classification methodology consisting of fourteen care groups. Twelve groups apply to clients served in residential settings, and for the in-home setting, two additional exceptional care groups apply. The department uses ((an automated assessment tool known as the comprehensive assessment reporting evaluation ())CARE(() tool)) to assess client characteristics. CARE places clients in a classification group based on the assessment. For in-home settings, each classification group is assigned a base number of care hours.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0070, filed 2/19/03, effective 3/22/03.]


AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0080   What ((are the elements that)) criteria does the CARE tool ((evaluates for each of the criteria in WAC 388-72A-0075)) use to place a client in one of the classification groups?   The CARE tool ((evaluates for)) uses the following criteria to place a client in one of the classification groups:

(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)), as defined in WAC 388-72A-0081, by using the cognitive performance scale (CPS) and assigning a score from zero to six.

(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)), as defined in WAC 388-72A-0082.

(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)) symptoms, as defined in WAC 388-72A-0083

(4) ((Activities of daily living ())ADLs((),)) by scoring the amount of assistance ((the client needs)) received to perform ((ADLs)) ADL in the past seven days as defined in WAC 388-72A-0084.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0080, filed 2/19/03, effective 3/22/03.]


NEW SECTION
WAC 388-72A-0081   How is cognitive performance measured in the CARE tool?   The CARE tool uses a standardized tool called the cognitive performance scale (CPS) to evaluate a client's cognitive impairment. The CPS results in a score that ranges from zero (intact) to six (very severe impairment), as shown in Table 2 below. Answers to the following questions are used to determine a client's CPS score:

(1) Is the client comatose?

(a) No,

(b) Yes.

(2) What is the client's ability to make everyday decisions about tasks or activities of daily living in the seven days prior to the assessment?

(a) Independent -- Decisions about the client's daily routine are consistent and organized; reflecting the client's lifestyle, choices, culture, and values.

(b) Modified Independence/difficulty in new situations -- The client has an organized daily routine, was able to make decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations.

(c) Moderately impaired/poor decisions; unaware of consequences -- Decisions are poor and the client requires reminders, cues and supervision in planning, organizing and correcting daily routines. Client attempts to make decisions, although poorly.

(d) Severely impaired/no or few decisions or preferences regarding ADLs -- Decision making severely impaired, never/rarely makes decisions.

(3) How is the client able to make himself/herself understood (to those closest to him/her), to express or communicate requests, needs, opinions, urgent problems and social conversations, whether in speech, writing, sign language, symbols, or a combination of these including use of a communication board or keyboard?

(a) Understood -- The client expresses ideas clearly;

(b) Usually understood -- The client has difficulty finding the right words or finishing thoughts, resulting in delayed responses; or requires some prompting to make self understood.

(c) Sometimes understood -- The client has limited ability, but is able;

(d) Rarely/never understood.

(4) Does the client have short-term memory problem, which is defined as client's capacity to remember recent events; or does the client have delayed recall?

(5) Does the client have total dependence for self performance in eating as defined in WAC 388-72A-0037?

Place illustration here.

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NEW SECTION
WAC 388-72A-0082   How is clinical complexity measured within the CARE tool?   Clinical complexity is determined only when you have one or more of the following conditions and corresponding ADL scores:


Condition AND an ADL Score of
ALS (Lou Gehrig's disease) >14
Aphasia (expressive and/or receptive) >=2
Cerebral Palsy >14
Diabetes Mellitus (insulin dependent) >14
Diabetes Mellitus (noninsulin dependent) >14
Emphysema & (SOB (at rest or exertion) or dizziness/vertigo) >10
COPD & (SOB (at rest or exertion) or dizziness/vertigo) >10
Explicit terminal progrnosis >14
Hemiplegia >14
Multiple sclerosis >14
Parkinson disease >14
Pathological bone fracture >14
Pressure ulcers, areas of persistent skin redness

OR

Pressure ulcers, partial loss of skin layers

OR

Pressure ulcers, a full thickness lost

OR

Skin problem, skin desensitized to pain/pressure

OR

Skin problem, open lesions

OR

Skin problem, stasis ulcers

>=2
AND
Receives ulcer care

OR

(Received) or (needs and received) or (need met) pressure relieving device

OR

(Receive) or (needs and received) or (need met) turning/reposition program

OR

Receives application of dressing

OR

Receives wound/skin care

Quadriplegia >14
Rheumatoid Arthritis >14
Skin problem, burns

AND

Receives application of dressings

OR

Receives wound/skin care

>=2
Frequently incontinent, bladder

OR

Incontinent all or most of the time, bladder

OR

Frequently incontinent, bowel

OR

Incontinent all or most of the time, bowel

AND

Uses, has leakage, needs assistance

OR

Does not use, has leakage

OR

Any scheduled toileting plan

>10

Current swallowing problem and not independent in eating >10
Edema >14
Pain daily >14
Bowel program receives and needs >10
Dialysis, needs >10
IV nutritional support, needs

OR

Tube feedings, needs

AND

Total calories received per IV or tube was greater than 50%

OR

Total calories per IV or tube was 25-50%

AND

Fluid intake greater than 2 cups

>=2

Hospice care, needs >14
Injections, needs >14
Intravenous medications, needs >10
Management of IV lines, needs >10
Ostomy care, needs >=2
Oxygen therapy, needs >10
Radiation, needs >10
Range of motion, passive, receives and needs >10
Walking, training, receives and needs >10
Suction, needs >=2
Tracheostomy care, needs >10
Ventilator/respirator, needs >10

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Reviser's note: The spelling error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-72A-0083   How are mood and behaviors measured within the CARE tool?   (1) When you do not meet the criteria for clinical complexity as defined in WAC 388-72A-0082 or the criteria for exceptional care, as defined in WAC 388-72A-0085, or have a cognitive performance scale score of five or six (in-home only), as defined in WAC 388-72A-0082 the mood and behavior criteria listed in subsection (3) below determines your classification group.

(2) Each documented behavior within CARE is described as:

(a) Current which means it occurred within seven days of the assessment date, including the day of the assessment. Behaviors that are indicated as current must also include information about:

(i) Whether the behavior is easily altered or not easily altered; and

(ii) The frequency of the behavior.

(b) Past which means it occurred between eight days and five years of the assessment date. For behaviors indicated as past, the assessor determines whether the behavior is addressed with current interventions or whether no interventions are in place.

(3) CARE places you in the Mood and behavior classification group only if you have one or more of the following behavior/moods that meets the corresponding description in the status, frequency, and alterability column. No other moods or behaviors documented in CARE are pertinent to this group.


Behavior/Mood AND Status, Frequency & Alterability
Assaultive Current
Combative during personal care Current
Combative during personal care In past and addressed with current interventions
Crying tearfulness Current, frequency 4 or more days per week
Delusions In past, addressed with current interventions
Depression score >=14
Disrobes in public Current and not easily altered
Easily irritable/agitated Current and not easily altered
Eats nonedible substances Current
Eats nonedible substances In past, addressed with current interventions
Hallucinations Current
Hiding items In past, addressed with current interventions
Hoarding/collecting In past, addressed with current interventions
Mental health therapy/program Need
Repetitive complaints/questions Current, daily
Repetitive complaints/questions In past, addressed with current interventions
Repetitive movement/pacing Current, daily
Resistive to care Current
Resistive to care In past, addressed with current interventions
Sexual acting out Current
Sexual acting out In past, addressed with current interventions
Spitting Current and not easily altered
Spitting In past, addressed with current interventions
Breaks/throws items Current
Unsafe smoking Current and not easily altered
Up at night and requires intervention Current
Wanders exit seeking Current
Wanders exit seeking In past, addressed with current interventions
Wanders not exit seeking Current
Wanders not exit seeking In past, addressed with current interventions
Yelling/screaming Current, frequency 4 or more days per week

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NEW SECTION
WAC 388-72A-0084   How are ADL scores measured within the CARE tool?   CARE determines an ADL score ranging from zero to twenty-eight. The ADL scores are determined by looking at the self-performance coding for each of the ADLs listed below. Although assessed in CARE, bathing and medication management are not scored to determine the classification groups.

(a) Personal hygiene,

(b) Bed mobility,

(c) Transfers,

(d) Eating,

(e) Toilet use,

(f) Dressing,

(g) Locomotion in room,

(h) Locomotion outside room,

(i) Walk in room.

(2) CARE assigns a points value as described in the chart below. Only one score is used for the locomotion in room, locomotion outside of room and walk in room. The highest score of the three is used in determining the overall ADL score.


ADL Scoring Chart
If Self Performance is: Score Equals
Independent 0
Supervision 1
Limited assistance 2
Extensive assistance 3
Total dependence 4
Did not occur/no provider 4
Did not occur/client not able 4
Did not occur/client declined 0

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AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0085   How does the CARE tool evaluate ((the criteria elements)) for the two exceptional care classifications of in-home care?   ((The CARE tool evaluates the criteria elements for:

(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.)) Exceptional care classification groups for the in-home setting occur only when the following criteria are met in either of the diagrams below:


Diagram 1 of Condition
One of the following diagnoses:

Quadriplegia

Paraplegia

ALS (Amyotrophic Lateral Sclerosis

Parkinson's Disease

Multiple Sclerosis

Comatose

Muscular Dystrophy

Cerebral Palsy

Post Polio Syndrome

TBI (traumatic brain injury)

AND

ADL score of greater than or equal to 22 AND
(Needs) or (needs and received) or (need met)

Turning/repositioning program

AND

External catheter

or

Intermittent catheter

or

Indwelling catheter care

or

Bowel program

or

Ostomy care

AND

Needs active range of motion (AROM)

or

Needs passive range of motion (PROM) with provider code of:

03= Individual provider or agency provider

04= Self-directed care (individual provider only)

10= Private duty nurse

Diagram 2 of Condition
ADL score greater than or equal to 22 AND
(Needs) or (needs and received) or (need met)

Turning/repositioning program

AND
Need for AROM or need for PROM

and

Provider code of:

03= Individual provider or agency provider

04= Self-directed care (individual provider only)

10= Private duty nurse

AND
IV nutrition support or tube feeding

and

Total calories received per IV or tube was greater than 50%

and

Fluid intake greater than 2 cups

AND
Needs dialysis (with provider code of 03, 04, or 10_

or

Needs ventilator/respirator (with provider code or 30, 04, or 10)

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0085, filed 2/19/03, effective 3/22/03.]


NEW SECTION
WAC 388-72A-0086   How is the information in WAC 388-72A-0081 through 388-72A-0084 used to determine the client's classification payment group for residential settings?   The information in WAC 388-72A-0081 through 388-72A-0084 is used to place an applicant or recipient into one of the twelve residential classification groups, as shown in the table below.


Classification ADL Score Group
Group D

Cognitive performance score = 4-6

and

Clinically complex = yes

and

Mood/behavior = yes or no

ADL Score

18-28

D High (12)
ADL Score

13-17

D Med (11)
ADL Score

2-12

D Low (10)
Group C

Cognitive performance score = 0-3

and

Clinically complex = yes

and

Mood/behavior = yes or no

ADL Score

18-28

C High (9)
ADL Score

9-17

C Med (8)
ADL Score

2-8

C Low (7)
Group B

Mood & behavior = Yes

and

Clinically complex = no

and

Cognitive performance score = 0-6

ADL Score

15-28

B High (6)
ADL Score

5-14

B Med (5)
ADL Score

0-4

B Low

(4)

Group A

Mood & behavior = No

and

Clinically complex = No

and

Cognitive performance score = 0-6

ADL Score

10-28

A High (3)
ADL Score

5-9

A Med (2)
ADL Score

0-4

A Low (1)

[]


NEW SECTION
WAC 388-72A-0087   How is the information in WAC 388-72A-0081 through 388-72A-0085 used to determine the classification payment group for in-home clients?   You are placed in a classification group based upon the criteria outlined in WAC 388-72A-0081 through 388-72A-0085. The in-home classification system is comprised of fourteen classification groups as shown in the table below.


Classification ADL Score Group Base Hours of Group
Group E

Exceptional care = yes

and

Mood and behavior = yes or no

and

Cognitive performance score = 0-6

ADL Score

26-28

E High (14) 420
ADL Score

22-25

E Med (13) 350
Group D

Cognitive performance score = 4-6

and

Clinically complex = yes

and

Mood and behavior = yes or no

OR

Cognitive performance score = 5-6

and

Clinically complex = no

and

Mood and behavior = yes or no

ADL Score

18-28

D High (12) 240
ADL Score

13-17

D Med (11) 190
ADL Score

2-12

D Low (10) 145
Group C

Cognitive performance score = 0-3

and

Clinically complex = yes

and

Mood and behavior = yes or no

ADL Score

18-28

C High (9) 180
ADL Score

9-17

C Med (8) 140
ADL Score

2-8

C Low (7) 83
Group B

Mood and behavior = yes

and

Clinically complex = no

and

Cognitive performance score = 0-4

ADL Score

15-28

B High (6) 155
ADL Score

5-14

B Med (5) 90
ADL Score

0-4

B Low (4) 52
Group A

Mood and behavior = no

and

Clinically complex = no

and

Cognitive performance score = 0-4

ADL Score

10-28

A High (3) 78
ADL Score

5-9

A Med (2) 62
ADL Score

0-4

A Low (1) 29

[]

DETERMINING HOURS FOR IN-HOME SERVICES
AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0090   What are the maximum hours that I can receive for in-home services?   The maximum hours that you can receive for in-home services ((is)) are determined through the CARE tool. The maximum hours are based upon your classification group. The highest hours attached to an in-home classification group is four hundred twenty per month. These hours are based on criteria outlined in WAC 388-72A-0095.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0090, filed 2/19/03, effective 3/22/03.]


NEW SECTION
WAC 388-72A-0092   How are my in-home hours determined?   (1) A base number of hours is assigned to each classification group as described in WAC 388-72A-0087.

(2) In accordance with WAC 388-72A-0095 and 388-71-0460, the base hours are adjusted to account for informal support, paid by individual(s) or group(s) other than the department and support shared living circumstances.

[]


AMENDATORY SECTION(Amending WSR 03-05-097, filed 2/19/03, effective 3/22/03)

WAC 388-72A-0095   ((How are)) What additional criteria are considered to determine the number of hours I ((can)) will receive for in-home services ((determined))?   (1) In addition to criteria defined in WAC ((388-72A-0075, 388-72A-0080, and 388-72A-0085)) 388-72A-0081, 388-72A-0082, 388-72A-0083, 388-72A-0084, 388-72A-0087, or 388-71-0460, CARE will take into account ((your)):

(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 amount of informal supports available to fully or partially meet your needs as described in WAC 388-72A-0041.

(i) As shown in the following table, CARE determines the adjustment by placing a numeric value on the amount of assistance available to meet your needs and reduces the base hours assigned to the classification group using the values listed below for each ADL and IADL.


Meds Self Performance Status Assistance Available Value Percentage
Self administration of medications Rules for all codes apply except independent is not counted Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .9
1/4 to 1/2 time .7
> 1/2 to 3/4 time .5
> 3/4 time .3
Unscheduled ADLs Self Performance Status Assistance Available Value Percentage
Bed mobility, transfer, walk in room, eating, toilet use Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider= 1;

Did not occur/client declined and independent are not counted.

Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .9
1/4 to 1/2 time .7
>1/2 to 3/4 time .5
>3/4 time .3
Scheduled ADLs Self Performance Status Assistance Available Value Percentage
Dressing

personal hygiene

bathing

Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider= 1;

Did not occur/client declined and independent are not counted .

Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .75
between 1/4 to 1/2 time .55
between 1/2 to 3/4 time .35
> 3/4 time .15
IADLs Self Performance Status Assistance Available Value Percentage
Meal preparation

Ordinary housework

Essential shopping

Rules for all codes apply except independent is not counted. Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met < 1/4 time .3
between 1/4 to 1/2 time .2
between 1/2 to 3/4 time .1
> 3/4 time .05

(ii) The value percentage assigned to each specified ADL/IADL is summed and carried two decimal places. The resulting number is then divided by the number of qualifying ADL and IADL needs. If self-performance is coded as independent or did not occur/client declined then they are not qualifying ADLs and IADLs. The result is value A. Value A is then subtracted from one. This is value B. Value B is divided by three. This is value C. Value A and value C are summed. This is value D. Value D is multiplied by the "base hours" assigned to the client's classification group in WAC 388-72A-0087.

(b) Your environment, as described in the diagrams below.


Condition Assessment Status Assistance Available Ad On Hours
Offsite laundry facilities, which means the client does not have facilities in own home and the caregiver is not available to perform any other personal or household tasks while laundry is done. Yes. N/A N/A 8
Client is > 45 minutes from essential services (which means he/she lives more than 45 minutes one-way from a full-service market.) If yes, then the assistance available for this task is assessed by the response to essential shopping. Unmet N/A 5
Met N/A 0
Partially met <1/4 time 5
between 1/4 to 1/2 time 4
between 1/2 to 3/4 time 2
>3/4 time 2
Wood supply used as only source of heat. Yes Unmet N/A 8
Met N/A 0
Declines N/A 0
Partially met < 1/4 time 8
between 1/4 to 1/2 time 6
between 1/2 to 3/4 time 41
> 3/4 time 2

(c) Your living arrangement.

(i) If there is more than one client living in the same household, the status cannot be unmet for the following IADLs:

(A) Meal preparation,

(B) Housekeeping,

(C) Shopping,

(D) Wood supply.

(ii) If you and your paid provider live in the same household, the status must be met for the following IADLs:

(A) Meal preparation,

(B) Housekeeping,

(C) Shopping,

(D) Wood supply.

(2) The ((CARE tool will provide a)) hours identified in WAC 388-72A-0095(1)(b) are added to the resulting hours in WAC 388-72A-0095(1)(a). The result is the 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. The hours may be used to authorize:

(a) Personal care services (per WAC 388-72A-0055, 388-72A-0060, or 388-72A-0065);

(b) Home delivered meals (per WAC 388-72A-0055);

(c) Adult day care (per WAC 388-72A-055 or 388-15-652);

(d) ((Adult day health (per WAC 388-72A-055 or 388-15-653);

(c))) A home health aide (per WAC 388-72A-0055).

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.090. 03-05-097, 388-72A-0095, filed 2/19/03, effective 3/22/03.]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-72A-0115   When the department adjusts an algorithm, when does the adjustment become effective?   When the department adjusts an algorithm used to evaluate the information gathered by the CARE tool, the effective date of any change generated by the adjustment(s) shall be:

(1) Immediate for applicants;

(2) The first of the month following the month in which the adjustment was made when the adjustment may reduce the care level or hours; or

(3) At the time of the client's yearly review when the adjustment may increase the care level or hours.

[]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-72A-0040 What information does the assessor gather?
WAC 388-72A-0075 What does the CARE computerized assessment tool do with the client information entered by department staff?

Legislature Code Reviser 

Register

Washington State Code Reviser's Office