Original Notice.

Preproposal statement of inquiry was filed as WSR 00-23-049.

Title of Rule: New WAC 388-71-05910 through 388-71-05954, Individual provider and home care agency provider qualifications; amending WAC 388-71-0500, 388-71-0520 and 388-71-0540; and repealing WAC 388-71-0525, 388-71-0530, and 388-71-0535.

Purpose: To implement SSB 6502 (chapter 121, Laws of 2000) on training requirements for individual providers and home care agency providers under Medicaid in-home services.

Statutory Authority for Adoption: RCW 74.39A.050, 34.05.020.

Statute Being Implemented: Chapter 121, Laws of 2000.

Summary: Implements requirements for staff and individual provider orientation in Medicaid home care; implements processes for approval of instructors.

Reasons Supporting Proposal: Implementing statutes referenced above.

Name of Agency Personnel Responsible for Drafting: Dotti Wilke, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2539; Implementation and Enforcement: Marta Acedo, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2549.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: This rule implements RCWs on training for Medicaid home care (agency and individual providers). The new requirements in the RCW is an orientation for in-home providers. The rule also describes the process for approval of instructors for certain trainings.

Proposal Changes the Following Existing Rules: This proposal moves existing rules into one new rule.

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

The purpose of this chapter is to:

&sqbul;	Define minimum training requirements;
&sqbul;	Define the types of training;
&sqbul;	Clarify instructor requirements; and
&sqbul;	Establish department procedures for approval of instructors.

The statutory authority for this chapter is RCW 74.39A.050 Long-term care services options -- Expansion.

The major proposed changes are:

&sqbul;	Incorporating a new requirement for orientation training for new staff, as required in chapter 74.39A RCW; and
&sqbul;	Creating an approval system for trainers as required by the RCW.

Background of the proposed rule:

In 1995, as part of long-term care reform, the legislature allocated funds for training during the following year. Providers and caregivers who were trained included:

&sqbul;	Caregivers in boarding homes that contract with DSHS;
&sqbul;	All licensed adult family home providers and caregivers; and
&sqbul;	Home care agency providers and individual providers serving clients through the Medicaid personal care, COPES, and chore programs.

In 1997, two task forces were created under the auspices of the legislature to review caregiver training:

&sqbul;	The Joint Executive-Legislative Long Term Care Task Force's subcommittee on training. This task force reported to the legislature in December 1998 and January 2000.
&sqbul;	The training task force, which was the responsibility of DSHS, the Department of Health, and the Nursing Care Quality Assurance Commission, was directed to review caregiver training. This task force reported to the legislature in December 1998.

The new training requirements created by legislation in the 2000 session were based largely on the recommendations from the two task forces. This same legislation created the Community Long Term Care Education and Training Steering Committee to advise the department on the development of rules to implement the new law (see RCW 74.39A.190.)

Goal for the proposed rules: The goal for this chapter is to ensure that all caregivers have an orientation when they begin to work with clients or residents.

Training improves caregiving skills and the quality of care delivered to more than 20,000 adults receiving care through these programs.

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. This statute outlines 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 disproportionate economic impact on small businesses.

Aging and Adult Services Administration has analyzed the proposed amendments to their rules and has determined that small businesses will be impacted by these changes, with some costs considered "more than minor."

INDUSTRY ANALYSIS: The Department of Health is responsible for home care agency licensing. As part of licensing, this state agency keeps current internal databases that identify all licensed 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.

INVOLVEMENT OF SMALL BUSINESSES: The data used in this analysis was gathered from several sources:

&sqbul;	The statewide organizations that represent the fifty-eight home care agencies affected, and
&sqbul;	The Department of Health licensing information for home care agencies.

The organizations that contributed current data on wages, benefits, and cost estimates for the businesses they represent, most of which are small businesses, include: The Home Care Association of Washington and the Washington State Association of Home Care Services.

The rule has been developed with the advice of the training steering committee, which has been meeting monthly for fifteen months to consider and recommend the rules to implement these laws. The small businesses affected are represented on the committee by the statewide provider organizations listed above.

In addition, four public forums were held during the summer (in Bellevue, Lacey, Spokane, and Yakima) to discuss the rule development and take public comment on the proposed rules as recommended by the steering committee. Approximately 2000 interested parties were invited; seventy-seven people attended and commented.

AASA staff also have regularly attended meetings with home care providers for the past year to update them on the rule development and take their comments and suggestions. To reach those who could not attend meetings, the proposed rules as recommended by the steering committee have been posted on the AASA Internet web site, with contact person information for anyone wishing to comment or make suggestions on the rule. All the input from these various groups and meetings has helped shape the development of this rule.

COST OF COMPLIANCE: Costs related to record keeping: Each business must keep on file copies of certificates showing successful completion of required trainings for each of their employees. The only new record-keeping requirement for home care agencies is orientation. Keeping orientation certificates on file will result in a minor cost to the business.

Estimated training costs: Expected costs include:

&sqbul;	The trainer's wages and benefits (on-staff trainers are used for orientation);
&sqbul;	The trainee's wages and benefits; and
&sqbul;	Costs for training materials.

See Table 1, below, for estimated costs.

To fairly consider costs of compliance, AASA has elected to look at costs per trainee. This is because there is no reliable data on the number of employees that will be required to have this training, or the rate of turnover, both of which affect total training costs.

The most costly wage scenarios were used for cost estimates. These include using a registered nurse who is on staff as the orientation trainer, and assuming a one-on-one training, rather than group training. Circumstances that may be used to mitigate these costs are noted in the section on mitigating expenses.

Orientation	Personnel, other costs	Wages	Benefits & Taxes	Total per hour	Hours	Total Cost
	Trainer (RN)	$24.24	$6.14	$30.38	2	$60.76
	Trainee	$7.68	$2.19	$9.87	2	$19.74
	Materials					$10.00
	Total per trainee					$90.50

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 costs between small businesses and ten percent of the largest businesses.

About 17% of home care agencies have more than fifty employees (Department of Health licensing data, 2001), but some are nonprofits. While the per-trainee costs do not differ between small and large businesses, the costs may be a higher proportion of overall costs for a small business. AASA elected to focus on mitigating expenses for small businesses regardless of actual figures resulting from an analysis comparing large and small businesses. AASA proposes several measures that will mitigate the cost impact for small businesses, thus helping them more easily comply with additional training requirements.

Mitigating Expenses: Aging and Adult Services Administration has included the following to help mitigate training costs for small businesses:

&sqbul;	Orientation of home care agency staff is already required under home care licensing, chapter 246-336 WAC. Many of the specific topics required in chapter 388-71 WAC may already be included in the orientation that agencies currently provide their staff.
&sqbul;	Orientation training costs can be significantly reduced if the person doing the orientation is not an RN (high wage rate). For instance, an RN's median hourly wage is estimated to be $24.24. If an LPN does the orientation, the hourly wage drops to $15.72; if a social worker does the orientation, the hourly wage is $18.74. Both LPNs and social workers are qualified to do this training. The agency has a choice of which staff to use for conducting the orientation training, and may save money with these other choices.
&sqbul;	Orientation training costs are further reduced if the agency orients more than one person at a time. This can be done any time the agency hires several new caregivers and has them start working at the same time. By doing this, the cost for the trainer's time is spread across several trainees, reducing the per trainee cost.
&sqbul;	Individuals who have already been oriented at another agency can have a much briefer orientation at a new agency, which is a saving for the second business. The orientation can be shorter because basic information on the required topics will be consistent across agencies. The agency will be able to spend less time on basic information, and focus primarily on information specific to the agency.

Additional cost savings: There are additional, overall cost savings for small businesses with the new training requirements, which are important to mention.

&sqbul;	The orientation reduces the time it takes new employees to begin to provide quality care to clients, translating into better care and higher satisfaction for the clients, and improved word-of-mouth publicity for the agency, which may increase income for the agency.
&sqbul;	Well-trained employees generally have higher job satisfaction and this leads to a lower turnover rate, significantly reducing overall costs. Turnover rates have been estimated as 50% or higher per year, for caregivers. Village Green, a Washington state boarding home, determined that monthly turnover for caregivers dropped from 21% to under 5% after implementing a thorough orientation program.

CONCLUSION: Aging and Adult Services Administration has given careful consideration to the impact of proposed amendments to chapter 388-71 WAC, Social services for adults, on small businesses. In accordance with the Regulatory Fairness Act, chapter 19.85 RCW, Aging and Adult Services Administration has analyzed impacts on small businesses and proposed ways to mitigate those costs associated with implementing the training requirements in these rules. The new requirements being implemented in these rules are contained in chapter 74.39A RCW. The proposed WAC amendments expand on the information in the RCW to assist providers in successfully meeting the new requirements. Training staff adequately to care for adult clients is a benefit to both the client and the provider.

A copy of the statement may be obtained by writing to Tresa Harambasic, Aging and Adult Services Administration, P.O. Box 45600, Olympia, WA 98504-5600, phone (360) 725-2548, fax (360) 725-2646.

RCW 34.05.328 applies to this rule adoption. A cost-benefit analysis has been prepared concerning these proposed rules, and may be obtained by contacting Tresa Harambasic, Aging and Adult Services Administration, P.O. Box 45600, Olympia, WA 98504-5600, phone (360) 725-2548, fax (360) 725-2646.

Hearing Location: Office Building-2 Auditorium, DSHS Headquarters, 1115 Washington, 14th and Jefferson, Olympia, WA 98504, on January 8, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by January 4, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by 5:00 p.m., January 8, 2002.

Date of Intended Adoption: Not earlier than January 9, 2002.

November 14, 2001

Brian H. Lindgren, 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 01-24 issue of the Register.

Washington State Code Reviser's Office