DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Aging and Long-Term Support Administration)

The following definitions apply to WAC 388-71-0702 through 388-71-0776:

(1) "Abuse" means the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment of a vulnerable adult.

(a) In instances of abuse of a vulnerable adult who is unable to express or demonstrate physical harm, pain, or mental anguish, the abuse is presumed to cause physical harm, pain, or mental anguish.

(b) Abuse includes sexual abuse, mental abuse, physical abuse, personal exploitation of a vulnerable adult, and improper use of a restraint against a vulnerable adult, which have the following meanings:

(i) "Sexual abuse" means any form of nonconsensual sexual conduct, including but not limited to unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing, and sexual harassment. Sexual contact may include interactions that do not involve touching, including but not limited to sending a client sexually explicit messages, or cuing or encouraging a client to perform sexual acts. Sexual abuse also includes any sexual conduct between a staff person, who is not also a client, with a client, of a center.

(ii) "Physical abuse" means the willful action of inflicting bodily injury or physical mistreatment. Physical abuse includes, but is not limited to, striking with or without an object, slapping, pinching, choking, kicking, shoving, prodding, or use of chemical or physical restraints unless the restraints are consistent with licensing requirements, and includes restraints that are otherwise being used inappropriately.

(iii) "Mental abuse" means a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces, intimidates, isolates, unreasonably confines, or punishes a vulnerable adult. Mental abuse may include ridiculing, yelling or swearing.

(iv) "Personal exploitation" means an act of forcing, compelling, or exerting undue influence over a vulnerable adult causing the vulnerable adult to act in a way that is inconsistent with relevant past behavior, or causing the vulnerable adult to perform services for the benefit of another.

(2) "Adult day care" or "ADC" means a supervised daytime program that provides services under WAC 388-71-0704 for clients who meet the eligibility requirements in WAC 388-71-0708.

(3) "Adult day center" means an adult day care or adult day health center.

(4) "Adult day health" or "ADH" means a supervised daytime program that provides ADC services under WAC 388-71-0704 and skilled services under WAC 388-71-0706 for clients who meet the eligibility requirements in WAC 388-71-0710.

(5) "Adult day services" is a generic term that refers to adult day care and adult day health services.

(6) "Authorizing practitioner" means a physician, osteopath, nurse practitioner, or physician assistant who has the licensed ability to write medical orders for skilled care and interventions that require a practitioner order.

(7) "Chemical restraint" means the administration of any drug to manage a vulnerable adult's behavior in a way that reduces the safety risk to the vulnerable adult or others, has a temporary effect of restricting the vulnerable adult's freedom of movement, and is not standard treatment for the vulnerable adult's medical or psychiatric condition.

(8) "Chronic-care management" means regular monitoring of the client's chronic health condition, training the client and caregiver, providing treatments or interventions when warranted and regular communication with primary care practitioners and caregivers to help implement and keep current the clinical care plan while ensuring the treatments have the intended effect of improving health, maintaining health, or slowing declining health when the diagnosis is a nonreversible condition.

(9) "Client" or "participant" means a person who receives services at an adult day center.

(10) "Department service plan" means a client's comprehensive assessment reporting evaluation (CARE) assessment including personal care and skilled care needs.

(11) "Direct care staff" are staff in an adult day center that interact with participants by providing care, services, and guidance.

(12) "The discharge plan" is a plan that outlines specific measurable goals expected to occur due to individualized treatments provided to a participant, indicating discharge is appropriate. This plan is developed and addressed on the participant's ADC and ADH negotiated care plan and is updated with each significant change of condition or when the client partially or completely meets the expected measurable goal(s). Planned discharge outcomes reflect the end of treatment because the client meets the measurable outcomes or he or she is unable to participate in or benefit from treatment.

(13) "Involuntary seclusion" means the involuntary confinement of a client to a room or area where the client is physically prevented from leaving.

(14) "Medical device" means any piece of medical equipment used to treat a client's assessed need. A medical device is not always a restraint and should not be used as a restraint, unless assessed and approved by a physician or primary care provider. Some medical devices have considerable safety risks associated with use. Examples of medical devices with known safety risks may be, but are not limited to transfer poles, posey or lap belts, and side rails.

(15) "Maintenance" is continuing clinically appropriate skilled services that are justified as reasonable, necessary, and appropriate to sustain minimal loss of function. Maintenance interventions have discharge measurable goals that outline when maintenance skilled services are no longer beneficial.

(16) "Medically necessary" means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions in the client that endangers life, causes suffering or pain, results in an illness or infirmity, threatens to cause or aggravate a disability, or causes physical deformity or malfunction.

(17) "Negotiated care plan" means a client centered, goal specific service plan that outlines the specific needs of the client, contains measurable, achievable, and realistic goals for the client, states how the adult day center will meet the assessed and agreed upon needs, when the assessed and agreed upon needs will be met, and by what discipline the assessed and agreed upon needs will be met.

(18) "Physical restraint" means the application of physical force without the use of any device, for the purpose of restraining the free movement of a vulnerable adult's body. "Physical restraint" does not include briefly holding, without undue force, a vulnerable adult in order to calm or comfort him or her, or holding a vulnerable adults hand to safely escort him or her from one area to another. 

(19) "Preliminary service plan" means the initial intake, evaluation, and preliminary care plan including the client's strengths, deficits, and potential needs. The adult day center must determine based on the preliminary service plan whether they can meet those needs and accept the client into the adult day program.

(20) "Rehabilitative service" means a service provided using applicable physical therapy, occupational therapy, or speech therapy standards of practice and is considered medically necessary if the type, amount, and duration of service outlined in the plan of care increases the likelihood of meeting one or more of the following goals: Improve function, minimize loss of function, improve cognition or minimize loss of cognition, or decrease risk of injury and disease.

(21) "Significant change" means:

(a) A lasting change, decline, or improvement in the client's baseline physical, mental, or psychosocial status;

(b) The change is significant enough so that the current assessment or negotiated care plan does not reflect the client's current status; and

(c) A new assessment may be needed when the client's condition does not return to baseline within a two week period of time.

(22) "Skilled nursing services" means services that are reasonable and necessary for the treatment of a client's illness or injury and are consistent with the unique nature and severity of the client's illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practices, including WAC 246-840-700, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last for a significant amount of time.

(23) "Specific goals" mean expected outcomes individualized to the client's need(s) that stipulate the measurable, detailed, and expected progress the client may make while receiving the service. The specific goals address the who, what, when, why, and how of the expected final outcome. If a client's specific goal is to prevent a decline in his or her condition, the goal must have measurable outcomes that identify the intervention to prevent the decline and how to measure this prevention. If you cannot measure the expected outcome of the clinical intervention then you are not preventing a decline.

(1) WAC 388-71-0702 through 388-71-0776 contains the eligibility requirements for ((COPES)) community options program entry system (COPES) waiver ((and)), roads to community living (RCL) ((demonstration funded)), or other agency approved funding for adult day care and adult day health services.

(2) These rules also contain the requirements that apply to adult day care ((or)) and adult day health centers that contract with the department, ((an)) area agency on aging, ((or)) other department designee to provide (([COPES waiver and RCL])) COPES waiver and RCL services to department clients, and adult day centers who are owned and operate on a private pay basis. Nothing in these rules may be construed as requiring the department, an area agency on aging, or other designee to contract with an adult day care or adult day health center.

(((2))) (3) An adult day ((services program)) center is a community-based program designed to meet the needs of adults with impairments through ((individual plans)) individualized goal specific plans of care. This type of structured, comprehensive, nonresidential program provides a variety of health, social, and related support services in a protective setting. ((By supporting)) Adult day centers support families and caregivers((, the goals are)) with the following goals:

(((i) To)) (a) Provide ((the)) an opportunity for the ((participant)) client to live in ((their)) his or her community;

(((ii) To)) (b) Provide the ((participant)) client with ((services,)) clinical and non((-))clinical services to meet ((their)) unmet ((skilled)) needs;

(((iii) To)) (c) Assist the ((participant)) client to maintain ((maximal)) maximum independence in ((their)) his or her activities of daily living (ADL); and

(((iv) To)) (d) Measure ((their)) the client's progress through ((the)) individualized interventions, as outlined in his or her negotiated care plan.

(4) An adult day ((services program)) center evaluates the client's needs ((of the participant served)) and offers services with goal specific interventions to meet those needs and enhance ((their)) his or her quality of life. The ((participants served attend)) client attends on a scheduled and planned basis. The ((centers evaluate the)) adult day center evaluates potential ((participants)) clients to determine if ((they are)) center is able to ((communicate with each participant in order to)) meet their identified ((need(s))) needs. Nothing in this generic description may be construed to modify the specific services or eligibility requirements referenced in ((the definition)) this chapter of adult day care and adult day health.

(1) Upon the department's or authorized case manager's referral of a ((COPES or RCL eligible)) community options program entry system (COPES), roads to community living (RCL), or other agency approved client ((by the department or authorized case manager)) to an ADC center, the ADC center ((will)) must respond in writing to the department or authorized case manager within two working days ((of)), acknowledging receipt of the referral and ((its)) the center's ability to process and evaluate the referred client. ((The ADC center must conduct an intake evaluation based on an interview with the client and/or the client's representative to assess the center's ability to meet the client's needs as identified in the department service plan.))

(2) The case manager will provide the client's department service plan to the ((adult day care provider)) ADC center within five working days after the client or client's representative has signed it.

(3) The ADC center ((will)) must schedule and conduct an intake ((evaluations visits)) and evaluation visit with the ((referral)) referred client ((and/or their)) or the client and his or her authorized representative to determine the client's willingness to attend the ADC center and evaluate the ADC center's ability to meet the ((needs of the client)) client's assessed needs and specific goals as defined in the client's department service plan. The intake and evaluation must be based on an interview with the client or the client and his or her authorized representative.

(4) Within ten ((working)) paid service days from the ((initial)) date ((of)) the client ((attendance at)) started attending the ((day care)) ADC center, the ADC center must complete and provide a preliminary service plan to the client or the client and his or her representative and the client's case manager that outlines the client's strengths, deficits, and potential needs. The ADC center must determine whether it can meet the client's needs, how ((those)) it will meet the client's needs ((will be met)), and whether ((to)) it will accept the client ((to)) into the program. The ADC center must not accept a client whose needs the center cannot meet. The ADC center ((will)) must document in the client's file the date ((he/she was)) it accepted the client into the ADC program. If the client is not accepted into the ADC program, the preliminary service plan must include the reason(s) why the client was not accepted.

(5) Within thirty calendar days of ((acceptance)) the date the client was accepted into the ADC program, the ((day care)) ADC center must work with the client ((and/or their)) or the client and his or her authorized representative to develop and complete a negotiated care plan signed by the client or the client's authorized representative and the ((day care)) ADC center.

(6) ((This care plan must be updated)) The negotiated care plan must limit the frequency of services to the number of days authorized in the department authorized service plan. The negotiated care plan must include:

(b) Update the negotiated care plan annually and ((when their)) whenever there is a significant change in the client's condition and needs((. The care plan when));

(c) Share the negotiated care plan with the client's case manager whenever it is updated, annually ((or)), and after a significant change((, must be shared with the client's case manager. The care plan must:));

(8) ((The negotiated care plan must limit the frequency of services to the number of days authorized in the department-authorized service plan)) The ADC center must report changes in the client's condition or unanticipated absences more than three consecutive scheduled days of service to the client's case manager within one week.

(b) The case manager may follow up with the client or the client and his or her representative and determine if any updates to the assessment, client's department service plan, or service authorizations are needed.

(1) Upon the department's or authorized case manager's referral of a ((COPES or RCL eligible)) community options program entry system (COPES), roads to community living (RCL), or other agency approved client ((by the department or an authorized case manager)) to an ADH center, the ADH center ((will)) must respond in writing to the department or authorized case manager within two working days ((of)), acknowledging receipt of the referral ((regarding its)) and the center's ability to process and evaluate the referred client.

(2) The ((department)) case manager ((will send)) must provide the client's ((signed)) department service plan to the ADH center within five working days after ((signature)) obtaining the client or client's authorized representative's signature on the service plan.

(3) The ADH center ((will)) must schedule and conduct an intake and evaluation ((visits)) visit with the referred client ((and/or their)) or the client and his or her authorized representative to ((assess)) determine the client's willingness to attend the ADH center and evaluate the ADH center's ability to meet the ((needs of the client)) client's needs as defined in the client's department service plan.

(4) Within ten paid ((days of service, the day health center must determine if it can meet the client's needs, whether to accept the client to the program, and how those needs will be met. The center must document in the client's file the date of acceptance into their program. The center must not accept a client whose needs the center cannot meet. The center will be reimbursed under WAC 388-71-0724 for any service days provided from the start of the intake evaluation if the case manager has authorized services. The written intake evaluation includes acceptance of the client to the center or reason(s) why not accepted, the development of the evaluation, and the preliminary service plan)) service days from the date the client started attending the ADH center, the center must complete an intake and evaluation and provide a preliminary service plan to the client or the client and his or her authorized representative and the client's case manager.

(e) The ADH center must provide the client, or the client's authorized representative, and the client's case manager, a copy of the evaluation and preliminary service plan within ten paid days of service.

(5) ((When the ADH center conducts the intake evaluation visits there must be a multidisciplinary assessment conducted based on an interview and evaluation of the client's strengths and deficits with the client or the client's representative to determine the center's ability to meet the client's adult day care service needs and potential adult day health needs as identified in the department service plan. If the department service plan indicates a nursing and/or rehabilitative need then during the intake evaluation period these professionals will conduct evaluations and assessment of the client's clinical/rehabilitative needs to determine if they can be met at the center)) The ADH center will be reimbursed under WAC 388-71-0724 for any service days provided from the state of the intake and evaluation, if the case manager has authorized services.

(6) ((The ADH center may provide up to ten days of paid service to the client to complete the evaluation with the development of a preliminary service plan to be provided to the client and the case manager.

(7))) Upon the department's or authorized case manager's approval ((by the case manager)) of the ((adult day health)) ADH center's preliminary service plan, the ((day health)) ADH center ((multidisciplinary team)) must obtain and provide to the case manager any required practitioner's orders for skilled nursing ((and)), rehabilitative therapy ((along with a copy of the preliminary service plan, according to department documentation requirements. Orders must indicate)) services, and medical devices that pertain to those services and interventions the ADH center is providing to the client under WAC 388-71-0712 through 388-71-0714. Orders from authorizing practitioners are not necessary for medical devices that are within the professional scope of practice of occupational or physical therapists working within the day center.

(iii) Include how often the client is to be seen by the ((authorized)) authorizing practitioner((.));

(v) Be reviewed, updated, or revised when a significant change occurs, at least annually, or sooner if required by the prescriber.

(b) The case manager or nursing services staff may follow up with the practitioner, or other pertinent collateral contacts, concerning the client's need for skilled services.

(c) Services ((may)) must not be authorized for payment without current practitioner orders ((and the client's consent to follow up with the practitioner)).

(((8))) (7) Within thirty calendar days of ((the client's)) acceptance into the program, the ((day health)) ADH center's multidisciplinary team must work with either the client or the client ((and/or their)) and his or her authorized representative to develop and complete a negotiated care plan signed by the client or the client's authorized representative and the ((day health)) ADH center. The negotiated care plan ((can)) may be developed ((initally [initially] in lieu of developing a)) initially in lieu of the preliminary service plan. ((The care plan must:

(a) Be)) (8) The negotiated care plan must be consistent with the department-authorized service plan ((and)), include all ((day health services)) authorized ADC and ADH services, limit the frequency of services to the number of days in the ((service plan;

(b) Include an)) department authorized ((practitioner's order(s) for skilled nursing and/or skilled rehabilitative therapy according to applicable state practice laws for licensed nurses or therapists. These authorizing practitioner orders must be reviewed, updated or revised when a significant change occurs or at least annually, or sooner if required by the prescriber;

(d) Document the client's needs as identified in the)) service plan, ((the authorized services that will be provided to meet those needs, and when, how, and by whom the services will be provided;)) and must include:

(((e) Establish time)) (a) A list of the care and services the ADH center will provide the client;

(b) Time specific, measurable, and individualized client goals((, not to exceed ninety days from));

(c) Who will provide the ((date of signature of the negotiated)) client's care ((plan, for accomplishing the goals of adult day health skilled)) and services ((and/or));

(h) Individualized discharging or ((transitioning the client to other appropriate settings or services)) transition goals;

(g) Document))

(i) Address potential behavioral issues identified in the assessment, service plan, or through the intake and evaluation((, and how those issues will be managed));

(((h) Document contingency plans for responding)) (ii) Follow in case of a foreseeable crisis due to a client's ((emergent care)) assessed needs ((or other crises; and));

(9) The adult day health center must keep the negotiated care plan in the client's file, provide a copy to the client or client representative, and a copy to the client's case manager, including any required authorizing practitioner orders.)) (iv) Respond to the client's special needs, including, but not limited to medical devices and related safety plans, and if medical devices are used, ADH center staff must ensure the medical device will not be used as a physical restraint for discipline or staff convenience, while attending the ADH center;

(10) The ((department)) client's case manager must review the negotiated care plan ((for inclusion of)) to ensure all services ((that)) are appropriate and all authorized ((for the client's)) care needs have been included.

(11) The ((day health center must review each service in the negotiated care plan every ninety days or more often if the client's condition changes, or if the client is reassessed for eligibility after a break in service of more than thirty days. Changes in the client's)) ADH center must report changes in the client's condition or unanticipated absences of more than three consecutive ((days of)) scheduled days of service ((must be reported)) to the client's case manager within one week.

(a) Unanticipated absences ((by way of example)) may include, but are limited to absences due to client illness or ((injury)) a change in transportation access.

(b) The case manager may ((follow-up)) follow up with the client or the client and ((determines)) his or her authorized representative and determine if any updates to the assessment, client's department service plan, or service ((plan, and service authorization)) authorizations are needed.

(1) Medical devices. When the adult day center staff use a medical device, it must not be used as a physical restraint for discipline or staff convenience.

(2) Physical restraints. When the adult day center staff provide services for a client, which may include but are not limited to transportation, outings, and services at the facility, the adult day center must ensure the client has a right to be free from physical restraints used for discipline or staff convenience.

(3) Chemical restraints. When the adult day center staff provide services for a client, which may include but are not limited to transportation, outings, and services at the facility, the adult day center must ensure the client is free from chemical restraints used for discipline or staff convenience.

(4) Involuntary seclusion. When the adult day center staff provides services for a client, which may include but are not limited to transportation, outings, and services at the facility, the adult day center must ensure the client's right to be free from involuntary seclusion or isolation used for discipline or staff convenience.

(5) Prevention of abuse. When the adult day center staff provides services for a client, which may include but are not limited to transportation, outings, and services at the facility, the adult day center must:

(a) Ensure the client's right to be free from abandonment, verbal, sexual, physical, and mental abuse, personal exploitation, financial exploitation, neglect, and involuntary seclusion;

(b) Protect the client who is an alleged victim of abandonment, verbal, sexual, physical, and mental abuse, personal exploitation, financial exploitation, neglect, and involuntary seclusion; and

(c) Meet the requirements of chapter 74.34 RCW regarding mandatory reporting.