DEPARTMENT OF HEALTH

[Filed March 10, 2025, 2:22 p.m.]

Preproposal statement of inquiry was filed as WSR 24-16-059.

Title of Rule and Other Identifying Information: Hospital at-home services. The department of health (department) is proposing rules to establish operating standards and fees for hospital at-home services. The department is proposing amendments to WAC 246-320-199 and creating new WAC 246-320-278 to add hospital at-home services as a type of service offered by hospitals. The rules establish operating standards and create a fee to cover the costs of reviewing applications for the hospital at-home program.

Hearing Location(s): On April 22, 2025, at 12:00 p.m., via Zoom. Register in advance for this webinar at https://us02web.zoom.us/webinar/register/WN_XdUpreKMRk-bq6B8qE9olA. After registering, you will receive a confirmation email containing information about joining the webinar. The department will be offering a virtual public hearing. You may also submit comments in writing.

Date of Intended Adoption: April 29, 2025.

Submit Written Comments to: Tiffani Buck, Department of Health, P.O. Box 47853, Olympia, WA 98504-7853, email ochsfacilities@doh.wa.gov, https://fortress.wa.gov/doh/policyreview/, beginning the date and time of this filing, by April 22, 2025, at 11:59 p.m.

Assistance for Persons with Disabilities: Contact Tiffani Buck, phone 564-233-1121, TTY 711, email ochsfacilities@doh.wa.gov, by April 8, 2025.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rules establish operating standards for acute care hospitals licensed under chapter 70.41 RCW and chapter 246-320 WAC to operate a hospital at-home program, expanding the location where hospital services can be provided. The department is proposing to create new WAC 246-320-278 to add hospital at-home services as a type of service that can be offered by hospitals and to create operating standards for hospital at-home care in rule. The proposed rules also establish an application process and a one-time application fee which is included in the proposed amendments to WAC 246-320-199. The fee is necessary to cover the costs of the hospital at-home program, including the review of hospital at-home applications.

Reasons Supporting Proposal: Early in the coronavirus disease 2019 (COVID-19) pandemic, Washington state and the federal government took steps to allow health care facilities to rapidly expand to meet the demands for acute hospital beds. Under the federal public health emergency, the Centers for Medicare and Medicaid Services created an acute hospital care at-home program. This program allowed licensed acute care hospitals to treat some patients in their home with similar services that would be provided in the hospital. At a state level, hospitals were permitted to participate in this program pursuant to waivers in Governor Inslee's COVID-19 emergency proclamation followed by the department's exercise of regulatory flexibility after those proclamations were rescinded.

In 2024, the legislature passed SHB 2295 (chapter 259, Laws of 2024), codified as RCW 70.41.550, which authorizes the continuation of hospital at-home services in Washington and directs the department to conduct rule making to establish operating standards for hospital at-home services. The intent of the statute is to allow hospitals licensed under chapter 70.41 RCW and chapter 246-320 WAC to continue to provide hospital at-home services while the department adopts rules, which must be adopted by December 31, 2025.

The proposed rules support the intent of the statute by establishing clear and enforceable standards for the operation of a hospital at-home program.

Statutory Authority for Adoption: RCW 43.70.110, 43.70.250, 70.41.030, and 70.41.100; and SHB 2295 (chapter 259, Laws of 2024), codified as RCW 70.41.550.

Statute Being Implemented: RCW 43.70.110, 43.70.250, and 70.41.550.

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

Name of Proponent: Department of health, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Tiffani Buck, 111 Israel Road, Tumwater, WA 98504, 564-233-1121.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is not required under RCW 34.05.328. The entire proposed rule is exempt from analysis under the following exemptions: Portions of the proposed rule adopt the federal regulations for hospital at-home services without material change and therefore are exempt under RCW 34.05.328 (5)(b)(iii), and portions of the rule only clarify language without changing the effect and are exempt under RCW 34.05.328 (5)(b)(iv). Portions of the rule are considered "procedural" as it creates a process for applying to an agency for a license or permit. These proposed rules by definition under RCW 34.05[.328] (5)(c)(i) are not subject to the cost-benefit analysis requirements. The proposed rule also adjusts fees and therefore that part of the proposed rule is exempt under RCW 34.05.328 (5)(b)(vi).

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules are adopting or incorporating by reference without material change federal statutes or regulations, Washington state statutes, rules of other Washington state agencies, shoreline master programs other than those programs governing shorelines of statewide significance, or, as referenced by Washington state law, national consensus codes that generally establish industry standards, if the material adopted or incorporated regulates the same subject matter and conduct as the adopting or incorporating rule; rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect; and rules set or adjust fees under the authority of RCW 19.02.075 or that set or adjust fees or rates pursuant to legislative standards, including fees set or adjusted under the authority of RCW 19.80.045.

Is exempt under RCW 19.85.025(4).

Explanation of exemptions: The entire proposed rule is exempt under RCW 19.85.025(4) as it only applies to licensed acute care hospitals which do not meet the definition of "small business" in RCW 19.85.020. The following exemptions also apply to WAC 246-320-278: RCW 34.05.310 (4)(c) and (d). WAC 246-320-199 is exempt under RCW 24-05-310 [ 34.05.310] (4)(f).

Scope of exemption for rule proposal:

Kristin Peterson, JD

for Jessica Todorovich, MS

Acting Secretary of Health

AMENDATORY SECTION(Amending WSR 24-16-045, filed 7/30/24, effective 11/1/24)

WAC 246-320-199Fees.

This section establishes the initial licensure and annual fees for hospitals licensed under chapter 70.41 RCW. ((The license must be renewed every three years.))

(1) Applicants and licensees shall submit to the department:

(a) An initial license fee for each bed space within the authorized bed capacity for the hospital;

(b) An annual fee for each bed space within the authorized bed capacity of the hospital by November 30th of the year;

(2) As used in this section, a bed space:

(a) Includes all bed spaces in rooms complying with physical plant and movable equipment requirements of this chapter for 24-hour assigned patient care;

(b) Includes level 2 and 3 bassinet spaces;

(i) Physical plant requirements of this chapter are met without movable equipment; and

(ii) The hospital currently possesses the required movable equipment and certifies this fact to the department.

(d) Excludes all normal infant bassinets;

(e) Excludes beds banked as authorized by certificate of need under chapter 70.38 RCW.

(3) A licensee shall submit to the department a late fee whenever the annual fee is not paid by November 30th. The total late fee will not exceed $1,200.

(4) Applicants and licensees shall submit to the department a one-time initial application fee if the applicant or licensee is applying to provide hospital at home services as described in WAC 246-320-278.

(5) An applicant may request a refund for initial licensure as follows:

(a) Two-thirds of the initial fee paid after the department has received an application and not conducted an on-site survey or provided technical assistance; or

(b) One-third of the initial fee paid after the department has received an application and conducted either an on-site survey or provided technical assistance but not issued a license.

(((5)))(6) The following fees will be charged:

Fee Type	Acute Care - Critical Access* Fee	Acute Care Fee
Initial Licensure Fee per bed	$380.00	$505.00
Renewal Licensure Fee per bed	$380.00	$505.00
Late Fee per day	$100.00	$100.00
One-time Hospital at Home Application fee	$5,800.00	$5,800.00

*	Federal designation.

WAC 246-320-278Hospital at home.

The purpose of this section is to guide the management and care of patients receiving hospital at home services as defined in RCW 70.41.550 (5)(a). Hospitals are not required to provide these services in order to be licensed. Hospitals must meet all inpatient service requirements in this chapter unless specified within this section. If providing hospital at home services, the hospital must:

(1) Provide or contract for the following services:

(a) Pharmacy;

(b) Infusion;

(d) Diagnostics like laboratory and radiology services;

(e) Patient monitoring with at least two sets of patient vitals daily;

(f) Transportation;

(g) Food and dietician services including meal availability as needed by the patient;

(h) Durable medical equipment;

(i) Physical, occupational, and speech therapy;

(j) Social work and care coordination;

(2) Adopt and implement detailed policies and procedures for:

(a) Meeting the pharmaceutical needs of each patient;

(b) Performing IV push and IV piggyback infusions;

(c) Providing respiratory care to patients including response times, the availability of oxygen delivery and treatment, nebulizer treatment, and any other respiratory services;

(d) Providing diagnostic studies including which laboratory studies, radiology tests, or other diagnostics are available, the expected time between the order placement and results, which diagnostic studies are unavailable in home, and how the hospital will provide services;

(e) Obtaining and delivering at least two sets of patient vital signs daily to an individual credentialed by the department of health that is working within the scope of their license and is part of the hospital team. Vital signs must include, at a minimum, heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature;

(f) Transporting patients between the emergency department and their homes, and back to the hospital if needed. Policies and procedures must include whether transport is provided by ambulance, nonambulance medical transport, or other means as medically appropriate;

(g) Providing meal services to patients to ensure the availability of meals as needed by the patient;

(h) Delivering the range of durable medical equipment that may be required during an acute hospital care at home admission;

(i) Delivering physical, occupational, and speech therapists to the home, including the ability to provide these services on same-day basis and during the course of an acute hospital care at home admission;

(j) Social work and care coordination teams. Policies and procedures must describe how these services will interact with patients and the discharge process;

(k) Selecting patients for acute hospital care at home. The policy must explain:

(i) If a published selection criteria is used or has been adapted or if criteria has been developed by the hospital;

(ii) All inclusion and exclusion criteria; and

(iii) A description of how the hospital ensures that only patients requiring an acute level of care are treated in the program;

(l) Staffing models that explain how the minimum level of oversight and care described in subsection (3)(c) and (e) of this section will be met;

(m) Technology and device use, staffing, and any limitations based on time of day or weekend;

(n) Meeting a 30 minute in-person response time with appropriate emergency personnel. The policy must:

(i) Include the algorithm and timing of each step in the process, including how to identify and correct response times that have not been met;

(ii) Describe which personnel will travel to the home;

(iii) Describe any partnerships with local paramedic groups or other professionals who will improve this response time; and

(iv) Detail equipment that will travel with this team;

(3) Ensure that:

(a) Each patient is admitted to acute hospital care at home from an emergency room or inpatient hospital;

(b) A provider with admitting privileges performs a history and physical exam in-person on each patient prior to admitting to the acute hospital care at home program;

(c) A physician, physician assistant, or advanced practice registered nurse must examine, remotely or in-person, each patient at least daily;

(d) There are at least two in-person visits by clinicians each day for each patient;

(e) There must be at least one in-person or remote visit with a registered nurse who develops and documents an individualized nursing plan;

(f) Each patient must be able to remotely connect to a hospital team member at all times;

(g) The hospital must meet a 30 minute in-person response time with appropriate emergency personnel;

(h) A minimum emergency response time can be met for each patient by providing:

(i) Immediate, on-demand remote audio connection with an acute hospital care at home team member who can immediately connect a registered nurse, physician, physician assistant, or advanced practice registered nurse to the patient; and

(ii) In-home appropriate emergency personnel team that can arrive at the patient's home within 30 minutes. This can be provided by 911 or emergency paramedics;

(4) Track and report data. Hospitals must:

(a) Track all data metrics required by the Centers for Medicare and Medicaid Services for hospital at home programs and must track, at a minimum, the following:

(i) Unanticipated mortality during the acute episode of care;

(ii) Escalation rate which for the purpose of this section is considered the transfer back to the traditional hospital setting during the acute episode;

(iii) Volume of patients treated in this program;

(b) Submit to the department, on request, all required hospital at home data;

(c) Establish a hospital safety committee to review required hospital at home data metrics or incorporate the review of hospital at home data into an existing safety or quality committee;

(5) Inform the department that the hospital intends to provide acute care hospital at home services. Hospitals must complete and submit application forms provided by the department and the application fee listed in WAC 246-320-199.