Original Notice.

Preproposal statement of inquiry was filed as WSR 99-10-010.

Title of Rule: Chapter 388-805 WAC, Certification requirements for chemical dependency service providers.

Purpose: Repeals chapter 440-22 WAC and WAC 440-44-020. Establishes the level of quality and patient care standards for chemical dependency service providers seeking certification by DSHS/DASA.

Statutory Authority for Adoption: RCW 70.96A.090.

Statute Being Implemented: Chapter 70.96A RCW.

Summary: DASA is proposing amendments to chapter 440-22 WAC. The key amendments proposed will:

•	Make changes to all sections pertaining to chemical dependency counselors (CDCs), CDC interns, and probation assessment officers as a result of the implementation of chapter 18.205 RCW, Chemical dependency professionals;
•	Update the agency certification fee sections by combining parts of chapter 440-44 WAC with chapter 388-805 WAC and adding procedural language;
•	Add new language defining patient noncompliance and agency reporting requirements for noncompliant patients participating in court referred treatment;
•	Add language to the intensive outpatient treatment section to clarify minimum treatment expectations for patients participating in treatment under deferred prosecution orders;
•	Add language to define outcomes evaluation;
•	Add essential requirements of chemical dependency services;
•	Add certification category for treatment alternatives to street crime (TASC) providers and services;
•	Eliminate application process for treatment providers offering off-site treatment services; and,
•	Make minor technical revisions to several sections to eliminate unnecessary rules and clarify others.

In addition, DASA received a directive from Secretary Lyle Quasim to consolidate all DSHS WAC chapters under one Title 388 WAC number. In response to this directive, chapter 440-22 WAC is being changed to its new designated number "chapter 388-805 WAC."

Reasons Supporting Proposal: The implementation of chapter 18.205 RCW, Chemical dependency professionals, made it necessary for DASA to make amendments to all sections of chapter 388-805 WAC that pertain to chemical dependency counselors (CDCs), chemical dependency counselor interns (CIs) youth chemical dependency counselors (YCDCs), and probation assessment officers (PAOs). In addition, other sections of chapter 388-805 WAC are subject to review and amendment as required by Governor Locke's Executive Order 97-02 and Secretary Quasim's April 17, 1997, Executive Order on regulatory improvement. The criteria used included: Need for the rule; statutory authority and intent; effectiveness and efficiency; clarity; coordination with other rules; cost; and fairness.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Dennis Malmer, Division of Alcohol and Substance Abuse, P.O. Box 45331, Olympia, WA 98504-5331, (360) 438-8086.

Name of Proponent: Department of Social and Health Services, Division of Alcohol and Substance Abuse, governmental.

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

Explanation of Rule, its Purpose, and Anticipated Effects: See above.

Proposal Changes the Following Existing Rules: See above.

A small business economic impact statement has been prepared under chapter 19.85 RCW.

The purpose of this chapter is to describe the standards and processes necessary for certifying chemical dependency treatment service providers.

The proposed amendments to this chapter include:

•	Changing all sections pertaining to qualifications for chemical dependency counselors (CDCs), CDC interns, and probation assessment officers in accordance with chapter 18.205 RCW called "Chemical dependency professionals." Note: These requirements now fall under the Department of Health, chemical dependency professionals (CDP) program requirements.
•	Adding procedures to agency certification fee sections.
•	Adding definitions of patient noncompliance and agency reporting requirements for noncompliant patients participating in court-referred treatment.
•	Clarifying minimum treatment expectations for patients participating in intensive outpatient treatment under deferred prosecution orders.
•	Specifying outcomes evaluation requirements.
•	Adding the essential requirements of chemical dependency services.

This chapter has been rewritten in plain English, using a question and answer format to make it more understandable to our customers. Unnecessary rules have been eliminated and others have been clarified.

SMALL BUSINESS ECONOMIC IMPACT STATEMENT: Chapter 19.85 RCW, the Regulatory Fairness Act, requires that the economic impact of proposed regulations be analyzed in relation to small businesses and that it outlines the information that must be included in a small business economic impact statement (SBEIS). Preparation of an SBEIS is required when a proposed rule has the potential of placing a more than minor economic impact on business. DASA has analyzed the proposed amendments to its rules and has determined that small businesses will be impacted by these changes with some costs considered "more than minor."

INDUSTRY ANALYSIS: DASA is responsible for certifying chemical dependency treatment agencies. As part of its monitoring, DASA keeps a current internal database that identifies all certified agencies. Since internal industry information can be obtained at a more accurate level than is required by chapter 19.85 RCW, it is unnecessary to conduct an industry analysis using the four-digit standard industrial classification (SIC) codes.

DASA has determined that there are one hundred twenty-six existing agencies (private and for-profit) that meet the criteria for small businesses under RCW 19.85.020.

INVOLVEMENT OF SMALL BUSINESSES: Many small businesses have been involved in writing the proposed rules and in ascertaining the costs associated with proposed rule changes. DASA engaged assistance of a writing group, which included representation from small businesses, and met and talked several times with a number of small businesses to consider costs that would impact their businesses.

COST OF COMPLIANCE: To consider costs of compliance, DASA has elected to look at cost per patient. This is because:

•	Patients drive the businesses that provide chemical dependency treatment and so using the cost per patient is a more accurate depiction of costs than costs per employee;
•	Business decisions and planning are based on the number of patients served; and,
•	The number of patients also influences the total amount that the most significant proposed changes will cost.

Chemical dependency treatment facilities that are considered small businesses serve an average of two hundred patients per year.

Cost of Outcomes Evaluations: The major cost anticipated by small businesses for proposed rule changes is the new requirement for outcomes evaluations (WAC 388-80-350). This requirement has been added to assess and improve patient outcomes since decisions about quality patient care will be based on outcomes derived from these evaluations. Programs may be developed, improved, and managed, based on the results of these evaluations.

Outcomes measurement is required at several times during a patient's involvement in treatment. All agencies must do an outcomes evaluation before treatment or at admission. This becomes the baseline measurement. In addition, outcomes evaluations must be conducted during at least two of the following times:

•	During treatment;
•	At discharge; or
•	After treatment.

The chemical dependency treatment providers determine the ways to meet this requirement for outcomes evaluations, including the random sample that they use.

There are agencies that already have outcomes evaluations as part of their programs. Eight of one hundred twenty-six small businesses exceed this requirement, since they are deemed by:

•	Joint Commission on Accreditation of Health Care Organizations (JCAHO);
•	CARF... The Rehabilitation Accreditation Commission (CARF); or
•	Council on Accreditation of Services for Families and Children, Inc. (COA).

The anticipated costs to conduct outcomes evaluation occur in the areas outlined in the chart below:

First Year	First Year Total per Average Number of Patients (200)	Subsequent Years	Subsequent Total per Average Number of Patients (200)
$816- $1,366	$4.08-$6.83 per patient	$216-$316	$1.08-$1.58 per patient

Disproportionate Economic Impact Analysis: When there are more than minor costs to small businesses as a result of proposed rule changes, the Regulatory Fairness Act requires an analysis to be done comparing these expenses between small businesses and 10% of the largest businesses. The costs identified with outcomes evaluations for small businesses would be considered by DASA to be "more than minor." Small businesses have expressed the most concern over this added requirement of all the other proposed rule changes submitted.

DASA looked at the possible disproportionate impact of this requirement on small businesses, as compared to 10% of the largest businesses. However, these largest businesses are deemed by DASA as already meeting or exceeding the outcomes evaluation requirement. They have met this requirement as part of their accreditation by JCAHO, CARF, or COA. Their accreditation costs average $5,000 every three years. Consequently, it is not possible to accurately delineate and compare costs between small businesses and 10% of the largest agencies. In its desire to be fair to small businesses and to meet the intent of the law, however, DASA has outlined ways to mitigate expenses for small businesses in meeting the new outcomes evaluation requirement.

Mitigating Expenses for Outcomes Evaluations: DASA has proposed a plan to mitigate expenses for small businesses. DASA will use one or more of the following to help small businesses meet the requirement for outcomes evaluations:

•	DASA will hire a consultant to develop policies, procedures, and written plans that would meet the requirements for outcomes evaluations for all chemical dependency service providers that wish to use them. This eliminates the need for individual agencies to develop policies and plans.
•	DASA will develop a package of public domain standardized outcomes evaluation questionnaires agencies could choose to use. This eliminates the need for individual agencies to develop or find evaluation questionnaires.
•	DASA will provide state-wide training to all staff through routine on-site technical assistance surveys and annual conferences. This would reduce the impact of training on staff time, since these events already are scheduled as part of staff time.
•	DASA will allow agencies to phase in outcomes evaluations over a two-year period.
•	Agencies have latitude in deciding what kind of random sample would work best in their own programs and how often to evaluate patients. They might start the first year with a smaller, though representative sample and increase that in subsequent years; or increase the number of times the patients complete outcomes evaluations after the first year the program is launched.

CONCLUSION: DASA has given careful consideration to the impact on small businesses of proposed rules in chapter 388-805 WAC, Certification requirements for chemical dependency service providers. In accordance with the Regulatory Fairness Act, chapter 19.85 RCW, DASA has analyzed impacts on small businesses and proposed ways to mitigate those costs associated with the new outcomes evaluation requirements. Other rule changes offer cost and time savings by eliminating, reducing, or streamlining requirements.

When beginning to assess costs, individual providers should consider measurable goals and objectives for their organization. These goals range from opening a new branch site, adding a women's program, or reducing the number of days for collecting patient fees. This planning activity requires provider time and should be an integral part of existing business planning rather than additional time and expense.

Once measurable goals and objectives are formalized, the provider should select a set of indicators (questions), i.e., Who to ask, when to survey, and how the data is collected and evaluated. An important step will be to use a survey form and process that meets the needs of the provider's efforts to improve services. For example, one provider may be concerned with telephone access to services, while another is interested in measuring patients' perceptions of counselor respect for their ethnicity. Lists of indicators are available from a number of sources. Providers can elect to use surveys developed by sources in the public domain. In addition, The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), and the National Institute on Drug Abuse (NIDA) have free or inexpensive resources.

Survey formats can combine efficiency, effectiveness, and patient satisfaction questions on one form. The formats can be done in a word processing program.

Time needs to be invested in the process. A protocol (procedures) needs to be written. Training would need to be offered for staff members. The survey needs to be tested on a sample of patients if an agency chooses a customized survey form rather than one from the public domain, which has already been standardized.

Costs can vary by size of the organization. A small provider might invest a day of staff time of the director and the staff involved in the process. A larger organization would need more coordination, opinions, and training.

An important consideration to the whole process is confidentiality and anonymity. Outcomes evaluation is covered under program audits as an exception to federal confidentiality regulations. Individual releases are not required, but providers should obtain a notification and acknowledgment signature during the admission process to authorized patient participation in outcomes evaluation. Patients must have some assurance of confidentiality and anonymity so that they will respond as candidly as possible. Choosing not to participate in outcomes evaluation should always be an option to the patient.

An agency staff member needs to be accountable for receiving the surveys, as well as confidential storage (some surveys might contain patient identifying information). The amount of storage space would equal the number of surveys the provider expects to receive and store. The provider should use existing document destruction procedures once the data is processed and validated (entered and checked for key entry accuracy).

Evaluation of the results can be as simple as reviewing the narrative comments on the survey forms, to using a spreadsheet program to create charts and tables. Data can be tabulated by hand for smaller samples. The result is not research, but simple histographs and trend charts.

A well thought-out utilized outcomes evaluation and patient satisfaction measurement system should result in increased operating effectiveness, efficiency, and better patient outcomes. Increased customer satisfaction should result in increased census and improved treatment compliance, both of which imply an operation that is more efficient. Providers would also have a process to discover opportunities for new services and to reach out to new populations within their communities. Increased revenue could be measured by setting goals on census and profit margins for different programs within an agency.

What are examples of a small business implementing outcomes evaluations? Agency A is a small, for-profit chemical dependency treatment provider in Washington state. Agency A has two hundred patients participating in treatment across various levels of care. About twenty to twenty-five patients are participating in intensive outpatient treatment services, sixty to seventy-five patients are attending outpatient continuing care groups on a weekly basis, and one hundred to one hundred twenty patients are attending monthly outpatient groups.

Agency A is owned and operated by Mr. Jones. He is a chemical dependency professional (CDP) and conducts many of the agency assessments. Mr. Jones employs three full-time CDPs, a receptionist, and a part-time bookkeeper.

Mr. Jones determines that he will consult with a person about outcomes evaluations, develop his plan after consultation, train his staff members, and conduct outcomes measurement on his own. He determines that he will evaluate 10% of the patients completing intensive outpatient and outpatient treatment at his agency. He understands that this means he needs ten patients (10% of one hundred patients) to complete baseline questionnaires, i.e., one questionnaire during treatment and one questionnaire after treatment. Because Mr. Jones has decided to conduct an evaluation after treatment (which is more difficult and costly), he realizes he will need more than ten patients completing the baseline questionnaire. Mr. Jones decides to ask fifty patients to complete his questionnaire at the time of admission. He believes that of the fifty original patients completing the admission baseline measurement, about forty to forty-five will complete intensive outpatient treatment. Of that number, about thirty to thirty-five will likely complete outpatient treatment. Mr. Jones believes that of the thirty to thirty-five patients completing outpatient treatment, he should be able to mail out and receive ten questionnaires at six months post discharge.

Cost Assumptions: Plan A.

Administrative costs for retaining a consultant to work with Mr. Jones: Consultant X will charge Mr. Jones $375 for an eight-hour day, plus expenses. The approximate cost is $450. In addition, Mr. Jones spends eight hours of his time or about $200 while working with his consultant.

Consultant X assists Mr. Jones in beginning to understand outcomes evaluations, develops policies and procedures for outcomes evaluation, and recommends some forms for use.

Administrative costs for Mr. Jones to ensure policy/procedure development is accurate, and that he has a documentation process: Four hours @ $25=$100 which is incurred when developing or updating program descriptions.

Administrative costs for Mr. Jones to determine which standardized or customized evaluation forms he will use: Four hours @ $25=$100.

Mr. Jones then determines that he will conduct staff orientation and training based upon new information, which is the policies and procedures developed with the help of a consultant, and he will distribute copies of the forms he has chosen to use for evaluation. Mr. Jones schedules a four hour training with the staff members. He will use a total of twelve hours of his CDPs' time @ $12 per hour, or $144, plus $100 of his time, and another $75 for reception and bookkeeping time, for a total of $319.

The estimated total cost for hiring a consultant to provide Mr. Jones with orientation, preparing policies and procedures, selecting tools to use, and staff orientation is $1,169.

Mr. Jones then develops his plan to administer the questionnaire he has chosen to use from the public domain. He was not required to pay for this tool since it is in the public domain. He selected a tool that will provide him with some measures of effectiveness, efficiency, and patient satisfaction.

His staff members (CDPs) will give the questionnaire to patients to complete during the patients' intake session. For that reason, there is no staff cost associated with this function. Mr. Jones will ask his receptionist to develop a manual checklist/spreadsheet so she can begin recording patient satisfaction measures concurrently. The effectiveness measures will be placed in the patient record until selected for post treatment analysis. The receptionist will enter data from fifty questionnaires (patient satisfaction information) at an estimated cost of $25 (three hours). Questionnaires will be distributed to patients completing intensive outpatient and outpatient treatment as determined by Mr. Jones. Questionnaires will be distributed to patients during discharge interviews with their primary CDP. Therefore, costs will not increase since patients currently participate in a discharge interview.

At six months, Mr. Jones' receptionist will mail out thirty post discharge questionnaires at an estimated cost of $30. Ten questionnaires are returned to the agency, in self-addressed stamped envelopes provided by the agency.

Total estimated costs for data tabulation of patient satisfaction measures and mailing thirty post treatment questionnaires is $55.

Mr. Jones will then evaluate, tabulate, and develop a written summary of the outcomes evaluation questionnaires received.

Administrative costs for evaluation of data, report preparation, and utilization of results: Six hours @ $25=$150.

Mr. Jones determines that he will share the positive results and opportunities for improvement at his next regularly scheduled staff meeting. Since Mr. Jones conducts routine staff meetings, his costs are assumed in this model.

The final cost factor includes the cost of printing questionnaires. Since Mr. Jones selected an evaluation tool, which consisted of two sheets of paper, he can reproduce a questionnaire for about five cents. He uses one hundred twenty questionnaires per year so his estimated printing costs will be about $6 per year.

Total estimated costs for initial implementation of outcomes evaluation at Agency A is $1,169. Annual, on-going costs to maintain outcomes evaluation are $211 per year.

Cost Assumptions: Plan B.

If Mr. Jones considered the initial costs of hiring a consultant to help him design questions to implement outcomes evaluation, he could recommend the Department of Social and Health Services (DSHS), Division of Alcohol and Substance Abuse (DASA) develop a plan to reduce his costs. Note: Some of these are ways that DASA can mitigate costs.

Mr. Jones could recommend that DASA hire a consultant to develop policies, procedures, and written plans that would meet the requirements for outcomes evaluations. He could request that DASA gather copies of all public domain questionnaires at the national level for consideration by certified agencies. He might recommend DASA develop policies and procedures in an electronic format that could be sent to Mr. Jones on his e-mail system.

Mr. Jones could also recommend that DASA invest in training agency administrators, clinical staff members, and other interested persons about outcomes evaluation. DASA could conduct training state-wide, begin offering technical assistance about outcomes evaluation during routine on-site technical assistance surveys, and provide training at annual conferences.

Therefore, Mr. Jones could reduce expenses significantly. He would save $450 of consultant time, $100 in preparing policies and procedures, and $100 in selecting questionnaires. He would pay a small fee to attend DASA sponsored training of about $25. His initial costs for implementing outcomes evaluation would decrease to $571 and estimated annual costs of $211 to maintain outcomes evaluation. Based upon the total number of patients at his agency, he could determine that it would cost about $2.86 per patient to implement outcomes evaluation and about $1.06 per patient per year to maintain outcomes evaluation.

To fully realize the benefits of an outcomes evaluation program at Agency A, Mr. Jones might also recommend that DASA consider a phase-in process for chapter 388-805 WAC. He could recommend that DASA provide training, policy/procedure development during the first year of implementation, while deferring data collection until the second year. Mr. Jones might also consider enrollment in the TARGET system as another method to collect data and ask DASA for computer software to implement this data collection system.

A copy of the statement may be obtained by writing to Dennis W. Malmer, Division of Alcohol and Substance Abuse, P.O. Box 45331, Olympia, WA 98504-5331, phone (360) 438-8086, fax (360) 407-5318, Internet e-mail malmedw@dshs.wa.gov.

RCW 34.05.328 applies to this rule adoption. A copy of the cost benefit analysis may be obtained by contacting the person listed above.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on August 22, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Fred Swenson by August 11, 2000, phone (360) 664-6097, TTY (360) 664-6178, e-mail swensfh@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, by August 22, 2000.

Date of Intended Adoption: No sooner than August 23, 2000.

June 13, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 00-15 issue of the Register.

© Washington State Code Reviser's Office