"Agency provider" means a long-term care worker who works for a home care agency.

"Area agencies on aging (AAA)" means a contracted entity that aging and long-term support administration (ALTSA) grants funds to in order to carry out the functions of the Older Americans Act, general-fund state programs and to provide case management services and supports to individuals 18 and older who receive medicaid-funded LTC in their own homes.

"Applicant" means a person who is in the process of becoming an in-home long-term care worker.

"Background check" means a name and date of birth check, or a fingerprint-based background check, or both.

"Background check result" is defined in WAC 388-113-0010.

"Background check central unit (BCCU)" means the DSHS entity responsible for conducting background checks for the department.

"Character, competence, and suitability determination (CC&S)" is defined in WAC 388-113-0050.

"Client" means an individual receiving medicaid-funded in-home long term services from the department.

"Department" means the department of social and health services or its designees.

"Family member" includes, but is not limited to a parent, child, sibling, aunt, uncle, niece, nephew, cousin, grandparent, grandchild, grandniece, grandnephew, or such relatives when related by marriage.

"Fingerprint-based background check" means a search of in-state criminal history records through the Washington state patrol and national criminal history records through the Federal Bureau of Investigation.

"Home care agency (HCA)" means an entity that is licensed by the department of health to provide home care services through a contract arrangement with the department to clients in places of permanent or temporary residence.

"Home care agency long-term care worker" means a long-term care worker who works for a home care agency.

"Long-term care worker" means direct care workers employed by home care agencies.

"Name and date of birth check" is a search conducted by the background check central unit (BCCU) of Washington state criminal history and negative action records using the applicant's name and date of birth.

"Negative actions" are listed in WAC 388-113-0030.

In order to be qualified as a long-term care worker, an applicant must:

(1) Not have a disqualifying crime or negative action under chapter 388-113 WAC based on a completed background check;

(2) Not be disqualified based on a character, competence, and suitability determination;

(3) Complete training and certification requirements listed in WAC 388-71-0520 and WAC 388-71-0523; and

(4) If required, have an active home care aide certification or other qualifying credential by the department of health.

(1) Agency providers are required to complete and pass a name and date of birth background check prior to working with a client.

(2) Agency provider workers are required to complete and pass a name and date of birth background check:

(a) Every two years; and

(b) Any time the home care agency employer requests a new check.

(3) In addition to the name and date of birth background check, agency providers are required to complete and pass a fingerprint-based background check:

(a) If hired after January 7, 2012, and in accordance with provisional hire rules in WAC 388-113-0109;

(b) If they have lived out of state since the last fingerprint-based background check was completed; or

(c) Any time the home care agency requests a new check.

(1) The agency provider must:

(a) Complete the background check authorization form;

(b) Answer all questions on the background check authorization form truthfully;

(c) Obtain a fingerprint-based background check result;

(d) Not have any automatically disqualifying conviction(s), pending charge(s), or negative action(s) as described in chapter 388-113 WAC;

(e) Review the background check results and if necessary provide documents or other information to BCCU to correct the background check results; and

(f) When requested by BCCU, provide additional information in order to complete a background check as mandated by statute.

(2) It is the responsibility of the home care agency to ensure compliance with subsection (1) of this section for its agency providers.

In providing care to a client, a home care agency must:

(1) Ensure that the assigned home care agency long-term care worker(s) understands the client's plan of care that is signed by the client or legal representative, and which may be translated or interpreted, as necessary for the client;

(2) Provide tasks from services outlined in a client's plan of care, as described in WAC 388-106-0010;

(3) Accommodate the client's individual preferences and unique needs in providing care;

(4) Contact the client, client's representative and case manager when there are changes observed by the assigned home care agency long-term care worker that affect the personal care and other tasks listed on the plan of care;

(5) Ensure that the assigned home care agency long-term care worker(s) observes the client for and consults with the client or representative, regarding change(s) in health, takes appropriate action, and responds to emergencies;

(6) Notify the case manager immediately when the client enters a hospital, or moves to another setting;

(7) Notify the case manager immediately in the event of the client's death;

(8) Notify the department or AAA immediately when unable to staff/serve the client;

(9) Notify the department or AAA when the home care agency will no longer provide services and the home care agency must:

(a) Give at least two weeks' notice; and

(b) Notify the client or the client's representative in writing; and

(c) Notify the case manager.

(10) Comply with time keeping requirements, and keep accurate time sheets of authorized/paid hours that are accessible to the appropriate department or designee staff; under WAC 388-106-0130, the department does not pay for voluntary informal support that may be provided to the client by anyone, including providers; and

(11) Comply with all applicable laws and regulations.

A home care agency must not bill the department for in-home medicaid-funded personal care or respite services when the agency employee providing care is a family member of the client served, unless approved to do so by the department or exempt as provided in RCW 74.39A.326.

A home care agency long-term care worker, hired on or after January 7, 2012, must meet the training requirements described in WAC 388-71-0836 through 388-71-1006. These training requirements also apply to home care agency long-term care workers who were hired before January 7, 2012, if they did not complete prior training requirements within 120 days of hire and they want to be reinstated to work as a long term care worker. These training requirements and certification, if required, must be met prior to reinstating these individuals to work as a long-term care worker.

The following chart provides a summary of the training and certification requirements for individual providers and home care agency long-term care workers. This includes criteria for those providers working limited hours for one person, caring only for one's child, parent, sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, providing respite services, or providing approved services only for a spouse or registered domestic partner and funded through the United States department of veterans' affairs home and community-based programs:

The department will deny payment to the home care agency for services provided to a department client by an agency provider that it employs who:

(1) Does not meet the qualifications in WAC 388-71-0510; or

(2) Is a family member of the client served, except as provided by RCW 74.39A.326.

(1) Unless payment is otherwise required by state or federal law, it is an overpayment as defined in RCW 43.20B.010 and 41.05A.170 if an individual provider (IP) is paid by the department and:

(a) Did not actually perform the work;

(b) Payment is for dates of service after the death of the client;

(c) Payment is for services provided when the client was admitted to a hospital, nursing home, or other institutional setting;

(d) Payment is for dates of service when the client was outside of the United States;

(e) Did not have a valid IP services contract at the time the services were provided and had been notified by the department to stop the provision of services;

(f) Had not completed required training or obtained required certification at the time the services were provided and had been notified by the department to stop the provision of services;

(g) Had a disqualifying crime or negative action at the time the services were provided and had been notified by the department to stop the provision of services;

(h) Provided services after being notified by the department to stop the provision of services;

(i) Provided services that are not included in the client's plan of care;

(j) Provided services that exceeded the amount of the client's benefit in the client's plan of care where those services were not necessitated by an emergent and immediate need of the client and the IP is not a family member or household member of the client; or

(k) Received erroneous or duplicate payment(s).

(2) If the department determines an IP was overpaid, even if it was due to department error, the department recovers any moneys that the IP received as a result of overpayments, as authorized under chapter 41.05A RCW or 43.20B RCW.

(a) The department will send the IP notice of the overpayment.

(b) The IP has a right to request an administrative hearing when notice of an overpayment is received from the department.

(c) To request an administrative hearing, an IP must send a written request to the office of financial recovery within twenty-eight days of the IP's receipt of notice of the overpayment that:

(i) States the basis for contesting the overpayment notice;

(ii) Includes a copy of the department's notice with the request; and

(iii) Is sent by certified mail return receipt requested (CMRRR) or another trackable delivery service.

(d) The appeal process will be governed by the Administrative Procedure Act (chapter 34.05 RCW).

(1) A medicaid contracted home care agency has the right to an administrative hearing when the department or a department designee terminates its contract or takes other enforcement action related to its contract because the home care agency:

(a) Knowingly employs a long-term care worker who has not completed training within the required time frame.

(b) Knowingly employs a long-term care worker who does not meet the certification or recertification requirements or whose certification has been revoked by the department of health.

(2) In an administrative hearing under subsection (1) or (2) above, the medicaid contracted home care agency may not challenge an action taken by the department of health that affects a long-term care worker's certification. Actions by the department of health must be challenged through an appeal to the department of health, as provided in department of health rules.

(3) To request an administrative hearing, a home care agency must send, deliver, or fax a written request to the office of administrative hearings (OAH). OAH must receive the written request within thirty calendar days of the date the department's notice letter is served upon the home care agency.

(4) The home care agency should keep a copy of the request.

(5) The appeal process will be governed by the Administrative Procedure Act (chapter 34.05 RCW), RCW 74.39A.085, chapter 388-02 WAC, Title 182 WAC and this chapter. If there is a conflict between chapter 388-02 WAC, Title 182 WAC and this chapter, this chapter will govern.

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 community options program entry system (COPES) waiver, roads to community living (RCL), residential support waiver (RSW), 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 and adult day health centers that contract with the department, area agency on aging, other department designee to provide COPES, RSW, 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.

(3) An adult day center is a community-based program designed to meet the needs of adults with impairments through 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. Adult day centers support families and caregivers with the following goals:

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

(b) Provide the client with clinical and nonclinical services to meet unmet needs;

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

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

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

Adult day care is a supervised nonresidential program providing services as defined in WAC 388-106-0800. Services are appropriate for adults with medical or disabling conditions that do not require the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's authorizing practitioner. The adult day care center must offer and provide on-site the following services. These services must meet the level of care needed by the client as assessed by the department case manager for waiver funded clients and do not exceed the scope of services that the adult day care center is able to provide.

(1) Assistance with activities of daily living:

(a) Locomotion outside of room, locomotion in room, walks in room;

(b) Body care;

(c) Eating;

(d) Repositioning;

(e) Medication management that does not require a licensed nurse;

(f) Transfer;

(g) Toileting;

(h) Personal hygiene at a level that ensures client safety while in attendance at the program; and

(i) Bathing at a level that ensures client safety and comfort while in attendance at the program.

(2) Social services on a consultation basis, which may include:

(a) Referrals to other providers for services not within the scope of COPES waiver or RCL reimbursed adult day care services;

(b) Caregiver support and education; or

(c) Assistance with coping skills.

(3) Routine health monitoring with consultation from a registered nurse that a consulting nurse acting within the scope of practice can provide with or without an authorizing practitioner's order. Examples include:

(a) Obtaining baseline and routine monitoring information on client health status, such as vital signs, weight, and dietary needs;

(b) General health education such as providing information about nutrition, illnesses, and preventative care;

(c) Communicating changes in client health status to the client's caregiver;

(d) Annual and as needed updating of the client's medical record; or

(e) Assistance as needed with coordination of health services provided outside of the adult day care program.

(4) General therapeutic activities that an unlicensed person can provide or that a licensed person can provide with or without an authorizing practitioner's order. These services are planned for and provided based on the client's abilities, interests, and goals, which are not limited by funding source. Examples include:

(a) Recreational activities;

(b) Diversionary activities;

(c) Relaxation therapy;

(d) Cognitive stimulation; or

(e) Group range of motion or conditioning exercises.

(5) General health education that an unlicensed person can provide or that a licensed person can provide with or without an authorizing practitioner's order, including but not limited to topics such as:

(a) Nutrition;

(b) Stress management;

(c) Disease management skills; or

(d) Preventative care.

(6) A nutritional meal and snacks every four hours, including a modified diet if needed and within the scope of the program, as provided under WAC 388-71-0770;

(7) Supervision and/or protection if needed for client safety;

(8) Assistance with arranging transportation to and from the program; and

(9) First aid and provisions for obtaining or providing care in an emergency. note: If the client requires the intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of an authorizing practitioner, consider adult day health services.

Adult day health is a supervised nonresidential program providing skilled nursing and/or rehabilitative therapy services in addition to all services provided in an adult day care center. Adult day health services are only appropriate for adults with medical or disabling conditions that require the skilled intervention or services of a registered nurse or licensed rehabilitative therapist acting under the supervision of the client's authorizing practitioner.

The adult day health center must offer and provide on-site the following services:

(1) All services under WAC 388-71-0704; and

(2) Skilled nursing services other than routine health monitoring with nurse consultation; or

(3) At least one of the following skilled therapy services: physical therapy, occupational therapy, or speech-language pathology or audiology, as defined under chapters 18.74, 18.59 and 18.35 RCW; and

(4) Psychological or counseling services, including assessing for psycho-social therapy need, dementia, abuse or neglect, and alcohol or drug abuse; making appropriate referrals; and providing brief, intermittent supportive counseling. These services are provided by social services professionals.

Clients are eligible for adult day care services if they meet criteria outlined in WAC 388-106-0805.

Clients are eligible for adult day health services if they meet the criteria outlined in WAC 388-106-0815 which references WAC 388-106-0300, 388-106-0305, 388-106-0336(9), and 388-106-0337.

(1) Skilled nursing services are medically necessary services provided directly or indirectly by a registered nurse under an authorizing practitioner's supervision, or by a licensed practical nurse under physician or registered nurse supervision, that a licensed nurse acting within the scope of practice can provide or supervise. Authorizing practitioner orders must be obtained when required by applicable state practice laws for licensed nurses. Authorizing practitioner orders must be obtained upon initial service, updated when a significant change occurs changing the nursing intervention or at least annually.

(2) Skilled nursing services must exceed the level of routine health monitoring, general health education, and general therapeutic activities as defined in WAC 388-71-0704, and must be provided with the reasonable expectation that the services will improve, restore, maintain function or slow the client's decline of the disease or functional ability. Skilled nursing services are:

(a) Specific to a client's diagnosis;

(b) Individualized to the client with planned measurable outcome goals; and

(c) Reevaluated every ninety days or sooner when there is a significant health change for effect on improvement or maintenance of health status, or slowing the decline of the disease or functional ability.

(3) Skilled nursing services, including the initial client nursing assessment and development of the nursing plan of care, must be provided or supervised by a registered nurse in accordance with nursing practice standards under chapter 246-840 WAC.

(4) A skilled nursing service is not a qualifying adult day health service merely because the service is ordered by an authorizing practitioner or is provided by a nurse. If, by way of example, the service can be performed by the client or at the client's direction by a person other than a licensed nurse, it is not a qualifying adult day health service.

(5) Skilled nursing services must be medically necessary as defined under WAC 182-500-0070. Medically necessary skilled nursing services include but at [are] not limited to:

(a) Assessment, care and evaluation with collaboration of services of an acute or chronic unstable or unpredictable medical condition, with time specific measurable treatment goals, requiring frequent skilled intervention by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse according to WAC 246-840-705 and ordered by the authorizing practitioner;

(b) Evaluation and management of the care plan when unstable medical conditions or complications require complex nonskilled care and skilled nurse oversight to ensure that the nonskilled care is achieving its purpose;

(c) Time-limited training by licensed nursing staff to teach the client and/or the client's caregiver self-care for newly diagnosed, acute, or episodic medical conditions that require the skills of a licensed nurse to teach, and that will optimize client function, as illustrated by the following examples:

(i) Self administration of an injection;

(ii) Prefilling insulin syringes;

(iii) Irrigating a catheter;

(iv) Caring for a colostomy or urostomy;

(v) Wound dressing changes or aseptic technique; or

(vi) Disease self-management.

(d) Skilled interventions provided directly by a licensed nurse such as:

(i) Inserting or irrigating a catheter;

(ii) Administering medications or oxygen;

(iii) Administering and managing infusion therapy; or

(iv) Treating decubitus ulcers, or other types of wound care.

(e) Provide holistic collaborative care of the client's acute, chronic, unstable or unpredictable medical condition or disease.

(6) Medically necessary skilled nursing services, by way of example, do not include:

(a) Reminding or coaching the client;

(b) Monitoring of a medical condition that does not require frequent skilled nursing intervention or a change in authorizing practitioner treatment orders, or where there is no reasonable expectation that skilled services will maintain, improve, or slow the effect of a progressive disabling condition on the pain, health or functioning of a client;

(c) Medication assistance when the client is capable of self-administration or is having this need met through paid or unpaid caregivers;

(d) Evaluation and management of the care plan when the complexity of care to be provided by nonskilled persons does not require skilled nurse oversight beyond routine health monitoring;

(e) Continued training by nursing staff to teach self-care for newly diagnosed, acute, or episodic medical conditions when it is apparent that the training should have achieved its purpose or that the client is unwilling or unable to be trained;

(f) ADC services that can be provided by an adult day care center, such as routine health monitoring, general health education, or general therapeutic activities; or

(g) Group therapy or training where three or more clients are being simultaneously treated or trained by the nurse.

(7) Skilled nursing services must be documented as provided under WAC 388-71-0746 and 182-502-0020.

(1) Skilled rehabilitative therapy services are medically necessary services provided by or under the supervision of a licensed physical, occupational, or speech-language pathology or audiology therapist that the therapist acting within the scope of practice can provide or supervise directly or indirectly. Authorizing practitioner orders must be initially obtained and updated when a significant change occurs or at least annually when required by applicable state practice laws for licensed therapists.

(a) Persons that can provide rehabilitative care under the direction and supervision of a licensed therapist include occupational therapy aides, occupational therapy assistants, physical therapy aides, physical therapy assistants, and nurses within their respective scopes of practice. Adult day health program aides, specifically trained in rehabilitative techniques, may also provide care under the direction and supervision of a licensed therapist.

(b) Services, group or individual, must be related to an active written plan of care with time specific measurable treatment goals approved by the authorizing practitioner;

(c) Services, group or individual, must require the assessment, knowledge and skills of a licensed therapist; and

(d) Services, group or individual, must be provided with the reasonable expectation that the services will improve, restore, maintain function, or slow decline. Rehabilitative services are:

(i) Specific to a client diagnosis;

(ii) Individualized to the client with planned, measurable outcomes; and

(iii) Reevaluated every ninety days for effect on improvement of health status or slowing the decline.

(2) Skilled rehabilitative therapy is not a qualifying adult day health service merely because the therapy is ordered by an authorizing practitioner or is provided by a therapist or under the supervision of a therapist. If, by way of example, the therapy can be performed independently by the client or at the client's direction by a person other than a licensed therapist, it is not a qualifying adult day health service.

Skilled rehabilitative therapy services must be medically necessary as defined under WAC 182-500-0070.

(3) Medically necessary physical therapy services may, but do not necessarily include:

(a) Assessing baseline mobility level, strength, range of motion, endurance, balance, and ability to transfer;

(b) One to one and group treatment to relieve pain, develop, restore, or maintain functioning, with individualized and measurable client treatment goals;

(c) Establishing a maintenance or restorative program with measurable treatment goals, and providing written and oral instruction to the client, caregivers, or program staff as needed to assist the client in implementing the program;

(d) Training the client or the client's caregivers in the use of supportive, adaptive equipment or assistive devices;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that the nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of a physical therapist acting within the therapist's scope of practice.

(4) Medically necessary occupational therapy services may, but do not necessarily include:

(a) Administering a basic evaluation to determine baseline level of functioning, ability to transfer, range of motion, balance, strength, coordination, activities of daily living and cognitive-perceptual functioning;

(b) Teaching and training the client, caregivers, or program staff in the use of therapeutic, creative, and self-care activities to improve or maintain the client's capacity for self-care and independence, and to increase the range of motion, strength and coordination;

(c) One to one and group treatment to develop, restore, or maintain functioning with individualized and measurable client treatment goals;

(d) Training the client or the client's caregivers in the use of supportive, adaptive equipment or assistive devices;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that the nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of an occupational therapist acting within the therapist's scope of practice.

(5) Medically necessary speech-language pathology or audiology services may, but do not necessarily include:

(a) Assessing baseline level of speech, swallowing, auditory, or communication disorders;

(b) Establishing a treatment program to improve speech, swallowing, auditory, or communication disorders;

(c) Providing speech therapy procedures that include auditory comprehension tasks, visual and/or reading comprehensive tasks, language intelligibility tasks, training involving the use of alternative communication devices, or swallowing treatment;

(d) Training the client or the client's caregivers in methods to assist the client in improving speech, communication, or swallowing disorders;

(e) Evaluation and management of the care plan when medical conditions or complications require complex nonskilled care and skilled therapist oversight to ensure that nonskilled care is achieving its purpose; or

(f) Providing other medically necessary services that can only be provided by or under the direct or indirect supervision of a speech-language pathology or audiology therapist acting with the therapist's scope of practice.

(6) Medically necessary skilled rehabilitative therapy services, by way of example, do not include:

(a) Reminding or coaching the client in tasks that are not essential to the skilled therapy or intervention in the client's service plan;

(b) Monitoring of a medical condition that does not require frequent skilled therapist intervention or a change in authorizing practitioner treatment orders, or where there is no reasonable expectation that skilled services will maintain, improve, or slow the effect of a progressive disabling condition on the pain, health or functioning of a client;

(c) Massage therapy;

(d) Evaluation and management of the care plan when the complexity of the care to be provided by nonskilled persons does not require the skills of a licensed therapist for oversight;

(e) Continued training by therapy staff to teach self-care for newly diagnosed, acute, or episodic medical conditions when it is apparent that the training should have achieved its purpose or that the client is unwilling or unable to be trained;

(f) ADC services that can be provided by an adult day care center, such as routine health monitoring, general health education, or general therapeutic activities; or

(g) Group therapy or training where the ratio of licensed therapists and assisting program staff to clients is inadequate to ensure that:

(i) The group activity contributes to the individual client's planned therapy goals; and

(ii) The complexity of the individual client's need can be met.

(7) Skilled therapy services must be documented as provided under WAC 388-71-0746 and 182-502-0020.

(1) The department or an authorized case manager must perform a comprehensive assessment reporting evaluation (CARE) to determine a client's need for adult day care, per WAC 388-106-0065. Based on the assessment, the case manager determines whether the client should be referred for day care services or whether the client's needs can be met in other ways.

(2) If the case manager determines an unmet need for an ADC service that may be provided at a day care center, the case manager works with the client and/or the client's representative to develop a service plan that documents the needed services and the number of days per week that the services are to be provided. The case manager refers the client to a waiver-contracted day care center that the client and the case manager agree can potentially meet the client's needs.

(3) Clients receiving adult day care services must be reassessed at least annually.

(1) Upon the department's or authorized case manager's referral of a COPES,RSW, RCL, or other agency approved client to an ADC center, the ADC center must respond in writing to the department or authorized case manager within two working days, acknowledging receipt of the referral and the center's ability to process and evaluate the referred client.

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

(3) The ADC center must schedule and conduct an intake and evaluation visit with the referred client or the client and his or her authorized representative to determine the client's desire to attend the ADC center and evaluate the ADC center's ability to meet the 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 paid service days from the date the client started attending the 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 it will meet the client's needs, and whether it will accept the client into the program. The ADC center must not accept a client whose needs the center cannot meet. The ADC center must document in the client's file the date 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 the date the client was accepted into the ADC program, the ADC center must work with the client 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 ADC center.

(6) 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:

(a) A list of the care and services the ADC center will provide the client;

(b) Identification of who will provide the client's care and services;

(c) When and how the ADC center will provide the care and services;

(d) How the ADC center will manage the client's medications and how the client will receive his or her medications when attending the ADC center;

(e) The client's activity preferences and how the ADC center will meet these preferences;

(f) Other preferences and choices about issues important to the client, including, but not limited to:

(i) Food;

(ii) Daily routine;

(iii) Activities;

(iv) Services received and who will provide the services received;

(v) Individuals they interact with;

(vi) Grooming;

(vii) How the ADC center will accommodate the client's preferences and choices; and

(g) If needed, a plan to:

(i) Follow in case of a foreseeable crisis due to the client's assessed needs;

(ii) Reduce tension, agitation, and problem behaviors;

(iii) Respond to the client's special needs, including, but not limited to medical devices and related safety plans, and if medical devices are used, ADC center staff must ensure the medical device will not be used as a physical restraint for discipline or staff convenience and must also ensure clients are free from coercion while attending the ADC center;

(iv) Respond to the client's refusal of care or treatment, including when the ADC center should notify the client's physician or practitioner of the client's refusal; and

(v) Identify any communication barriers the client may have and how the ADC center will use the client's behaviors and nonverbal gestures to communicate with him or her.

(7) The ADC center must:

(a) Ensure medical devices will never be used as a physical restraint for discipline or staff convenience;

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

(c) Share the negotiated care plan with the client's case manager whenever it is updated, annually, and after a significant change;

(d) Ensure the client's case manager reviews the negotiated care plan to ensure all services are appropriate and all authorized care needs have been included;

(e) Keep the current negotiated care plan in the client's file; and

(f) Offer a copy of the negotiated care plan to the client or the client and his or her authorized representative.

(8) 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.

(a) Unanticipated absences may include but are not limited to absences due to client illness or change in transportation access.

(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) The department or an authorized case manager must perform a CARE assessment to determine a client's need for adult day health, per WAC 388-106-0065. Based on the assessment, the case manager determines whether the client should be referred for day health services or whether the client's needs can be met in other ways.

(2) If the client has a department or area agency on aging case manager, the adult day health center or other referral source must notify the case manager of the client's potential adult day health service need. The case manager must assess the client's need for skilled nursing or skilled rehabilitative therapy within the department's normal time frames for client reassessments.

(3) If the client does not have a department or area agency on aging case manager, the adult day health center or other referral source must notify the department of the referral and the client's potential adult day health service need, or refer the client to the department for intake. The department's assigned case manager must assess the client's need for adult day health services within the department's normal time frames for initial client eligibility assessments.

(4) The case manager may consult with the client's authorized practitioner, department or area agency on aging nursing services staff, or other pertinent collateral contacts, concerning the client's need for skilled nursing or rehabilitative therapy.

(5) If the department or area agency on aging case manager determines and documents a potential unmet need for day health services, the case manager works with the client and/or the client's representative to develop a service plan that documents the potential unmet needs and the anticipated number of days per week that the services are needed. The case manager refers the client to a department contracted adult day health center for evaluation and the development of a preliminary service plan.

(6) The department or area agency on aging case manager must reassess adult day health clients at least annually. Clients must also be reassessed if they have a break in service of more than thirty days. The adult day health center must inform the case manager of the break in service so payment authorization can be discontinued.

(7) COPES, RSW, and RCL recipients of adult day health services must be assessed by the department or an authorized case manager for initial or continued eligibility as follows:

(a) Annual reassessment for department clients; or

(b) A new client to the center who potentially could be eligible for state paid ADH services are to be referred to the local department offices for intake and assessment for eligibility.

(8) The department or area agency on aging case manager must review a client's continued eligibility for adult day health services every ninety days, coinciding with the quarterly review completed by the adult day health program. At the case manager's discretion, additional information will be gathered through face to face, collateral or other contact methods to determine continued eligibility. Services will be continued, adjusted, or terminated based upon the case manager's determination during the eligibility review.

(1) Upon the department's or authorized case manager's referral of a COPES,RSW, RCL, or other agency approved client to an ADH center, the ADH center must respond in writing to the department or authorized case manager within two working days, acknowledging receipt of the referral and the center's ability to process and evaluate the referred client.

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

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

(4) Within ten paid 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.

(a) The ADH center's intake and evaluation must include multidisciplinary assessments based on interviews and evaluations of the client's strengths and limitations with the client or the client and his or her authorized representative.

(b) If the department service plan indicates a nursing or rehabilitative need during the intake and evaluation period, licensed professionals must conduct evaluations and assessments of the client's clinical or rehabilitative needs.

(c) The preliminary service plan must include:

(i) Client specific problems or needs as identified in the intake and evaluation;

(ii) The needs for which the client chooses not to accept services or refuse care or services;

(iii) What the center will do to ensure health and safety of the client related to the refusal of any care or service;

(iv) Client specific and agreed upon goals;

(v) Client preferences; and

(vi) How the center will meet the client's needs and preferences.

(d) Based on the ADH center intake and evaluation, the ADH center must determine whether it can meet the client's needs, how it will meet the client's needs, and whether it will accept the client into the ADH program.

(i) The ADH center must not accept a client whose needs the center cannot meet.

(ii) If the client is accepted into the ADH program, the ADH center must document the date of acceptance in the client file.

(iii) If the client is not accepted into the ADH program, the preliminary service plan must include the reason(s) why the client was not accepted.

(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) 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) Upon the department's or authorized case manager's approval of the ADH center's preliminary service plan, the ADH center must obtain and provide to the case manager any required practitioner's orders for skilled nursing, rehabilitative therapy 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.

(a) The authorizing practitioner orders must:

(i) Include the frequency of authorized service;

(ii) Include use of and parameters for the authorized medical devices;

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

(iv) Include the client's consent to follow up with the authorizing practitioner; and

(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 must not be authorized for payment without current practitioner orders.

(d) The authorizing practitioner must only authorize services, supports, and interventions that are within the practitioner's professional scope of practice.

(7) Within thirty calendar days of acceptance into the program, the ADH center's multidisciplinary team must work with either the client 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 ADH center. The negotiated care plan may be developed initially in lieu of the preliminary service plan.

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

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

(b) Time specific, measurable, and individualized client goals;

(c) Who will provide the client's care and services;

(d) When and how the ADH center will provide the care and services;

(e) How the ADH center will manage the client's medications, including how the client will receive his or her medications when attending the ADH center;

(f) The client's activity preferences and how the ADH center will meet these preferences;

(g) Other preferences and choices about issues important to the client including, but not limited to:

(i) Food;

(ii) Daily routine;

(iii) Activities;

(iv) Services received and who will provide the services received;

(v) Individuals they interact with;

(vi) Grooming; and

(vii) How the ADH center will accommodate the preferences and choices;

(h) Individualized discharging or transition goals;

(i) If needed, a plan to:

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

(ii) Follow in case of a foreseeable crisis due to a client's assessed needs;

(iii) Reduce tension, agitation, and problem behaviors;

(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;

(v) Respond to the client's refusal of care or treatment, including when the ADH center should notify the client's physician or practitioner of the client's refusal; and

(vi) Identify any communication barriers the client may have and how the ADH center will use the client's behaviors and nonverbal gestures to communicate with him or her.

(9) The ADH center must:

(a) Ensure medical devices will never be used as a physical restraint for discipline or staff convenience;

(b) Review and update each service in the negotiated care plan every ninety days or more often if the client's condition changes;

(c) Share the negotiated care plan with the client's case manager whenever it is updated, annually, or after significant change;

(d) Ensure the client's case manager reviews the negotiated care plan to ensure all services are appropriate and all authorized care needs have been included;

(e) Obtain the case manager's approval whenever it is updated, annually, or after a significant change;

(f) Keep the current negotiated care plan in the client's file; and

(g) Offer a copy of the negotiated care plan to the client or the client and his or her authorized representative.

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

(11) The ADH center must report changes in the client's condition or unanticipated absences of more than three consecutive scheduled days of service to the client's case manager within one week.

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

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

(1) The department, or an area agency on aging (or other department designee) as authorized by the department, must determine that the adult day care or day health center meets the applicable adult day care or day health requirements and any additional requirements for contracting with the area agency on aging, according to each AAA's procurement procedure, through a state contract.

(2) All ADH centers must also have a core provider agreement with the health care authority in order to bill for providing care and services to the COPES, RSW, and RCL participants.

(3) If a center is contracting for both day care and day health, requirements of both adult day services must be met.

(4) A prospective provider desiring to provide adult day services shall be provided an application form from the department or the area agency on aging. A prospective provider convicted of abuse or neglect of a vulnerable adult is not eligible to provide adult day services in any capacity within the organization per chapter 74.34 RCW.

(5) The prospective provider will provide the area agency on aging with evidence of compliance with, or administrative procedures to comply with, the adult day service rules under this chapter.

(6) The area agency on aging will conduct a site inspection of the adult day center and review of the requirements for contracting.

(7) Within thirty days of completing the site visit, the area agency on aging will advise the prospective provider in writing of any deficiencies in meeting contracting requirements.

(8) The area agency on aging will verify correction of any deficiencies within thirty days of receiving notice from the prospective provider that deficiencies have been corrected, before contracting can take place.

(9) The area agency on aging will provide the department with a written recommendation as to whether or not the center meets contracting requirements.

(10) Minimum application information required to apply for contract(s) with the department, or an area agency on aging includes:

(a) Mission statement, business structure, bylaws, articles of organization or articles of incorporation if applicable and current business license;

(b) Names and addresses of the center's owners, officers, and directors as applicable;

(c) Organizational chart;

(d) Fiscal policies and procedures;

(e) A business plan to address the future financial needs of the center. This plan must include projected program growth, capital purchases, projected revenue, projected expenses, and plans for fund raising, if applicable. Also include an annual program operating budget including all anticipated revenue sources and expenditures and any fees generated;

(f) The most current financial statement prepared in accordance with generally accepted account principles (GAAP) or the latest audit report of the organization by a certified public accountant;

(g) Program policies and operating procedure manual;

(h) Personnel policies and job descriptions and qualifications of each paid staff position and volunteer position functioning as staff;

(i) Policies and procedures meeting the requirements of mandatory reporting procedures as described in chapter 74.34 RCW to adult protective services for vulnerable adults and local law enforcement for other participants;

(j) Floor plan of the facility;

(k) Local building inspection, fire department, and health department reports with food handler permits if applicable;

(l) Updated TB test results for each staff member according to WAC 388-71-0750;

(m) Sample client case file including all forms that will be used;

(n) Activities calendar with alternative choice activities, for the month prior to application, or a sample calendar if the day service provider is new;

(o) Role and function of the board of directors and advisory committee, if applicable;

(p) Monthly menu or sample if center is new, which accommodates each resident's:

(i) Preferences;

(ii) Food allergies and sensitivities;

(iii) Caloric needs;

(iv) Cultural and ethnic background; and

(v) Physical condition that may make food intake difficult such as being hard for the resident to chew or swallow; and

(q) Certificates of insurance per WAC 388-71-0736.

(11) The area agency on aging or other department designee monitors the adult day center at least annually to determine continued compliance with adult day care and/or adult day health requirements and the requirements for contracting with the department or the area agency on aging.

(a) The area agency on aging will send a written notice to the provider indicating either compliance with contracting requirements or any deficiencies based on the annual monitoring visit and request a corrective action plan. The area agency on aging will determine the date by which the corrective action must be completed.

(b) The area agency on aging will notify the department of the adult day center's compliance with contracting requirements or corrected deficiencies and approval of the corrective action plan for continued contracting.

(12) Adult day care services are reimbursed on an hourly basis up to four hours per day. Service provided four or more hours per day will be reimbursed at the daily rate.

(13) Adult day center reimbursements are adopted by rule with adjustments determined by the state legislature. Providers seeking current reimbursement rates can refer to the billing instructions.

(14) A one-time only initial intake evaluation provided by an adult day health center, including development of a negotiated care plan, is reimbursed at an established rate as may be adopted in rule. Rate adjustments are determined by the state legislature. Separate reimbursement is not available for subsequent evaluations.

(15) Transportation to and from the program site is not reimbursed under the adult day care rate. Transportation arrangements are made with locally available transportation companies or informal resources.

(16) Transportation to and from the program site is reimbursed under the adult day health daily rate. Adult day health is required to assist clients in arranging or providing transportation to and from the program sites.

(1) A COPES, RSW, or RCL eligible client may receive adult day care services on some days and adult day health services on different days if the service plan documents which level of service are to be provided on which days. However, ADC services must be provided on all days that adult day health skilled services are provided, and reimbursement is limited to the day health rate on days that day health services are provided.

(2) Clients receiving services from the department in an adult family home, assisted living, or other licensed community residential facility may not receive COPES, RSW, or RCL funded adult day care, but may receive COPES funded adult day health services when the skilled nursing or rehabilitative services are approved by the client's case manager as part of the client's service plan.

(3) A licensed assisted living facility providing department-approved day care under chapter 388-78A WAC is subject to any applicable provisions of that chapter and is also subject to the rules under this chapter if the facility contracts with an area agency on aging or the department to provide COPES waiver or RCL funded adult day services.

(1) Except as provided under this section, the adult day services rules under this chapter do not apply to adult day care or day health services funded under chapters 74.38 and 74.41 RCW.

(2) An area agency on aging that elects to provide adult day services using Senior Citizens Services Act funding under chapter 74.38 RCW or respite care funding under chapter 74.41 RCW must contract with an adult day center that meets all administrative and facility requirements under WAC 388-71-0736 through 388-71-0774.

(3) The adult day care or day health services funded under chapters 74.38 or 74.41 RCW must be the same as the day care services required under WAC 388-71-0704 or the day health services required under WAC 388-71-0706. The area agency on aging may require additional services by contract.

(4) The area agency on aging may, by contract, establish eligibility and assessment requirements for day care or day health services in accordance with locally identified needs. However, funding provided under chapters 74.38 or 74.41 RCW may only be used to meet the needs of individuals who are not eligible for adult day care under WAC 388-71-0708 or for adult day health under WAC 388-71-0710, or who are eligible for those services and are not receiving them because of funding limitations.

(5) Nothing in this section or chapter may be construed as requiring an area agency on aging to contract with an adult day center, whether or not the center has a COPES and RCL contract. Nor may anything in this section or chapter be construed as creating an entitlement to state-funded adult day services authorized under chapters 74.38 and 74.41 RCW.

(1) If the department or area agency on aging denies, terminates, or reduces a COPES, RSW, or RCL individual client's adult day care or day health services, the client has the right to an administrative hearing as provided under chapter 388-02 WAC. If a client funded with Senior Citizen Services Act or respite care has a complaint, grievance or dispute, the resolution process is a hearing as outlined in the department's area agency on aging policy and procedure manual chapter 6. The area agency on aging would work with the client through this process.

(2) An adult day care or day health center has those hearing or dispute resolution rights that are afforded under RCW 43.20B.675 and the center's contract with the area agency on aging or the department. An adult day health center has any other applicable hearing or dispute resolution rights under WAC 182-502-0220.

(3) Adult day health centers are subject to all applicable provisions of chapter 182-502 WAC, and the department's aging and long term support administration may exercise the department's authority under that chapter to the same extent as the health care authority.

(1) In order to provide adult day services within the limits of available funding, the department may limit services when program expenditures exceed the budget appropriation or when limiting services is required to prevent expenditures from exceeding the appropriation.

(2) When adult day health program expenditures exceed available funding, the department may limit adult day health services based on the four care level system as determined through the established department assessment and described in chapter 388-105 WAC.

(a) Using the care level determined by the department assessment tool, the department will limit adult day services on a statewide basis to clients whose total scores exceed the assessed need level identified by the department as necessary to provide adult day health services to the extent of available funding.

(b) At least thirty days before implementing the limitation on services under this subsection, the department will notify the area agencies on aging, adult day health centers, and the affected adult day health clients that services are being limited and for what period of time the limitation is estimated to remain in effect.

(c) For purposes of RCW 74.08.080, the reduction in services shall be deemed an assistance adjustment for an entire class of recipients that is required by state laws prohibiting the department from expending funds in excess of appropriations.

(3) The department may adopt additional or alternative rules to control costs, such as, but not limited to, imposing a moratorium on contracting with new adult day centers, limiting services to clients based on level of care need, or reducing the numbers of days per week that clients may receive services.

(1) Adult day centers must have written documentation of the organizational structure and administration of the program.

(2) Organizational and administrative documentation must include but are not limited to:

(a) Core values and mission statement of the organization;

(b) Ethical standards of the center and professional standards of conduct;

(c) Short and long-range program goals;

(d) Definition of the target population, including number, age, and needs of participants;

(e) Geographical definition of the service area;

(f) Hours and days of operation of the center or a combination of centers under single ownership must operate at least three days a week for four consecutive hours, with each center providing at least four hours of programming a day;

(g) Description of basic services and any optional services;

(h) Description of service delivery;

(i) Business structure, articles of organization or bylaws, as applicable;

(j) Current business license;

(k) Names and addresses of the center's owners, officers, and directors, as applicable;

(l) Certificates of insurance, including but not limited to property and general liability insurance; business auto if the center uses vehicles to transport clients; professional liability; workers' compensation; employers' liability if applicable; coverage for acts and omissions of employees and volunteers; and certificates of insurance for any subcontractors;

(m) Minutes of last three meetings of the board of directors, if applicable, and the advisory committee;

(n) Role and functions of an advisory committee which must:

(i) Meet at least twice a year; and

(ii) Be representative of the community and include family members of current or past clients and nonvoting staff representatives;

(A) When an adult day center is a subdivision of a multifunction organization, a committee or subcommittee of the governing body of the multifunction organization may serve as the advisory committee; or

(B) A single purpose agency may utilize its governing board as an advisory committee;

(o) An organizational chart illustrating the lines of authority and communication channels of the center, which must be available to all staff and clients;

(p) A calendar of programming (or sample calendar if the center is new), including alternative programming options;

(q) A monthly menu or sample menu if the center is new, which accommodates each resident's:

(i) Preferences;

(ii) Food allergies and sensitivities;

(iii) Caloric needs;

(iv) Cultural and ethnic background; and

(v) Physical condition that may make food intake difficult such as being hard for the resident to chew or swallow;

(r) Current building, health, food service and fire safety inspection reports, and food handler permits, as applicable; and

(s) Quality improvement plans and results.

(1) All policies and procedures must include date of initial development and/or revision along with date of being reviewed and approved on a regular basis, at least annually, by the advisory committee, and conform to the requirements outlined in WAC 388-71-0702 through 388-71-0774, as applicable.

(2) Policies and procedures must include:

(a) Procedures for evaluations, reevaluation, and the development of a negotiated care plan with clients and/or representatives, including provisions for the utilization of a multidisciplinary team for this process;

(b) If applicable, research procedures that comply with chapter 388-04 WAC;

(c) Procedure for developing staffing schedules with staff to participant ratios being at a minimum one staff to six participants;

(d) Policy regarding the utilization of community resources;

(e) Gift policy;

(f) Marketing policy and procedures;

(g) Policy and procedure for contracting for services;

(h) Medication policy including but not limited to: Disposal of wasted or contaminated medications;

(i) Emergency and evacuation policy and procedures for fire safety as approved by the local fire authority must be adopted and posted, including provisions for fire drills, inspection and maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. The center must conduct and document quarterly fire drills and document the center's ability to meet procedures. Improvements must be based on the fire evaluation drills;

(j) Grievance and complaint policies and procedures for staff and participants;

(k) Admission and discharge criteria policy and procedure. Discharge policies must include specific measurable criteria that establish when the participant is no longer eligible for services and under what circumstances the participant may be discharged. Unless the discharge is initiated by the client's department or authorized case manager, the center must notify the client, client representative if applicable, and case manager in writing of the specific reasons for the discharge. The center must also provide the client with adequate information about appeal and hearing rights. The discharge may occur due to the client's choice, other criteria as defined in the center's policy such as standards of conduct or inappropriate behavior, or changes in circumstances making the client ineligible for services under WAC 388-71-0708 or 388-71-0710;

(l) Health Insurance Portability and Accountability Act (HIPAA) policy and procedure;

(m) Confidentiality policy and procedure;

(n) Policy regarding how the center will comply with all applicable nondiscrimination laws, including but not limited to age, race, color, gender, religion, national origin, creed, marital status, sexual orientation, Vietnam era or disabled veteran's status, or sensory, physical, or mental handicap;

(o) A policy and procedure to afford the participants' their bill of rights describing the client's rights and responsibilities must be developed, posted, distributed to, and explained to participants, families, staff, and volunteers. Participants will be provided the bill of rights in the language understood by the individual upon request;

(p) Policies and procedures to ensure that the client's record/chart is appropriately organized and thinned according to the center's policy.

(q) Client record policy and procedures for:

(i) Confidentiality and the protection of records that define procedures governing the use and removal, and conditions for release of information contained in the records;

(ii) The release of client information and circumstances under which a signed authorization from the client or client representative is required; and

(iii) The retention, storage and access to records per the agency's contract with the department and/or the department's designee, including contingency plans in the event the center discontinues operation.

(r) The center must have an advance directive policy as required by the Patient Self Determination Act of 1990 (see 42 C.F.R. § 489.102 and chapter 70.122 RCW); and

(s) A policy and procedure for illness/injury/medical emergency/death must be followed in the event a participant becomes ill, is injured, or dies. The procedures must describe arrangements for hospital inpatient and emergency room service and include directions on how to secure ambulance transportation and complete incident reports.

(1) Adult day centers must demonstrate fiscal responsibility. Fiscal policies, procedures, reports, statements and records must be developed in accordance with generally accepted accounting principles (GAAP) and enable the administrator to meet the fiscal reporting needs of the governing body.

(2) Adult day centers must develop a yearly plan to address the future financial needs of the center. The plan must include projected program growth, capital purchases, projected revenue, projected expenses, and plans for fund raising, if applicable.

(3) Adult day centers must create a total center operating budget, including all expenditures, revenue sources and participant fees generated annually.

(4) An annual financial statement or the latest audit report of the organization by a certified public accountant performed at least every two years must be available.

(5) A statement of charges for services (fee schedule), including private pay rates and/or ancillary charges for additional services outside the scope of these rules, must be available.

(1) The adult day center must follow their policies and procedures to ensure that the client's record/chart is appropriately organized and that confidentiality of information is maintained.

(2) Client information forms must be standardized, with each page showing the client's name or identification number.

(3) Individual client files must include:

(a) Personal/biographical data, including addresses, phone numbers, emergency contacts, and client representatives, reviewed and updated as needed;

(b) Application, enrollment, and consent to services forms;

(c) Department-authorized service plan and service authorization;

(d) All client information, including but not limited to the intake evaluation, date of acceptance to the center, negotiated care plan, attendance and service records, progress notes, and correspondence;

(e) Signed authorizations concerning the release of client information, photographs, and receipt of emergency medical care, as appropriate;

(f) Client photograph, with client or client representative permission, updated as needed per change in the client's appearances or picture being difficult to clearly view;

(g) Transportation plans regarding how the client will be transported back and forth from the center and who is responsible for the transportation;

(h) Fee determination forms;

(i) Appropriate medical information, with client consent, including but not limited to significant illnesses, accidents, treatments, medical conditions, allergies, medications, tobacco use, and alcohol or substance use;

(j) Advance directives (if any) and a statement signed by the client that he or she has received the center's policies concerning advance directives; and, as applicable;

(k) Authorizing practitioner orders for skilled nursing and/or rehabilitative therapy containing department-required information and in accordance with applicable licensing and practice act regulations.

(1) If the client's record is hand-written it must be legibly written in ink, dated, and signed by the recording person with his/her title. Identification of the author may be a signature, initials, or other unique identifier within the requirements of applicable licensing standards and center policy. All hand-written documentation must be legible to someone other than the author. If signature is a unique identifier, such as initials, there must be a key readily available for use by the department or their designee. The negotiated care plan must have the center's author's full name and title on the signature line.

(2) If the client's record is an automated electronic record then it must be within a secured client record system to ensure confidentiality for all records, in accordance with state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA). If electronic signature is a unique identifier then there must be a key readily available for use by the department or their designee. The negotiated care plan must have the center's author's full name and title on the signature line.

(3) Progress notes must be entered into the file chronologically and timely. Adult day health centers' professional interventions must be charted directly after providing the service. Adult day care centers must have progress summary notes at least monthly. Client dates and hours of attendance are to be kept daily.

(4) Consultation, care plan reviews and updating orders, hardcopy or electronic records, must be dated and initialed by the center's reviewer(s) or authorizing practitioner. The authorizing practitioner must update the skilled clinical orders at least annually or when a significant change occurs warranting a change in the skilled clinical intervention. The authorizing practitioner does not need to review the care plan but does need to update skilled clinical orders as outlined above.

(5) Documentation of medication use must include the name of the medication, dosage, frequency of administration, route of administration, site of injection if applicable, date and time and signature or initials of the person administering the medication, title, and date.

(6) If the client records are thinned or archived, per your policy and procedure, all records must be readily available to the federal, state, or agency designee for monitoring purposes.

(7) Department-contracted adult day health centers must comply with all other applicable documentation requirements under WAC 182-502-0020.

(1) The adult day center must maintain a secure client record system to ensure confidentiality for all records, whether paper or electronic, in accordance with state and federal laws, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA).

(2) The adult day center must maintain a permanent registry of all clients with dates of admission, attendance and discharge.

(3) The adult day center must follow their written policies concerning record and maintenance and retention, see WAC 388-71-0738 operating policy section.

(4) Client records maintained on the center's premises must be in a secure storage area that includes locking cabinets or storage. Computerized records must be backed up, daily for any changes made in the record that day and a full backup on a weekly basis. Weekly backup records would be stored off-site either in a physical, (cd, tape or thumb drive) or electronic file, (through the cloud backup system) compliant with HIPAA.

(1) Personnel policies and procedures must be in place to ensure that staff is trained and knowledgeable to provide quality services in a safe environment. Policies must include at least the following:

(a) The center must have policies concerning the recruitment, orientation, training, evaluation, and professional development of staff and volunteers.

(b) The center must have job descriptions for each paid staff and volunteer position, which functions as staff, that are in accordance with ADA requirements and that specify qualifications for the job, delineation of tasks, essential functions and lines of supervision and authority.

(c) Each employee must receive, review, and sign a copy of the job description at the time of employment and whenever job descriptions are modified. Volunteers who function as staff must receive written descriptions of responsibilities.

(d) Probationary evaluations and annual performance evaluations, in accordance with job descriptions, must be conducted and must conform to the policy of the funding or parent organization. Both the employee and supervisor will sign and date the written evaluation. Copies will be kept in locked personnel files.

(e) Each staff person or volunteer, who functions as a staff person, is to have tuberculosis (TB) testing according to current local health authorities recommendations.

(f) The center must have policies to restrict a staff person or participant's contact with clients when the staff person or participant has a known communicable disease in the infectious stage that is likely to spread in the center.

(g) Policies must also be established concerning hand washing, universal precautions, infection control, infectious waste disposal, bloodborne pathogens, and laundry and handling of soiled and clean items.

(2) The center must have policies and procedures concerning suspected participant abuse, neglect, or exploitation reporting that include provisions preventing access to any participant until the center investigates and takes action to assure the participants' safety.

(3) The center must not interfere with the lawful investigation of a complaint, coerce a participant, or conceal evidence of alleged improprieties occurring within the center.

(4) The center must have policies that meet the requirements of mandatory reporting procedures as described in chapter 74.34 RCW to adult protective services for vulnerable adults and to local law enforcement for other participants.

(5) Each employee must receive or have access to a copy of the program's personnel policies at the time of employment.

(6) Whenever volunteers function in the capacity of staff, all applicable personnel policies pertain.

(7) The center must conform to federal and state labor laws and be in compliance with equal opportunity guidelines.

(1) Staff selection is dependent on participant needs, program design, and contracting requirements. The center must have the proper balance of professionals and paraprofessionals or nonprofessionals to adequately meet the needs of participants. Services must be delivered by those with adequate professional training. A staff person can have multiple functions, such as an administrator who is also responsible for providing nursing services or social services.

(2) To ensure continuity of direction and supervision, there must be a clear division of responsibility between the governing body and the adult day center administrator.

(3) The administrator must be given full authority and responsibility to plan, staff, direct, and implement the program. The administrator must also have the responsibility for establishing collaborative relations with other community organizations to ensure necessary support services to participants and their families/caregivers.

(4) The administrator must be on site to manage the center's day-to-day operations during hours of operation. If the administrator is responsible for more than one site, or has duties not related to adult day center administration or provision of services, a program director must be designated for each additional site and must report to the administrator.

(5) The administrator must be responsible for the development of a written plan of operation with approval of the governing body and the development, coordination, supervision, fiscal control, and evaluation of services provided through the adult day center.

(6) A nurse or other personnel with a current first aid and CPR card must be on-site whenever participants are attending the adult day care or health program.

(7) Required credentials must be verified to ensure that they are current and in good standing for licensed and certified staff.

(8) Adult day centers may utilize a range of staff under contract or consulting from a larger parent organization or from a private entity to provide services.

(9) Staff commonly utilized by both adult day care and adult day health centers must meet the following requirements:

(a) An activity coordinator must have a bachelor's degree in recreational therapy or a related field and one year of experience (full-time equivalent) in social or health services; or an associate degree in recreational therapy or a related field plus two years of appropriate experience; or three years of paid experience in an activity program and expertise with the population served at the center.

(b) The nurse must be a registered nurse (RN) with valid state credentials in good standing and have at least one-year applicable experience (full-time equivalent) in ambulatory care or hospital nursing or geriatric or preferably in home health or older adult community based nursing and/or work with disabled clients. In addition to a registered nurse, an adult day center can utilize a licensed practical nurse (LPN), but the LPN must be supervised in compliance with all applicable nurse practice acts and standards. The LPN must have valid state credentials in good standing and at least one-year applicable experience (full-time equivalent) in ambulatory care of hospital nursing or geriatric or preferably in home health or older adult community based nursing and/or work with disabled clients. In the adult day care center the RN/LPN does not need to be on site during all hours of operation. In the adult day health center the RN and/or LPN must be on site when the attending participants' who need nursing services are attending the ADH program. If there are no participants who have nursing service interventions identified on their negotiated care plan in attendance then the nurse is not required to be on site during the ADH program time.

(c) The social services professional must have a master's degree in social work, gerontology, or other human services field, or counseling and at least one year of professional work experience (full-time equivalent), or a bachelor's degree in social work, counseling, or a related field and two years of experience in a human services field.

(d) Program assistant/aides or personal care aides must have the appropriate knowledge, skills and training to meet the individual needs of the participants before they are allowed to provide care and services. The assistant/aide competencies must be documented demonstrating their qualification to meet the needs of the center's participants within their job description.

(e) Consultants from a larger parent organization without formal contracts may be utilized whenever the center is part of a larger organization that has the ability to provide professional services within the larger framework.

(f) Consultants, with appropriate, valid state credentials may be utilized as needed to meet the requirements outlined in this chapter. The rehabilitative consultants must perform the professional assessment of the participant, train the staff regarding the participants therapy needs and therapeutic intervention/s, monitor the rehabilitation program and evaluate the participants progress for discharge planning.

(g) Secretary/bookkeepers must have at least a high school diploma or equivalent and skills and training to carry out the duties of the position.

(h) If the adult day center provides transportation drivers must have a valid and appropriate state driver's license, a safe driving record, and training in first aid and CPR. The driver must meet all state requirements for licensure or certification.

(i) Volunteers may be individuals or groups who desire to work with adult day center clients and must take part in program orientation and training. Volunteers and staff must mutually determine the duties of volunteers. Duties to be performed under the supervision of a staff member must either supplement staff in established activities or provide additional services for which the volunteer has special talents. Volunteers will be included in the staff ratio only when they conform to the same standards and requirements as paid staff, meet the job qualification standards of the organization, and have designated responsibilities.

(j) Dietitians must be certified with valid state credentials and have a minimum of one year applicable experience (full-time equivalent).

(1) Direct care staff in adult day centers will vary based upon the number of participants and their care and service requirements. The centers must provide sufficient numbers of qualified staff to meet the participants' needs, but at a minimum must have one staff to six clients for:

(a) Adequate nutrition and hydration;

(b) Health monitoring, education and referral to health services if needed;

(c) Assistance with activities of daily living;

(d) Socialization, recreation, therapeutic activities and stimulation;

(e) Transportation assistance;

(f) Supervision and protection; and

(g) Provision of a safe environment.

(2) The staffing level must be sufficient to serve the number and functioning levels of adult day center participants, meet program objectives, and provide access to other community resources.

(3) There must be sufficient maintenance and housekeeping personnel to assure that the facility is clean, sanitary, and safe at all times.

(4) To ensure adequate care and safety of participants, there must be provision for qualified substitute staff.

(5) As the number of participants with functional impairments, skilled nursing or skilled rehabilitative therapy needs increases, the required staff-participant ratio must be adjusted accordingly.

(6) Direct service staff to participant ratio must be met according to each program the center is contracted to provide, i.e. COPES/RCL and memory care and wellness services (MCWS). The center is required to have daily documentation outlining how they met the staff to resident ratio. This data would include but not be limited to names/titles of employees with date and hours worked and participants' names and date and hours attended.

(7) Staff counted in the staff-participant ratio is those who are trained and able to provide direct service to participants. When there is one participant present, to ensure safety of participant, there must be at least two organizational staff members who have the skills, knowledge and ability to meet the clients need and at least one is currently certified in CPR and first aid.

(1) The minimum staffing requirements for adult day care centers include an administrator/program director, activity coordinator, a consulting registered nurse, and a consulting social worker.

(2) The administrator/program director must have a master's degree and one year of supervisory experience in health or social services (full-time equivalent); or a bachelor's degree in health, social services or a related field, with two years of supervisory experience (full-time equivalent) in a social or health service setting; or a high school diploma or equivalent and four years of experience in a health or social services field, of which two years must be in a supervisory position, and have expertise with the populations served at the center.

(1) The minimum staffing requirements for adult day health centers include an administrator, program director, registered nurse, activity coordinator, a PT/OT or speech therapist, and a social worker. The administrator and program director may be the same person.

(2) The program administrator must have a master's degree and one year of supervisory experience in health or social services (full-time equivalent), or a bachelor's degree and two years of supervisory experience in a social or health service setting. The degree may be in nursing.

(3) The program director must have a bachelor's degree in health, social services or a related field with one year of supervisory experience (full-time equivalent) in a social or health service setting. Upon approval by the department, a day health center may request an exception for an individual with an associate's or vocational degree in health, social services, or a related field with four years of experience in a health or social service setting, of which two years must be in a supervisory position.

(4) Registered nurses and licensed practical nurses per WAC 388-71-0752.

(5) Therapists, regardless of specific expertise, such as physical therapists, occupational therapists, speech therapists, recreation therapists, mental health therapists, or any other therapists used, must have valid state credentials and one year of experience in a social or health setting.

(6) Rehabilitative therapeutic assistants must be certified with valid state credentials, have at least one year of applicable experience (full-time equivalent), and meet the requirements of chapter 246-915, 246-847, or 246-828 WAC.

(7) A certified or registered nursing assistant must meet the requirements of chapter 18.88A RCW.

(1) Each employee must have an individual file containing the employee's application, verification of references, TB status, signed job description, and all performance evaluations. Copies of current license, certificate, or registration and verification of current good standing, and a current certification of CPR and first aid training, if applicable, must also be in the file.

(2) Centers must maintain employee records for the duration of staff employment and at least seven years after termination of employment.

(3) Employee records must contain documentation demonstrating the employee was oriented to the facility, job and possesses the knowledge, skills and ability to perform their assigned duties. The record should also contain documentation demonstrating the employee understands and will follow the center's policies and procedures regarding but not limited to medication disposal, the emergency and evacuation plan, the abuse, neglect, abandonment and financial exploitation of vulnerable adults and universal precaution policies and procedures.

(4) Background checks pursuant to RCW 43.43.830 and 43.43.832 must be performed for all applicants hired, existing employees, and volunteers who function as staff or who have unsupervised access to participants. Unsupervised access to participants is prohibited until a background check has been completed and the employee's suitability for employment has been determined. Background checks must be updated every two years and documentation maintained in the employees' or volunteers' functioning as staff, record.

(1) Provision must be made for orientation of new employees, contractors, and volunteers.

(2) Every year, all staff, contractors, and volunteers, functioning as staff, must receive, at a minimum, quarterly in-service training and staff development that meets their individual training needs to support program services. This must be documented and readily accessible in the personnel file.

(3) Staff, contractors, and volunteers, who function as staff, must receive training regarding the following at a minimum:

(a) How to document in participants' records;

(b) What the center's emergency plan and evacuation procedure is and how to implement;

(c) How to respond to aggressive or assaultive participants;

(d) How to receive and respond to grievances;

(e) What are universal precautions and how to implement in the day to day operations in the center;

(f) Reporting requirements such as but not limited to:

(i) Mandatory reporting for abuse, neglect, abandonment, and exploitation of vulnerable adults; and

(ii) Local health department procedure for disease outbreak.

(4) At a minimum, one staff person per shift must have current training and certification in CPR/first aid.

(5) Staff and volunteers functioning as staff, must receive education and training on all applicable policies and procedures within two weeks of employment.

(1) The center must develop written medication policies that support and promote safe medication storage and administration for each participant and meet the requirements of chapters 69.41 RCW and 246-88 WAC and other applicable statutes. These policies must be explained and accessible to all staff, contractors, volunteers, and participants that have responsibility in this area.

(2) Participants who need to take medications while at the center, and who are able to self-medicate, must be encouraged and expected to bring and take their own medications as prescribed. Some participants may need assistance with their medications, and some may need to have their medications administered by qualified program staff.

(3) In order for the center staff to administer any prescribed medication, there must be a written authorization from the participant's authorizing practitioner stating that the medication is to be administered at the program site.

(4) Staff must be trained to observe medication usage and effects, and to document and report any concerns or difficulties with medications.

(5) At a minimum, medication policies must include the following:

(a) How medications will be labeled and stored. Medications must be:

(i) Labeled according to your policy including prescribed and over the counter medications;

(ii) Kept in a locked storage area organized so client's medications are not mixed together; and

(iii) If refrigeration is necessary, medications should be in a locked box, if not in a separate refrigerator dedicated to medication refrigeration.

(b) Procedures for administration of medications, including:

(i) What program staff are allowed and able to administer medications and under what circumstances;

(ii) How nonprescription medications such as aspirin or laxatives are to be used; and

(iii) How the administration of medications will be entered in participant case records as described in WAC 388-71-0744.

(1) Selection of a location for a center must be based on information about potential participants in the service area and be made in consultation with other agencies, organizations, and institutions serving older individuals and those with functional impairments, as well as considering the availability of a suitable location.

(2) Centers must have available a current floor plan of the facility indicating usage of space with interior measurements, building inspection report from the local, city or county, building department, if applicable, fire department inspection report, and the local health department kitchen inspection report and permit if operating an on-site kitchen.

(3) When possible, the facility should be located at street level. If the facility is not located at street level, it is essential to have a ramp and/or elevators. All new adult day service centers contracted with the department after February 1, 2014 must have a ramp, at least a 1:12 slope, for emergency evacuation if the center has any steps or stairs to be navigated during an emergency evacuation. An evacuation plan for relocation of participants to another building must also be in place in the event of an emergency. The center must post a floor plan of the center and indicate the evacuation route from each room to the outside meeting place.

(4) Each adult day center co-located in a facility housing other services must have its own separate identifiable space for main activity areas during operational hours. Certain space can be shared, such as the kitchen and therapy rooms.

(5) Each center must provide appropriate hardware on doors of storage rooms, closets, bathrooms, and other rooms to prevent participants from being accidentally locked in.

(6) When possible, the location should be within a transit authority's core service area.

(7) The facility must have:

(a) Sufficient space to accommodate a full range of programs and activities necessary for participant needs;

(b) Be adaptable to accommodate variations of activities for group and individual services;

(c) Maintain essential space when providing services to protect the privacy and dignity of each participant in a respectful manner;

(d) Sufficient space available for private discussions; and

(e) Private and designated space allowing staff to work without interruption.

(8) The facility must provide at least sixty square feet of program space for multipurpose use for each day center participant. In determining adequate square footage, only those activity areas commonly used by participants are to be included. Hallways, dining and kitchen areas are to be included only if these areas are used by clients for activities other than meals. Reception or lobby areas, storage areas, offices, restrooms, passageways, treatment rooms, service areas, or specialized spaces used only for therapies are not to be included when calculating square footage.

(9) Storage space.

(a) There must be adequate storage space for program and operating supplies.

(b) Toxic substances, whether for activities or cleaning, must be stored in an area not accessible to participants. Substances must be clearly marked, the contents identified, and stored in original containers.

(10) Restrooms.

(a) The facility's restrooms must be located as near the activity area as possible, preferably no more than forty feet away. The facility must include at least one toilet for every ten participants. The facility must provide privacy for the participant when using the restroom facilities.

(b) Programs that have a large number of participants who require more scheduled toileting or assistance with toileting must have at least one toilet for every eight participants.

(c) The toilets shall be equipped for use by mobility-limited persons and easily accessible from all program areas. One toilet area should be designed to allow assistance from one or two staff. More accessible units may be required based upon the needs of the participants.

(d) Each restroom must contain an adequate supply of soap, toilet tissues, and paper towels.

(e) After month/day/year all newly contracted adult day service facilities or contracted adult day service providers opening another site must have at least one roll in shower for participant use. Showers are to be accessible to those who require bathing as an ADC service.

(11) Rest area.

(a) In addition to space for program activities, the facility must have a designated rest area which provides privacy and maintains dignity for participants who become ill, disruptive, or who may require rest. The designated space must not be used for discipline or staff convenience.

(b) The rest area must be located away from activity areas and near a restroom and the nurse's office. There must be at least one bed, couch, or recliner for every ten participants that can be used for resting or the isolation of a participant who is ill or suspected of coming down with a communicable disease.

(c) If beds are used, the mattresses and pillow must be protected, cleaned and disinfected after each participant use. The bed linens must be clean and changed after each use by different participants to prevent the spread of infection.

(12) Loading zones/parking/entrances/exits.

(a) A loading zone with sufficient space for getting in and out of a vehicle must be available for the safe arrival and departure of participants and the use of emergency personnel.

(b) There must be sufficient parking available to accommodate family caregivers, visitors, and staff.

(c) When necessary, arrangements must be made with local authorities to provide safety zones for those arriving by motor vehicle and adequate traffic signals for people entering and exiting the facility.

(d) Adequate lighting must be provided in all loading and parking zones, entrances, and exits.

(e) An adult day center must be visible and recognizable as a part of the community. The entrance to the facility must be clearly identified. The center must also be appealing and protective to participants and others.

(f) At least two well-identified exits must be accessible from the building.

(13) Atmosphere and design.

(a) The center's design must facilitate the participants' movement throughout the facility and encourage involvement in activities and services.

(b) The environment must reinforce orientation and awareness of the surroundings by providing cues and information about specific rooms, locations, and functions that help the participant to get his/her orientation to time and space.

(c) A facility must be architecturally designed in conformance with the requirements of section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act to accommodate individuals with a disability and meet any state and local barrier-free requirements.

(d) Illumination levels in all areas must be adequate, and careful attention must be given to avoiding glare. Attention must be paid to lighting in transitional areas, such as outside to inside and between different areas of the facility.

(e) Sound transmission must be controlled. Excessive noise, such as fan noise, must be avoided.

(f) Comfortable conditions must be maintained within a comfortable temperature range. Excessive drafts must be avoided uniformly throughout the facility.

(g) Sufficient furniture must be available for the entire population present. Furnishings must accommodate the needs of participants and be attractive, comfortable, sturdy, clean and safe. Straight-backed chairs with arms must be used during activities and meals.

(h) A telephone must be available for participant use. Local calls are to be available at no cost to the participant.

(14) Safety and sanitation.

(a) The facility and grounds must be safe, clean, and accessible to all participants, and must be designed, constructed, and maintained in compliance with all applicable local, state, and federal health and safety regulations.

(b) Nonslip surfaces must be provided on stairs, ramps, and interior floors.

(c) Alarm/warning systems are necessary to ensure the safety of the participants in the facility in order to alert staff to potentially dangerous situations. This system needs to be activated when the center's staff have determined a participant has a potential safety issue of wandering. It is recommended that call bells be installed or placed in the rest areas, restroom stalls, and showers.

(d) An emergency evacuation plan with outside meeting location at a safe distance from the building must be strategically posted in each facility so that all participants, staff, and visitors can view it. If the center provides services to primarily non-English speaking clients the evacuation plan must also contain instructions in the primary language used by clients of the center. The center's emergency disaster plan must be readily available to all staff and reviewed routinely to ensure a safe and secure environment during a disaster.

(e) The facility must be free of hazards, such as high steps, steep grades, and exposed electrical cords. Steps and curbs must be painted and the edges of stairs marked appropriately to highlight them. All steps, stairs, ramps, and bathrooms accessible to those with disabilities must be equipped with securely anchored handrails on both sides.

(f) Emergency first-aid kits and manuals must be visible and accessible to staff. Contents of the kits must be replenished after use and reviewed as needed.

(g) Maintenance and housekeeping must be carried out on a regular schedule and in conformity with generally accepted sanitation standards, without interfering with the program.

(h) If smoking is permitted, the center must follow chapter 70.160 RCW, Smoking in public places.

Centers must provide meal service to all participants as outlined in WAC 388-71-0704 and 388-71-0706.

(1) All meals provided are to meet one-third of the minimum required daily allowance or dietary reference intake as determined by the Food and Nutrition Board of the Institute of Medicine.

(2) The center must ensure that food served meets nutritional needs, takes into consideration individual and ethnic preferences to the extent reasonably possible, caloric need, special dietary requirements, and any physical condition making food intake difficult.

(3) The center must provide a variety of foods and not repeat menus for a minimum of three weeks.

(4) Participant input must be gathered when planning meals.

(5) Menus must be posted at least one week in advance; indicate the month, year, date, day of the week; and include food and snack choices served that contribute to nutritional requirements.

(6) Nutrient concentrates, supplements, and dysphagia-modified diets related to a choking or aspiration risk, are to be served only with the written approval of the participant's authorizing practitioner.

(7) Safe and sanitary handling, storage, preparation, and serving of food must be assured. If meals are prepared on the premises, kitchen appliances, food preparation area, and equipment must meet state and local requirements and pass inspections annually.

(8) All staff and volunteers handling or serving meals must have the appropriate food handler's permits, if applicable.

(9) In the event meals are prepared at a separate kitchen facility, the adult day center must ensure that persons preparing food have a food handler's permit and that the food is transported in airtight containers to prevent contamination.

(10) The center must ensure that the food is transported and served at the appropriate and safe temperature.

(1) A written emergency/disaster/earthquake plan must be readily available to all staff at each program site and in all program owned vehicles. Staff must be trained to ensure smooth implementation of the emergency plan.

(2) All staff and volunteers must be trained in evacuation/fire safety procedures.

(3) The center's written illness/injury/medical emergency/death procedure must be followed in the event a participant becomes ill, is injured, or dies. The procedures must be readily available to all staff during program hours and must be explained to staff, volunteers, and participants.

(4) Procedures for fire safety as approved by the local fire authority must be adopted and readily available to all staff, including provisions for fire drills, inspection and maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. The center must conduct and document quarterly fire drills and document the center's ability to meet procedures. Improvements must be based on the fire drill evaluation. The center must post their building's floor plan with evacuation route from each room to the outside predetermined meeting place. Smoke detectors must also be used and serviced on a routine basis per the center's policy.

(5) Each center must provide adequate emergency lighting or flashlights in all areas.

(6) Each center must provide and maintain first-aid kits with manuals in adequate numbers to meet the needs of the participant and staff.

(7) Each center must ensure, in accordance with local emergency procedures, that supplies, food, water and equipment are available in the event power, heat and/or electricity are not available during an emergency.

(1) All adult day centers must develop an annual quality improvement plan that identifies specific concerns regarding the quality of care and services to clients. The plan must also include a description of the plan of action that would address the concerns. The plan must have specific measurable objectives, designed to meet requirements of any licensing, funding sources, professional standards, or regulatory compliance.

(2) Policies and procedures for monitoring program quality and determining further action must be developed by the administrator with the advice of the multidisciplinary staff team and the advisory committee, and with the approval of the governing body and center clients and/or representatives.

(3) Quality assurance and improvement plans may include but are not limited to annual program evaluations, utilization reviews, participants' and former participants' satisfaction surveys, and sampling participant care plans to audit for assurances of meeting the WAC requirements.

WAC 388-71-0702 through 388-71-0776 is effective [July 1, 2003] [February 1, 2014].

The following definitions apply to the long-term care worker training requirements:

(1) "Activities of daily living" means self-care abilities related to personal care such as bathing, eating, using the toilet, medication assistance, dressing, and transfer. Instrumental activities of daily living may also be used to assess a person's functional abilities in the home and the community such as cooking, shopping, house cleaning, doing laundry, working, and managing personal finances.

(2) "Care team" means the client and everyone involved in the individual's care. The care team may include family, friends, doctors, nurses, long-term care workers, social workers, and case managers. The role of the care team is to support the client's well-being. However, the client directs the care plan.

(3) "Challenge test" means a competency test taken for specialty training without first taking the class for which the test is designed and may only be used when basic training is not required.

(4) "Client" means an individual receiving in-home services.

(5) "Competency" means the integrated knowledge, skills, or behavior expected of a long-term care worker after completing training in a required topic area. Learning objectives are associated with each competency.

(6) "Competency testing" means evaluating a student to determine if the student can demonstrate the required level of skill, knowledge, and behavior with respect to the identified learning objectives of a particular course. The department only requires competency testing for nurse delegation core and specialized diabetes training, and the specialty and expanded specialty trainings. Training programs may integrate competency testing within each programs' approved curricula.

(7) "Core basic training" means the portion of the 70-hour home care aide basic training that covers the core competencies and skills that long-term care workers need in order to provide personal care services efficiently and safely. The core basic training hours also includes hours devoted to student practice and demonstration of skills.

(8) "Date of hire" for determining time frames related to training and certification, means the first day the long-term care worker is employed by any employer.

(9) "DDA" refers to the developmental disabilities administration.

(10) "Direct care worker" means a paid individual who provides direct, personal care services to persons with disabilities or the elderly requiring long-term care (see also the definition of long-term care worker, which includes client care workers).

(11) "Department" or "DSHS" means the department of social and health services.

(12) "Enhancement" means additional time provided for skills practice and additional training materials or classroom activities that help a long-term care worker to thoroughly learn the course content and skills. Enhancements can include new student materials, videos or DVDs, online materials, and additional student activities.

(13) "Expanded specialty training" means optional curricula that provide caregivers with advanced knowledge and skills to provide person-centered care to clients or residents living with conditions other than developmental disabilities, dementia, and mental health. The optional expanded specialty training may include such topics as traumatic brain injury, diabetes care, and bariatric care. The optional expanded specialty training curricula must be DSHS developed and based on competencies and learning objectives established by the department.

(14) "Guardian" means an individual as defined in chapter 11.130 RCW.

(15) "Home care aide" or "certified home care aide" means a long-term care worker who has obtained and maintains a home care aide certification through the department of health.

(16) "Hybrid" means a combination of online training and in-person, remote, or virtual classroom instruction.

(17) "Individual provider" or "IP" means a person employed by the consumer directed employer to provide personal care or respite care services to persons with functional disabilities under a medicaid state plan program, such as the medicaid personal care or community first choice programs, under a federal medicaid waiver program, or through the veteran directed home care (VDHC) program.

(18) "Learning objectives" means measurable, written statements that clearly describe what a long-term care worker must minimally learn to meet each competency. Learning objectives are identified for each competency. Learning objectives provide consistent, common language and a framework for curriculum designers, the curriculum approval process, and testing. Curriculum developers have the flexibility to determine how learning objectives are met and may include additional content deemed necessary to best meet the competency in a particular setting.

(19) "Long-term care worker" means:

(a) All persons who provide paid, personal care services for the elderly or persons with disabilities, including but not limited to individual providers of home care services, direct care workers employed by home care agencies, providers of home care services to persons with developmental disabilities under Title 71A RCW, all direct care workers in state-licensed assisted living facilities, adult family homes, respite care providers, community residential service providers, and any other direct care staff who provide home or community-based services to the elderly or persons with functional disabilities or developmental disabilities.

(b) Long-term care workers do not include:

(i) Persons employed by the following facilities or agencies: Nursing homes subject to chapter 18.51 RCW, hospitals or other acute care settings, residential habilitation centers under chapter 71A.20 RCW, facilities certified under 42 C.F.R., Part 483, hospice agencies subject to chapter 70.127 RCW, adult day care centers; or

(ii) Persons who are not paid by the state, by a private agency, or facility licensed by the state to provide personal care services.

(20) "Online training" means a course taken through an automated, asynchronous learning management system or other technology that conforms to the online training standards posted on the DSHS website at https://bit.ly/dshs-online-standards.

(21) "Personal care services" means physical or verbal assistance with activities of daily living, or activities of daily living and instrumental activities of daily living that are provided to the client.

(22) "Remote skills training" means training conducted in a virtual classroom environment, or online when a student either demonstrates a skill live or provides a video recorded file of themselves performing a skill that is forwarded for feedback to an approved instructor or a proctor trained by an approved instructor, or both. A training program must be approved by DSHS to provide remote skills training.

(23) "70-hour home care aide training" means the 70 hours of required training that a new long-term care worker must complete within 120 days of hire. It has three components: Core competencies, practice of skills, and population specific topics, which may include specialty and nurse delegation training.

(24) "Specialty training" means curricula that meets the requirements of RCW 18.20.270 and 70.128.230 to provide basic core knowledge and skills that caregivers need to learn and understand to effectively and safely provide care to residents living with mental illness, dementia, or developmental disabilities. The specialty training curricula may be DSHS developed or DSHS approved and must be based on the competencies and learning objectives in WAC 388-112A-0430, 388-112A-0440, or 388-112A-0450.

(25) "Training entity" means an organization, including an independent contractor, who provides or may provide training under this chapter using approved curriculum. Training entities may only deliver approved curriculum.

(26) "Training partnership" means a joint partnership or trust that includes the office of the governor, and the exclusive bargaining representative of individual providers under RCW 74.39A.270 with the capacity to provide training, peer mentoring, and workforce development, or other services to individual providers.

(27) "Virtual classroom" means a synchronous, instructor-led, remote learning environment conducted in real time that conforms to the virtual classroom standards posted on the DSHS website at https://bit.ly/dshs-online-standards. A training program must be approved by DSHS to provide virtual classroom instruction.

(1) The department determines a long-term care worker's date of hire according to the first day the long-term care worker is employed by any employer.

(2) The date of hire is specific to each long-term care worker. A long-term care worker, including an individual or agency provider who has worked as a long-term care worker in the past, but who did not complete the training or certification that was required at the time, and a worker who is not currently certified or eligible to reactivate an expired credential, shall receive a new date of hire when beginning work with either a new employer or returning to a former employer after prior employment has ended.

(3) This section does not apply to background check requirements under this chapter.

The following long-term care workers are exempt from the 70-hour, 30-hour, nine-hour, or seven-hour basic training requirement:

(1) An individual employed as a long-term care worker on January 6, 2012, who complied with the basic training requirements in effect on the date of hire;

(2) An individual previously employed as a long-term care worker who completed the basic training requirements in effect on the date of hire, and was employed as a long-term care worker at some point between January 1, 2011, and January 6, 2012;

(3) Registered nurses, licensed practical nurses, and advanced registered nurse practitioners licensed under chapter 18.79 RCW;

(4) Nursing assistants certified under chapter 18.88A RCW and persons in an approved training program for certified nursing assistants under chapter 18.88A RCW provided that they complete the training program within 120 days of the date of hire and the department of health has issued a nursing assistant certified credential within 200 days of the date of hire;

(5) A home health aide who was employed by a medicare certified home health agency within the year before being hired as a long-term care worker and has met the requirements of 42 C.F.R., Sec. 484.36;

(6) An individual with special education training who has an endorsement granted by the Washington state superintendent of public instruction as described in RCW 28A.300.010; and

(7) A home care aide (HCA) certified under chapter 18.88B RCW.

(1) Long-term care worker orientation is two hours of orientation training regarding the long-term care worker's role and the applicable terms of employment. Individuals required to complete the 70-hour home care aide basic training must complete long-term care worker orientation before providing care to a client.

(2) Long-term care worker orientation training, unless taken through a department approved online training program, must be provided by qualified instructors who meet the requirements of WAC 388-71-1060.

(3) The department must approve orientation curricula and instructors.

(4) There is no competency test for long-term care worker orientation.

(1) For long-term care worker orientation required of those individuals identified in WAC 388-71-0860, long-term care worker orientation is a two hour training that must include introductory information in the following areas:

(a) The care setting and the characteristics and special needs of the population served;

(b) Basic job responsibilities and performance expectations;

(c) The care plan or negotiated service agreement, including what it is and how to use it;

(d) The care team;

(e) Process, policies, and procedures for observation, documentation, and reporting;

(f) Resident rights protected by law, including the right to confidentiality and the right to participate in care decisions or to refuse care and how the long-term care worker will protect and promote these rights;

(g) Mandatory reporter law and worker responsibilities as required under chapter 74.34 RCW; and

(h) Communication methods and techniques that may be used while working with a resident or guardian and other care team members.

(2) One hour of completed classroom instruction or other form of training (such as a video or online course) in long-term care orientation training equals one hour of training. The training entity must establish a way for the long-term care worker to receive feedback from an approved instructor or a proctor trained by an approved instructor.

(1) Safety training is part of the long-term care worker requirements. It is a three-hour training that must meet the requirements as described in WAC 388-71-0855, and includes basic safety precautions, emergency procedures, and infection control. Safety training must be completed prior to providing care to the client.

(2) All long-term care workers who are not exempt from home care aide certification as described in RCW 18.88B.041 hired after January 7, 2012, must complete three hours of safety training. This safety training must be provided by qualified instructors who meet the requirements in WAC 388-71-1060.

(3) The department must approve safety training curricula and instructors.

(4) There is no competency test for safety training.

Safety training consists of introductory information in the following areas:

(1) Safety planning and accident prevention, including but not limited to:

(a) Proper body mechanics;

(b) Fall prevention;

(c) Fire safety;

(d) In-home hazards;

(e) Long-term care worker safety; and

(f) Emergency and disaster preparedness.

(2) Standard precautions and infection control, including but not limited to:

(a) Proper hand washing;

(b) When to wear gloves and how to correctly put them on and take them off;

(c) Basic methods to stop the spread of infection;

(d) Protection from exposure to blood and other body fluids;

(e) Appropriate disposal of contaminated/hazardous articles;

(f) Reporting exposure to contaminated articles; and

(g) What to do when sick or injured, including whom to report this to.

(3) Basic emergency procedures, including but not limited to:

(a) Evacuation preparedness;

(b) When and where to call for help in an emergency;

(c) What to do when a client is falling or falls;

(d) Location of any advanced directivesif available; and

(e) Basic fire emergency procedures.

(4) One hour of completed classroom instruction or other form of training (such as video or online course) equals one hour of training. The training entity must establish a way for the long-term care worker to receive feedback from an approved instructor or a proctor trained by an approved instructor.

(1) Unless exempted in WAC 388-71-0839 (1) through (7), all long-term care workers must complete orientation and safety training prior to providing care to a client.

(2) All individual providers must contact the training partnership and follow the required procedures to confirm that they have completed the orientation and safety training, once it is completed.

(1) The 70-hour home care aide basic training is in addition to orientation and safety training. It is 70 hours and includes:

(a) The core competencies and skills that long-term care workers need in order to provide personal care services effectively and safely;

(b) Practice and demonstration of skills; and

(c) Population specific competencies.

(2) DSHS must approve the 70-hour home care aide basic training curricula.

(3) On-the-job training, as described in WAC 388-71-0932, may be applied to the 70-hour home care aide basic training for an amount that must be approved by the department.

(4) The DSHS developed fundamentals of caregiving (FOC) or another department approved training may be used to teach core basic training but the FOC must include enhancements. Additional student materials are required to ensure the enhancements are well planned and documented for students. Materials must be submitted for approval and approved per WAC 388-71-1026. Examples of enhancements include, but are not limited to:

(a) More time for workers to practice skills including:

(i) The mechanics of completing the skill correctly;

(ii) Client centered communication and problem solving associated with performing the skill;

(iii) The different levels of care required for each skill including independent, supervision, limited, extensive, and total;

(iv) Working with assistive devices associated with a skill.

(v) Helpful tips or best practices in working through common client challenges associated with a skill; and

(vi) Disease specific concerns or challenges associated with a skill.

(b) Augmenting or adding additional materials, student activities, videos, or guest speakers that:

(i) More deeply reinforce and fortify the learning outcomes required for basic training;

(ii) Ensure each student integrates and retains the knowledge and skills needed to provide quality basic personal care; and

(iii) Prepares workers for the certification testing environment and process.

(c) Enhancements are not materials or activities that are one or more of the following:

(i) Are out of the scope of practice for a long-term care worker such as content clearly written for registered nurses;

(ii) Are identical to, or a direct replacement of, those already included in FOC;

(iii) Fail to reinforce Washington state laws associated with client rights and client directed care;

(iv) Long-term care workers are not paid to provide; and

(v) Are written above a high school reading level.

(5) The delivery mode of the 70-hour home care aide basic training may be either in-person or virtual classroom instruction, or a hybrid of online and in-person, remote, or virtual classroom instruction. One hour of completed classroom instruction or other form of training (such as virtual classroom, remote, or online course) equals one hour of training.

(a) Online and virtual classroom modules must be interactive, provide the student with access to the instructor, and adhere to the DSHS online and virtual classroom standards posted on DSHS's website https://bit.ly/dshs-online-standards.

(b) The in-person skills training or remote skills training portion of hybrid modules must be no less than 16 hours of the total basic training hours and include in-person or remote instruction on the personal care tasks supporting activities of daily living as described in WAC 388-71-0911.

(6) The long-term care worker must be able to ask the instructor questions during the training.

(7) There is no challenge test for the 70-hour home care aide basic training.

(1) A training program offering remote skills training must meet the following minimum requirements:

(a) Provide students with:

(i) The opportunity to practice, review, and receive coaching for every skill;

(ii) Virtual classroom demonstrations or videos of each skill;

(iii) Access to all supplies and materials required for practice;

(iv) Reasonable alternatives for skills when a live partner would not be safe or practical;

(v) Clearly outlined student performance guidelines for each skill that provide definitions for the levels of performance, such as:

(A) Excellent – Exceeds expectations;

(B) Satisfactory – Meets expectations;

(C) Developing – Approaching expectations;

(D) Potential for harm – Fails to meet expectations.

(vi) The opportunity to receive individualized feedback on every skill within seven business days unless other mutual arrangements are made;

(vii) The ability to receive instructional support through multiple formats such as by phone, chat, text, or email, or using the technology provided through a learning management system;

(viii) Equal access to knowledge acquisition through such methods as providing materials in multiple formats, allowing access through different devices, and providing learner-centered approaches for individual situations;

(ix) Accessible instructions for all technology skills required;

(x) Technical support for any technology that students need to access the training;

(xi) The ability to communicate with an instructor, peer mentor, or basic support team in real time to answer questions scheduled with varying hours to accommodate students who may work different shifts;

(xii) Downloadable and printable step-by-step guides for each skill taught.

(b) Include scheduled, flexible opportunities for students to access support during which a student may ask questions and have skills demonstrated.

(c) Support knowledge acquisition of skills equitably using methods designed to accommodate the needs of diverse learning styles and the use of various devices; and

(d) Provide reasonable accommodations to students upon request.

(2) If a student fails to attain a satisfactory skill level for any skill through remote training, the training program will provide opportunities for remediation or additional practice for the skill.

(3) A training program must be approved by DSHS to provide remote skills training. Initial approval shall be provisional for one year during which a training program will be required to:

(a) Confer with DSHS training quality assurance staff no less than quarterly;

(b) Allow DSHS training quality assurance staff access to any materials, processes, training sessions, and documentation when requested; and

(c) Track student certificates of completion and monitor pass/fail data to the extent feasible for all students trained remotely and provide that data to DSHS when requested.

(4) Renewal of approval to provide remote skills training after the one-year provisional period shall be conditional upon a training program's:

(a) Adherence to the standards outlined in this section; and

(b) Satisfactory demonstration, to the extent feasible, that the training program's pass/fail rate for students trained remotely meets or exceeds the statewide average pass/rate for students trained in person.

(5) If data for renewal is insufficient to determine an accurate pass/fail rate, the department may renew provisional certification for an additional year.

Unless exempt from training in WAC 388-71-0839(1) through (7), all long-term care workers must complete core and population specific competencies within 120 days of the date of hire as described in WAC 388-71-0837.

(1) Unless exempt from training as described in WAC 388-71-0839 or WAC 388-112A-0090, a long-term care worker affected by the COVID-19 public health emergency must complete training, including required specialty training, as follows:

(2) Unless exempt from certification as described in WAC 246-980-025, a worker affected by the COVID-19 public health emergency who is required to be certified as a home care aide must obtain certification as follows:

(3) "Hired" and "rehired" as used in this section mean the date of hire as defined in chapter 246-980 WAC. A long-term care worker is considered rehired if they held previous employment as a long-term care worker and did not have an active home care aide credential when hired during the time frames outlined in section (1) of this section.

(4) If a long-term care worker is limited-English proficient, the worker may request an additional 60 days to obtain certification.

(5) Nothing in this section prevents a long-term care worker hired between 8/17/2019 and 9/30/2022 from completing training or obtaining certification in advance of the deadlines stipulated in subsections (1) or (2) of this section.

Unless exempt from the basic training requirements under WAC 388-71-0839 (1) through (7), the following individuals must complete the 30-hour basic training under WAC 388-71-0885 within 120 days of the date of hire as described in WAC 388-71-0837:

(1) An individual provider who only cares for that provider's:

(a) biological, step, or adoptive child, or parent; or

(b) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(2) A long-term care worker providing approved services only for a spouse or registered domestic partner and funded through the United States department of veterans' affairs home and community-based programs; or

(3) A long-term care worker who provides no more than 20 hours of nonrespite care for one person who is not the individual provider's:

(a) biological, step, or adoptive child, or parent; or

(b) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership.

The thirty hour training is a subset of the seventy hour basic training that must include core and population specific basic training. Topics completed in the subset must be on topics relevant to the care needs of the client(s). There is no challenge test for the thirty hour training.

(1) The following individual providers must complete 70 hours of basic training and become a certified home care aide under WAC 388-71-0523:

(a) Individual providers who previously provided no more than 20 hours of nonrespite care in any calendar month for one person who is not the provider's:

(i) biological, step, or adoptive child or parent;

(ii) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(iii) spouse or registered domestic partner and funded through the United States department of veterans' affairs home and community-based programs;

(A) who continue to work for one unrelated client whose authorized monthly hours fluctuate above 20 hours per month; or

(B) who begin to work for a second client.

(b) Individual providers who provide respite services and worked more than 300 respite hours in any calendar year;

(c) Individual providers who begin working for an unrelated client who previously only provided personal care to the provider's:

(i) biological, step, or adoptive child, or parent; or

(ii) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(iii) spouse or registered domestic partner and funded through the United States department of veterans' affairs home and community-based programs.

(2) When an IP described in subsection (1) of this section is required to complete the 70-hour basic training and become a certified home care aide, the IP will:

(a) Have 120 days from the date of the change to complete the 70-hour basic training and 200 days from the date of the change to become certified; and

(b) Be required to complete continuing education under WAC 388-71-0990.

(3) For the purpose of this section, the date of the change means the date on which the IP:

(a) Began working for a client that is not the individual's:

(i) biological, step, or adoptive child, or parent; or

(ii) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(iii) spouse or registered domestic partner receiving approved services funded through the United States department of veterans' affairs home and community-based programs.

(b) Exceeded 20 hours of work in one month; or

(c) Exceeded 300 respite hours in one calendar year.

(4) If an IP is required to or chooses to become a certified home care aide and completes the 70-hour training requirements under this section, the individual will be required to continue to comply with these requirements to maintain the credential and complete continuing education requirements even if:

(a) The monthly authorized hours are later reduced to 20 or fewer hours;

(b) The individual no longer works for more than one unrelated client; or

(c) The individual works 300 or fewer respite hours in a calendar year.

(5) The training and certification requirements for an individual that met the criteria in subsection (4) of this section does not apply if the individual returns to work only for the individual's:

(a) biological, step, or adoptive parent, or adult child,

(b) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(c) spouse or registered domestic partner receiving approved services funded through the United States department of veterans' affairs home and community-based programs.

Unless exempt from the basic training requirements as defined in WAC 388-71-0839 (1) through (7), a biological, step, or adoptive parent who is the individual provider for his or her adult child receiving services through the DSHS developmental disabilities administration must complete the twelve hour parent provider training, as described in WAC 388-71-0895, within one hundred twenty days from the begin date of the authorization to provide department paid, in-home services.

(1) Unless exempt from the basic training requirements under WAC 388-71-0839 (1) through (7), an individual provider must complete orientation and safety training and nine hours of training within 120 days of the date of hire as described in WAC 388-71-0837 if the provider meets the following criteria:

(a) Provides respite services for individuals with developmental disabilities receiving services under Title 71A RCW; and

(b) Works 300 hours or less of respite in any calendar year.

(2) The individual provider must complete the orientation and safety training before providing care.

(3) The training partnership identified in RCW 74.39A.360 must offer at least 12 of the 14 total hours online and five of these online hours must be individually selected from elective courses.

(4) An individual must complete the nine hours basic training required under this section within 120 days of the long-term care worker's date of hire.

(1) The twelve hour parent provider training must include five hours of orientation and safety training as described in WAC 388-71-0841 and 388-71-0850. The remaining seven hours will cover the following topics:

(a) Medicaid personal care;

(b) Assessments completed by the division of developmental disabilities;

(c) Community resources;

(d) State and federal benefits;

(f) Networking; and

(g) Client self-determination.

(2) There is no challenge test for this training.

Basic training must include all of the competencies under WAC 388-71-0911 for the following topics:

(1) Communication skills;

(2) Long-term care worker self-care;

(3) Problem solving;

(4) Client rights and maintaining dignity;

(5) Abuse, abandonment, neglect, financial exploitation, and mandatory reporting;

(6) Client directed care;

(7) Cultural sensitivity;

(8) Body mechanics;

(9) Fall prevention;

(10) Skin and body care;

(11) Long-term care worker roles and boundaries;

(12) Supporting activities of daily living;

(13) Food preparation and handling;

(14) Medication assistance;

(15) Infection control and bloodborne pathogens; and

(16) Grief and loss.

Home care aide basic training includes core competencies that describe the behavior and skills that a long-term care worker must exhibit when working with clients and the learning objectives associated with each competency as follows:

(1) Communicate effectively and in a respectful and appropriate manner with clients, family members, and care team members:

(a) Recognize how verbal and nonverbal cues impact communication with the client and care team;

(b) Engage and respect the client through verbal and nonverbal communication;

(c) Listen attentively and determine that the client, when able, understands what has been communicated;

(d) Recognize and acknowledge clients' communication including indicators of pain, confusion, or misunderstanding;

(e) Utilize communication strategies to deal with difficult situations; and

(f) Recognize common barriers to effective communication and identify how to eliminate them.

(2) Regarding long-term care worker self-care:

(a) Identify behaviors, practices, and resources to reduce stress and avoid burnout;

(b) Recognize common barriers to self-care and ways to overcome them; and

(c) Recognize aspects of a long-term care worker's job that can lead to stress and burnout, common signs and symptoms of stress and burnout, and the importance of taking action to practice self-care to avoid burnout.

(3) Regarding the competency of effective problem solving, use effective problem solving skills to:

(a) Explain why it is necessary to understand and utilize a problem solving method;

(b) Implement a problem solving process/method; and

(c) Identify obstacles to effective problem solving and ways to overcome them.

(4) Regarding the competency of client rights and dignity, take appropriate action to promote and protect a client's legal and human rights as protected by federal and Washington state laws including:

(a) Protect a client's confidentiality, including what is considered confidential information, to whom a long-term care worker is allowed or not allowed to give confidential information, and how to respond if a non-care team member asks for confidential information;

(b) Promote client's dignity and privacy, and encourage, and support a client's maximum independence when providing care;

(c) Maintain a restraint-free environment, including physical, chemical, and environmental restraints. Use common, safe alternatives to restraint use; and

(d) Protect and promote the client's right to live free of abuse, neglect, abandonment, and financial exploitation.

(5) Regarding the competency of recognizing indicators of abuse and understanding the mandatory reporting requirements, recognize the signs of abuse and report suspected abuse, abandonment, neglect, and financial exploitation:

(a) Describe long-term care worker's responsibilities as a mandatory reporter as defined in RCW 74.34.020 through 74.34.053; and

(b) Identify common indications of abuse, abandonment, neglect, and financial exploitation.

(6) Regarding the competency of client directed care, take appropriate action when following a client's direction regarding care:

(a) Describe a long-term care worker's role in client directed care including determining, understanding, and supporting a client's choices;

(b) Describe the importance and impact of client directed care on a client's independence, self-determination, and quality of life;

(c) Identify effective problem solving strategies that help balance a client's choice with personal safety; and

(d) Report concerns when a client refuses care or makes choices that present a possible safety concern.

(7) Regarding the competency of cultural sensitivity, provide culturally appropriate care:

(a) Describe how cultural background, lifestyle practices, and traditions can impact care; and

(b) Use methods to determine and ensure that these are respected and considered when providing care.

(8) Regarding the competency of body mechanics, utilize current best practices and evidence-based methods of proper body mechanics while performing tasks as outlined in the care plan.

(9) Regarding the competency on fall prevention:

(a) Identify fall risk factors and take action to reduce fall risks for a client; and

(b) Take proper steps to assist when a client is falling or has fallen.

(10) Regarding the competency of skin and body care, use personal care practices that promote and maintain skin integrity:

(a) Explain the importance of observing a client's skin, when to observe it, and what to look for including common signs and symptoms of skin breakdown;

(b) Identify risk factors of skin breakdown;

(c) Observe skin at pressure point locations and report any concerns;

(d) Describe what a pressure ulcer is, what it looks like, and what actions to take if a client appears to be developing or develops a pressure ulcer;

(e) Describe current best practices that protect and maintain a client's skin integrity including position changes when sitting or lying for extended periods, and proper positioning and transfer techniques;

(f) Implement current best practices that promote healthy skin including hygiene, nutrition, hydration, and mobility; and

(g) Identify when to report skin changes and who to report them to.

(11) Regarding the competency on long-term care worker roles and boundaries, adhere to basic job standards, expectations, and requirements and maintain professional boundaries:

(a) Identify when, how, and why to obtain information from appropriate sources about a client's condition or disease for which they are receiving services, and describe how to use this information to provide appropriate, individualized care;

(b) Describe a client's baseline based on information provided in the care plan and explain why it is important to know a client's baseline;

(c) Identify changes in a client's physical, mental, and emotional state through observation;

(d) Report changes from baseline and concerns to the appropriate care team member(s);

(e) Identify basic job standards and requirements (such as coming to work on time) and describe how maintaining these standards are critical to a client's safety and well-being;

(f) Explain the purpose of a care plan and describe how it is created, used, and modified;

(g) Use a client's care plan to direct a long-term care worker's job tasks and any client directed care tasks;

(h) Identify what is required of a long-term care worker, as described in WAC 388-71-0946, prior to performing a nurse-delegated task;

(i) Describe the role of a care team and a long-term care worker's role in the care team;

(j) Describe professional boundaries and the importance of maintaining them; and

(k) Identify signs of unhealthy professional boundaries, barriers to keeping clear professional boundaries, and ways to avoid or eliminate them.

(12) Regarding the competency on supporting activities of daily living, perform required personal care tasks to the level of assistance needed and according to current best practices and evidence-based guidelines:

(a) Demonstrate, in the presence of a qualified instructor, all critical steps required for personal care tasks including but not limited to:

(i) Helping an individual walk;

(ii) Transferring an individual from bed to wheelchair;

(iii) Turning and repositioning an individual in bed;

(iv) Providing oral care;

(v) Cleaning and storing dentures;

(vi) Shaving a face;

(vii) Providing fingernail care;

(viii) Providing foot care;

(ix) Providing a bed bath;

(x) Assisting an individual with a weak arm to dress;

(xi) Putting knee-high elastic stockings on an individual;

(xii) Providing passive range of motion for one shoulder;

(xiii) Providing passive range of motion for one knee and ankle;

(xiv) Assisting an individual to eat;

(xv) Assisting with peri-care;

(xvi) Assisting with the use of a bedpan;

(xvii) Assisting with catheter care;

(xviii) Assisting with condom catheter care; and

(xix) Providing medication assistance;

(b) In the process of performing the personal care tasks, use proper body mechanics, listen attentively, speak clearly and respectfully while explaining what the long-term care worker is doing, incorporate client preferences, maintain privacy and dignity, support the client's level of ability, and assure the client's comfort and safety;

(c) Appropriately utilize assistive device(s) specified in the care plan;

(d) Describe any safety concerns related to each task and how to address the concerns;

(e) Demonstrate an understanding of bowel and bladder functioning, including factors that promote healthy bowel and bladder functioning, and the signs, symptoms, and common causes of abnormal bowel and bladder function; and

(f) Identify the importance of knowing a client's bowel and bladder functioning baseline and when to report changes.

(13) Regarding the competency on food preparation and handling, plan and prepare meals using a basic knowledge of nutrition and hydration, incorporating any diet restrictions or modifications, and prevent food borne illness by preparing and handling food in a safe manner:

(a) Describe how nutrition and hydration can impact a client's health;

(b) Plan, shop, and prepare meals for a client according to the guidelines of good nutrition and hydration, incorporating any dietary requirements and restrictions from the care plan and client preferences;

(c) Describe common signs of poor nutrition and hydration, and when to report concerns and who to report concerns to;

(d) Understand that diet modification is required for certain health conditions, including dysphagia, and describe how to identify diet modifications required for a client;

(e) Recognize when a client's food choices vary from specifications on the care plan, describe when to report concerns and who to report them to;

(f) Describe what causes food borne illness, the risks associated with food borne illness and examples of potentially hazardous foods;

(g) Describe appropriate food handling practices, including:

(i) Avoiding cross contamination from one food to another;

(ii) Safe storage requirements for cooling of leftover foods, including:

(A) Depth;

(B) Types of containers and temperatures;

(C) The need to maintain food at proper temperatures to limit bacterial growth; and

(D) Safe food storage and holding temperatures for both cold and hot foods;

(iii) Best practices for thawing and re-heating food; and

(iv) Using clean gloves (if possible), and clean utensils when preparing food;

(h) Describe the importance and correct procedure for cleaning and disinfecting food contact surfaces; and

(i) Describe why a long-term care worker with certain types of illnesses, symptoms, or both must not prepare food.

(14) Regarding the competency of medication assistance, appropriately assist with medications:

(a) Identify what a long-term care worker is allowed and not allowed to do when assisting with medications;

(b) Define terms related to medication assistance including prescription drugs, over the counter medications, and as needed (PRN) medications, medication side effects, and drug interactions;

(c) Identify common symptoms of medication side effects and when and to whom to report concerns;

(d) Store medications according to safe practices and the label instructions;

(e) Describe, in the proper sequence, each of the five rights of medication assistance; and

(f) Identify what to do for medication-related concerns, including describing ways to work with a client who refuses to take medications, identifying when and to whom to report when a client refuses medication or there are other medication-related concerns, and identifying what is considered a medication error, when to report a medication error, and who to report it to.

(15) Regarding the competency of infection control and bloodborne pathogens, implement best practices to prevent and control the spread of infections:

(a) Identify commonly occurring infections, ways that infections are spread, and symptoms of infections;

(b) Describe the purpose, benefit, and proper implementation of standard precautions in infection control;

(c) Implement current best practices for controlling the spread of infection, including the use of hand washing and gloves;

(d) Demonstrate proper hand washing and putting on and taking off gloves;

(e) Identify immunizations that are recommended for adults to reduce the spread of virus and bacteria;

(f) Describe laundry and housekeeping measures that help in controlling the spread of infection;

(g) Describe proper use of cleaning agents that destroy micro-organisms on surfaces;

(h) Describe what bloodborne (BB) pathogens are and how they are transmitted;

(i) Identify the major BB pathogens, diseases, and high-risk behaviors for BB diseases;

(j) Identify measures to take to prevent BB diseases;

(k) Describe what to do if exposed to BB pathogens and how to report an exposure; and

(l) Explain the importance of emotional issues and support for clients and long-term care workers.

(16) Regarding the competency on grief and loss, support yourself and the client in the grieving process:

(a) Define grief and loss;

(b) Describe common losses a client and long-term care worker may experience;

(c) Identify common symptoms associated with grief and loss;

(d) Describe why self-care is important during the grieving process; and

(e) Identify beneficial ways and resources to work through feelings of grief and loss.

(17) Long-term care workers who complete DSHS approved basic training meet the training requirements for adult family homes in RCW 70.128.250.

(18) Regarding the competency on identifying indicators of hearing loss, which may be part of the basic training or population specific hours:

(a) Identify common symptoms associated with hearing loss; and

(b) Identify what to do for hearing loss related concerns, including describing ways to communicate with a client who is experiencing hearing loss and identifying when and to whom to report when a client's hearing ability changes.

(1) Population specific basic training is training on topics unique to the care needs of the population that the home or provider serves. Topics may include but are not limited to:

(a) Dementia;

(b) Mental health;

(c) Developmental disabilities;

(d) Young adults with physical disabilities; and

(e) Aging and older adults.

(2) Population specific classes may include but are not limited to:

(a) DSHS developed or approved specialty training, such as:

(i) Dementia specialty training;

(ii) Mental health specialty training; and

(iii) Developmental disabilities specialty training.

(b) DSHS developed or approved curriculum on population specific topics, such as:

(i) Traumatic brain injury, surviving and thriving; and

(ii) Navigating challenging behaviors.

(1) Effective July 1, 2012, on-the-job training is a method of training where the long-term care worker successfully demonstrates in the 70-hour home care aide basic training, the core competencies for personal care or infection control skills while working with a client on the job, instead of in a practice training setting.

(2) A qualified instructor as described in WAC 388-71-1055, provides on-the-job training and directly observes, coaches, and reinforces skills training for up to two long-term care workers at a time. The qualified instructor who provides the on-the-job training:

(a) Need not be the instructor who taught the core competency training; and

(b) May be the immediate supervisor in a home care agency of the long-term care worker receiving this training.

(3) The person who oversees on-the-job training must:

(a) Submit DSHS required forms and become an approved instructor for the core competency of basic training;

(b) Verify on a DSHS approved skills checklist or other department approved form, the long-term care worker's successful completion of the demonstrated skills; and

(c) Not relinquish required duties to trainee caregivers when acting as a trainer.

(4) The department must approve the number of on-the-job hours included in the 70-hour home care aide basic training.

(1) Nurse delegation core training is required before certified or registered nursing assistants or certified home care aides being may be delegated a nursing task.

(2) DSHS approves instructors for nurse delegation core training.

(1) Nurse delegation specialized diabetes training is the required course for nursing assistants, certified or registered, and certified home care aides who will be delegated the task of insulin injections.

(2) DSHS approves the instructors for the nurse delegation specialized diabetes training.

(1) Before performing any delegated nursing task, long-term care workers must:

(a) Successfully complete the DSHS designated nurse delegation core training, "nurse delegation for nursing assistants & home care aides";

(b) Be one or more of the following:

(i) Certified home care aide under chapter 18.88B RCW;

(ii) Nursing assistant certified under chapter 18.88A RCW.

(2) If the long-term care worker is exempt from the home care aide certification under WAC 246-980-025, the long-term care worker must be a nursing assistant registered and complete the core competencies of basic training, unless they already completed the 28 hours of revised fundamentals of care or a department approved alternative;

(3) If nurse delegation is needed to implement a care plan or negotiated service agreement earlier than home care aide certification can be obtained, the long-term care worker must become a nursing assistant registered and complete core competencies (the core basic training) of the 70-hour home care aide basic training.

(4) Before long-term care workers may perform the task of insulin injections, the long-term care workers must:

(a) Meet the requirements in subsection (1)(a) and (b) of this section; and

(b) Successfully complete the DSHS designated nurse delegation specialized diabetes training.

Nurse delegation core and specialized diabetes training may be required in the same year as basic training if delegated tasks need to be performed. If completed within one hundred and twenty days of hire, the nurse delegation core and specialized diabetes training hours may be applied towards the population specific component of the seventy-hour long-term care worker basic training.

Passing the DSHS competency test is required for successful completion of nurse delegation core training and specialized diabetes training, as provided in WAC 388-71-1106 through 388-71-1130.

There is no challenge test for nurse delegation core or specialized diabetes training.

Only the DSHS developed curriculum for nurse delegation entitled, "nurse delegation for nursing assistants & home care aides," meets the training requirement for nurse delegation core training.

Nurse delegation specialized diabetes training consists of three modules on diabetes, insulin, and injections. Only the curriculum developed by DSHS, "nurse delegation for nursing assistants: special focus on diabetes," may be used for the nurse delegation specialized diabetes training.

(1) Orientation, safety, basic training, including core and population specific, the 30-hour training, the seven-hour parent provider training, on-the-job training, continuing education, nurse delegation core and specialized diabetes training, specialty and expanded specialty training, and adult education training must be documented by a certificate, transcript, or proof of completion of training issued by a qualified instructor or qualified training entity that includes:

(a) The name of the student;

(b) The title of the training as approved by the department;

(c) For continuing education the department assigned curriculum approval code;

(d) The number of hours of the training;

(e) The name and identification number of the training entity;

(f) The instructor's name;

(g) For core basic training and the 75-hour certificate, the instructor's name and identification number;

(h) The instructor's signature or an authorized signature from the training entity the qualified instructor is training on behalf of; and

(i) The completion date of the training.

(2) The long-term care worker must be given documentation of the proof of completion of the training that the student should retain. A home care agency must keep a copy of the proof of completion as specified in subsection (1) of this section on file.

(3) An instructor who is approved for Core Basic may sign a 75-hour certificate from the same training program.

Before hiring a long-term care worker, the home care agency or the department acting on behalf of the client, as defined under RCW 74.39A.009; or the consumer directed employer under chapter 74.39A RCW; must review and verify the highest level of training or certification achieved by the individual. 

(1) When the individual is a home care aide certified under chapter 18.88B RCW, the home care agency, CDE, or department must:

(a) Verify that the individual's home care aide certification is current and in good standing; and

(b) Confirm and document that the individual is in compliance with continuing education as required under WACs 388-71-0990 and 388-71-0991 for the compliance year in which they are hired.

(2) When the individual is exempt from the 70-hour home care aide training and certification requirements under WAC 388-71-0839, the home care agency, CDE, or department must review and verify the following:

(a) Documents demonstrating the individual's exemption status from training and certification which may include:

(i) Washington state provider active credential number, showing that the individual's license or certification is current and in good standing;

(ii) A letter from a former or current employer documenting work history during the exemption period described in WAC 388-71-0839;

(iii) Employment history records from the Washington state employment security department documenting work history information during the exemption period;

(iv) Federal tax statements documenting work history information during the exemption period; or

(v) Documentation showing completion of the basic training as required under WAC 388-71-0839;

(b) For the year in which they are hired, documentation of completion of 12 hours of continuing education, or information on when the continuing education must be completed, that complies with WAC 388-71-0990 and WAC 388-71-0991.

(3) Individuals who have worked as long-term care workers in the past, but who did not complete the basic training or certification required at the time, may be eligible to have the date of hire reset in accordance with this section and WAC 388-71-0980. 

(a) Individuals who are eligible to reset their date of hire as provided in WAC 388-71-0980 must submit a new application and fee to the department of health and adhere to the training or certification requirement under this chapter.

(b) Individuals who are not eligible to reset the date of hire as provided in WAC 388-71-0980 must not be paid to provide personal care assistance until they complete required training and become certified as a long-term care worker.

(4) The home care agency, or the department acting on behalf of the client, as defined under RCW 74.39A.009; or the consumer directed employer under chapter 74.39A RCW must comply with continuing education documentation requirements under WAC 388-71-0970.

(a) Individuals who worked in the previous year in a long-term care setting during the previous calendar year, are held accountable for continuing education completion by their new employer on the date of hire and shall provide at new hire, documentation of their continuing education compliance during the calendar year hired; or

(b) Individuals who work for multiple employers or move between employers shall on the date of hire, provide documentation of continuing education compliance for the year in which they are hired, if hired after their birthdate.

(1) Successful completion of the 70-hour home care aide basic training, the two hours of orientation, and the three hours of safety training (referred to collectively as the 75 hours of training) must be documented on a DSHS approved 75-hour training certificate, transcript, or proof of completion by an approved training entity verifying that a total of 75 hours of training have occurred.

(2) An approved training entity issuing and signing a DSHS 75-hour training certificate must verify that the long-term care worker has the certificates or transcript required documenting two hours of DSHS-approved orientation, three hours of DSHS-approved safety training, and the 70-hour home care aide basic training, as described in this chapter. When applying to the department of health for home care aide certification, the long-term care worker may only submit a 75-hour training certificate that has been issued by the department or the training partnership.

(3) For annual home care aide recertification, successful completion of 12 hours of DSHS-approved continuing education training must be documented on a certificate(s) or transcript(s) issued by a department approved training entity.

(4) The long-term care worker, certified home care aide, and employer must retain any 12-hour continuing education training certificates, transcripts, or other approved proof of completion as described in WAC 388-71-0970(1) as long as the worker is employed.

In order to be authorized to provide department paid in-home services, all long-term care workers must obtain home care aide certification as provided in chapter 246-980 WAC unless exempt for the 70-hour basic training as described in WAC 388-71-0875.

(1) If an individual is required to or chooses to become a certified home care aide and completes the 70-hour training requirements under this section, the individual will be required to continue to comply with these requirements to maintain the credential and complete continuing education requirements even if:

(a) The monthly authorized hours are later reduced to 20 or fewer hours;

(b) The individual no longer works for a second unrelated client; or

(c) The individual works 300 respite hours or less in a calendar year.

(2) The training and certification requirements for an individual that met the criteria in subsection (1) of this section does not apply when the individual returns to work only for the individual's:

(a) biological, step, or adoptive parent, or adult child; or

(b) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership; or

(c) spouse or registered domestic partner receiving approved services funded through the United States department of veterans' affairs home and community-based programs.

(1) If an individual has previously worked as a long-term care worker, but did not complete the training or certification requirements under RCW 18.88B.041, 74.39A.074, and 74.39A.076, and this chapter, a home care agency or client must not employ the individual to work as a long-term care worker until the individual has completed the required training certification unless the date of hire has been reset as described under subsection (2) of this section.

(2) The date of hire may be reset according to WAC 388-71-0837.

(3) Unless exempt from the 70-hour basic training as described in WAC 388-71-0875, individuals who meet the criteria in subsection (2) of this section are allowed a new 120 days to complete the 70-hour home care aide basic training and a new 200 days to become certified as a home care aide, if required by WAC 246-980-020.

(4) Individuals who meet the criteria in subsection (2) of this section must submit a new application and fee to the department of health.

The department is authorized under RCW 74.39A.086 to take enforcement action for noncompliance related to training and certification requirements.

(1) Continuing education is annual training designed to promote professional development and increase a person's knowledge, expertise, and skills. DSHS must approve continuing education curricula and instructors.

(2) The same continuing education course must not be repeated for credit unless it is a new or more advanced training on the same topic. However, a long-term care worker may repeat up to five credit hours per year [on] the following topics:

(a) Bloodborne pathogens and infection control;

(b) CPR training;

(c) First-aid training;

(d) Food handling training;

(e) Health Insurance Portability and Accountability Act (HIPAA);

(f) Medication assistance;

(g) Disaster preparedness;

(h) Aging sensitivity;

(i) Client rights as it relates to caregiving issues in chapter 70.129 RCW;

(j) Client safety;

(k) Abuse and neglect identification and mandatory reporting; and

(l) Topics where the home care agency, CDE, or department can demonstrate a need for retraining.

(3) Continuing education must be on a topic relevant to the care setting, care needs of clients, or long-term care worker career development. In addition to the topics listed in subsection (2) of this section, topics or courses may include:

(a) Personal care services;

(b) Mental illness;

(c) Dementia;

(d) Developmental disabilities;

(e) Depression;

(f) Communication skills;

(g) Positive client behavior support;

(h) Developing or improving client centered activities;

(i) Dealing with wandering or aggressive client behaviors;

(j) Deescalating challenging behaviors; and

(k) Medical conditions.

(4) Nurse delegation core and nurse delegation specialized diabetes training hours when not applied to basic training hours may count towards continuing education.

(5) Specialty training, except if completed through a challenge test, may be used to meet continuing education requirements.

(6) When hours from a class approved as specialty training are counted toward basic training requirements, the hours must not be counted toward continuing education.

(7) Successful completion of a department of health approved home care aide certified alternative bridge program may be applied for up to 12 hours of continuing education in the year it was completed.

(1) The following long-term care workers must complete 12 hours of continuing education by their birthday each year unless exempt from continuing education as described in WAC 388-71-1001:

(a) A certified home care aide;

(b) A long-term care worker who is exempt from home care aide certification as described in RCW 18.88B.041;

(c) A certified nursing assistant;

(d) A person with special education training and an endorsement granted by the Washington state office of superintendent of public instruction, as described in RCW 28A.300.010.

(2) The continuing education requirements of this section do not apply to a registered nurse, a licensed practical nurse, or an advanced registered nurse practitioner licensed under chapter 18.79 RCW, even if voluntarily certified as a home care aide under chapter 18.88B RCW.

(3) A long-term care worker or certified home care aide who did not complete the continuing education requirements by the time frame described in this section or in WAC 388-71-0991 must not be paid to provide care after that date and must not be reinstated as a long-term care worker until the worker has completed the continuing education requirements.

(1) All long-term care workers who are certified home care aides must comply with the continuing education requirements under chapter 246-980 WAC.

(2) Long-term care workers, who are exempt from home care aide certification as described in RCW 18.88B.041, unless exempt from continuing education as described under WAC 388-71-1001 must complete and provide documentation of 12 hours of continuing education within 45 calendar days of being hired or by the long-term care worker's birthday in the calendar year hired, whichever is later; and

(a) Must complete 12 hours of continuing education by the long-term care worker's birthday each calendar year worked thereafter; or

(b) If the 45 calendar day time period allows the long-term care worker to complete continuing education in January or February of the following year, the credit hours earned will be applied to the calendar year in which the long-term care worker was hired.

(3) If the renewal period following initial certification as a home care aide or nursing assistant (NA-C), is less than a full year from the date of certification, no continuing education will be due for the first renewal period.

(4) For long-term care workers who are caring for a biological, step, or adoptive parent, continuing education must be completed on or before their birthday in the year after basic training was completed. If these long-term care workers have not worked in long-term care for a calendar year or longer, the worker can complete the continuing education requirement as provided in subsection (2) of this section.

(1) The department finds that long-term care workers employed during the COVID-19 pandemic between March 1, 2020, and February 28, 2021, required emergent and intensive on-the-job training. Long-term care workers received critical, ongoing training in such topics as:

(a) Donning and doffing personal protective equipment (PPE);

(b) Hand hygiene;

(c) Disinfection of high-touch surfaces;

(d) Managing visitations and physical distancing;

(e) Responding to newly infected residents;

(f) Promotion of vaccination;

(g) Protocols for quarantine;

(h) Use of cloth face coverings;

(i) Personal protection outside of the work environment; and

(j) How to reduce exposure and spread.

(2) This on-the-job training was required of all workers in all long-term care environments in Washington state. Instruction was provided in assisted living facilities, adult family homes, home care agencies, enhanced services facilities, certified community residential services, and to individual providers by the SEIU775 benefits group and DSHS to discuss infection control and the availability and distribution of personal protective equipment. Recognition of this training as a valid learning experience, in its various forms, was agreed upon with input from consumer and worker representatives, as the content was based on guidelines established by the Centers for Disease Control (CDC) and other federal, state, and local health care authorities.

(3) During this time, long-term care workers required ongoing critical training because guidance from the CDC, department of labor and industries, and other health authorities changed as more was learned about the SARS-CoV-2 virus. The department finds that this unprecedented on-the-job training constituted at least 12 hours of continuing education between March 1, 2020, and February 28, 2021, and that this training is not considered to be repeated training as described in WAC 388-112A-0600(2).

(4) All long-term care workers employed during the dates in section (3) of this section are granted 12 hours of DSHS-approved continuing education credit for the training entitled "COVID-19 On-The-Job Training Protocols," bearing the DSHS approval code CE2135218. No physical certificate for this training will be issued or required. The COVID-19 continuing education hours may be applied to renewal periods ending no earlier than March 1, 2020, and no later than December 31, 2021.

(5) The department recognizes that long-term care workers may not have completed training hours in excess of the 12 hours of CE granted in section (4) of this section due to the COVID-19 public health emergency. All long-term care workers shall have until December 31, 2022, or 120 days from the end of the COVID-19 training waivers established by gubernatorial proclamation, whichever is later, to complete any additional CE that may have become due while training waivers were in place in excess of the 12 hours of CE granted in subsection (4) of this section. If a worker's next birthday allows fewer than 120 days after the waivers are lifted to complete required CE for their current renewal cycle, the worker will have 120 days from the end of training waivers to complete the required CE.

Continuing education is not required for any of the following:

(1) Individual providers caring only for the provider's:

(a) biological, step, or adoptive child; or

(b) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership.

(2) Individual providers that:

(a) Provide no more than 20 hours of nonrespite care in any calendar month to only one person who is not the provider's:

(i) biological, step, or adoptive child; or

(ii) sibling, aunt, uncle, cousin, niece, nephew, grandparent, or grandchild, including when related by marriage or domestic partnership;

(b) Provide respite services and work 300 hours or less of respite in any calendar year;

(3) Before January 1, 2016, a long-term care worker employed by a community residential service business; and

(4) Registered nurses, licensed practical nurses, and advanced registered nurse practitioners licensed under chapter 18.79 RCW, even if voluntarily certified as a home care aide under chapter 18.88B RCW.

(1) If a training entity modifies a department developed curricula in any manner, the training entity must submit the curriculum to the department for approval.

(2) Training must not be offered before receiving department curriculum and instructor approval.

(3) Online classes when applicable, must adhere to the DSHS online class standards in effect at the time of approval. These online standards are posted on the DSHS website https://bit.ly/dshs-online-standards.

(4) For orientation and safety training:

(a) Submit an outline of what will be covered in each training offered including a table of contents that shows where the required introductory topics as listed in WAC 388-71-0846 for orientation and WAC 388-71-0855 for safety training are covered in the training.

(b) Department required orientation and safety training application forms must be submitted to the department at least 45 days in advance of when the training is expected to be offered.

(c) Training cannot be offered before the department approves the curriculum and instructor.

(5) For continuing education:

(a) Continuing education curriculum delivery models must only include instructor led, online instructor led (such as a webinar), or an online interactive self-paced learning with access to an approved instructor or a proctor trained by an approved instructor.

(b) For continuing education classes, submit on a department developed form, a summary that includes the topic, a brief description of what it will cover, a course outline, the number of training hours, and a description of how the training is relevant to the care setting, care needs of the clients, or long-term care worker career development.

(c) For online training courses, submit the information requested in (b) of this subsection and submit a description of how the instructor or training entity will assess that the students have integrated the information being taught. The training entity must establish a way for the long-term care worker to receive feedback from an approved instructor or a proctor trained by an approved instructor.

(d) One hour of completed classroom instruction or other form of training (such as an online course) equals one hour of continuing education.

(e) Department required continuing education training application forms must be submitted at least 45 days in advance of the training. The department must approve the curriculum and instructor before the training may be offered.

(6) For the 70-hour home care aide basic training, the 30-hour basic training, and the seven-hour parent provider training:

(a) If the instructor or training entity uses the DSHS developed fundamentals of caregiving learner's guide or its substitute with enhancements, they must submit the DSHS required form with all required information.

(b) If the instructor or training entity does not use the DSHS developed fundamentals of caregiving learner's guide or its substitute with enhancements to teach the 70-hour home care aide basic training, the 30-hour basic training, and for the seven-hour parent provider training, they must submit to DSHS the following for approval:

(i) A completed DSHS curriculum checklist indicating where all of the competencies and learning objectives, described in this chapter, are located in the long-term care worker materials from the proposed curriculum for that course;

(ii) Any materials long-term care workers will receive, such as a textbook or long-term care worker manual, learning activities, audio-visual materials, handouts, and books;

(iii) The table of contents or outline, including the allotted time for each section;

(iv) Demonstration skills checklists for the personal care tasks described in WAC 388-71-0911 (12)(a) and (b), and infection control skillssuch as hand washing and putting on and taking off gloves; and

(v) The teacher's guide or manual that includes for each section of the curriculum:

(A) The goals and objectives;

(B) Methods of teaching, including learning activities that incorporate adult learning principles;

(C) Methods used to determine whether each long-term care worker understands the material covered and can demonstrate all skills;

(D) A list of sources or references that were used to develop the curriculum and if the primary source or reference is not a published citation, the instructor must provide detail on how the content is evidence based;

(E) Description of how the curriculum was designed to accommodate long-term care workers with either limited English proficiency, learning disabilities, or both; and

(F) Description and proof of how input was obtained from consumers and long-term care worker representatives in the development of the curriculum.

(c) Curricula submitted for the core competency section of the basic training as described in WAC 388-71-0911 must include how much time long-term care workers will be given to practice skills and how instructors will evaluate and ensure each long-term care worker can proficiently complete each skill.

(d) Entities that submit curriculum for population specific component of home care aide basic training must submit a list of competencies and learning objectives used to develop the population specific basic training curriculum.

(7) For specialty training:

(a) For specialty training that is not DSHS developed curriculum or another department approved specialty training curriculum, submit the required specialty training application form and any additional learning objectives added to the competency and learning objectives checklist, the enhancements that have been added, and additional student materials or handouts.

(b) To be approved, an alternative curriculum must at a minimum include:

(i) All the DSHS published learning outcomes and competencies for the course;

(ii) Student materials that support the curriculum, a teacher's guide or manual, and learning resource materials such as learning activities, audio-visual materials, handouts, and books;

(iii) The recommended sequence and delivery of the material; and

(iv) The teaching methods or approaches that will be used for different sections of the course, including for each lesson:

(A) Learning activities that incorporate adult learning principles and address the learning readiness of the student population;

(B) Practice of skills to increase competency;

(C) Feedback to the student on knowledge and skills;

(D) An emphasis on facilitation by the teacher; and

(E) An integration of knowledge and skills from previous lessons to build skills;

(v) A list of the sources or references, if any, used to develop the curriculum;

(vi) Methods of teaching and student evaluation for students with either limited-English proficiency, learning disabilities, or both; and

(vii) A plan for updating material.

(8) Substantial changes to a previously approved curriculum must be approved before they are used.

To obtain the department's approval of the curriculum for the 70-hour basic training, population specific training, the 30-hour basic training, the seven-hour parent provider training, and continuing education:

(1) Submit the required training application forms and any other materials required for specific curricula to the department.

(2) After review of the curriculum, DSHS will send a written response to the submitter, indicating approval or disapproval of the curriculum.

(3) If the curriculum is not approved, the reason(s) for denial will be given and the submitter will be told what portion(s) of the training must be changed and resubmitted for review in order for the curriculum to be approved.

(4) The submitter may then make the requested changes and resubmit the curriculum(s) for review.

(5) If after working with the department, the reasons why the curriculum is not approved cannot be resolved, the submitter may seek a review of the nonapproval decision from the assistant secretary of aging and long-term support administration (ALTSA). The assistant secretary's review decision will be the final decision of DSHS. No other administrative review is available to the submitter.

The training entity is responsible for:

(1) Coordinating and teaching classes;

(2) Assuring that the curriculum used is DSHS-approved and taught as designed;

(3) Selecting qualified guest speakers, where applicable;

(4) Establishing a method whereby the long-term care worker can receive feedback from an approved instructor or a proctor trained by an approved instructor;

(5) Administering or overseeing the administration of the DSHS competency and challenge tests;

(6) Maintaining training records electronically or on paper including long-term care worker certificates, transcripts, or proof of successful completion of training, and attendance records for a minimum of six years;

(7) Reporting training data to DSHS when requested by the department; and

(8) Issuing or reissuing training certificates or transcripts to long-term care workers.

Training entities and their instructors must be approved by DSHS as follows:

(1) For DSHS contracted training entities:

(a) DSHS must approve or approve and contract with a training entity and its instructor(s) to conduct orientation, safety, 70-hour basic training, population specific training, specialty training, 30-hour training, seven-hour DDA parent provider training, nurse delegation core training, and nurse delegation specialized diabetes training, on-the-job training, and continuing education.

(b) DSHS may select training entities using any applicable contracting procedures. Contractors must meet the minimum qualification for instructors under this chapter and any additional qualifications established through the contracting procedure.

(1) DSHS may deny a person or organization seeking a contract with DSHS to conduct orientation, safety, 70-hour basic training, population specific training, specialty training, 30-hour training, seven-hour DDA parent provider training, nurse delegation core training, and nurse delegation specialized diabetes training, on-the-job training, or continuing education. No administrative remedies are available to dispute DSHS' decision not to contract with or approve a person or organization, except as may be provided through the contracting process.

(2) DSHS may terminate an existing training contract in accordance with the terms of the contract. The contractor's administrative remedies are limited to those specified in the contract.

(3) DSHS may terminate an existing training approval of a person or entity to conduct orientation, safety, 70-hour basic training, population specific training, specialty training, 30-hour training, seven-hour DDA parent provider training, nurse delegation core training, and nurse delegation specialized diabetes training, on-the-job training, or continuing education.

An instructor for basic (including 30-hour and seven-hour DDA parent providers), population specific, on-the-job, nurse delegation core, and nurse delegation specialized diabetes training must meet the following minimum qualifications:

(1) Be at least 21 years of age;

(2) Has not had a professional health care, adult family home, enhanced services facility, assisted living facility, or social services license or certification revoked in Washington state; and

(3) Meets one or more of the following education or work experience requirements upon initial approval or hire:

(a) Is a registered nurse with work experience within the last five years with the elderly or persons with disabilities requiring long-term care in a community setting; or

(b) Has an associate degree or higher degree in the field of health or human services and six months of professional or caregiving experience within the last five years in an adult family home, enhanced services facility, assisted living facility, supported living through DDA, or home care setting; or

(c) Has a high school diploma, or equivalent, and one year of professional or caregiving experience within the last five years in an adult family home, enhanced services facility, assisted living facility, supported living through DDA, or home care setting.

(4) Meets one or more of the following teaching experience requirements:

(a) 100 hours of teaching adults in an appropriate setting on topics directly related to the basic training or basic training topics that may be offered as continuing education; or

(b) 40 hours of teaching basic training while being mentored by an instructor who is approved to teach basic training;

(5) Except for instructors for nurse delegation core and specialized diabetes training, completion of a class on adult education that meets the requirements in WAC 388-71-1066;

(6) The instructor must be experienced in caregiving practices and demonstrate competency with respect to teaching the course content or units being taught;

(7) Instructors who will administer tests must have experience or training in assessment and competency testing; and

(8) Community instructors for nurse delegation core and specialized diabetes trainings must have a current Washington state registered nurse (RN) license in good standing without practice restrictions.

(1) An instructor for orientation and safety [training] must be a registered nurse or other person with specific knowledge, training, and work experience relevant to the topics required in orientation and safety training.

(2) An instructor for continuing education must be a registered nurse or other person that is proficient in the content they cover in the course or have specific knowledge, training, or experience in the provision of direct, personal care, or other relevant services to the elderly or persons with disabilities requiring long-term care.

(1) The minimum qualifications for community instructors of adult education training using DSHS curriculum, in addition to the general qualifications in WAC 388-71-1055 (1) and (2), include:

(a) The instructor must be experienced in adult education practices and capable of demonstrating competency in the entire course content;

(b) Education:

(i) Has a bachelor's degree or is a registered nurse with at least one year of education in seminars, conferences, continuing education, or in college classes in subjects directly related to adult education, such as, but not limited to English as a second language (ESL), adult basic education, and adult secondary education (one year of education equals 24 semester credits in a semester system, 36 quarter credits in a quarter system, or at least 80 hours of seminars, conferences, and continuing education); and

(ii) Successful completion of the DSHS adult education training curriculum prior to beginning to train others;

(c) Meets one or more of the following teaching experience requirements:

(i) Two years of experience teaching long-term care workers; or

(ii) 200 hours of experience teaching adult education or closely related subjects;

(d) Successful completion of the DSHS instructor qualification/demonstration process; and

(e) Instructor approved and contracted by the department as a community instructor.

(2) Instructors that administer tests must have experience or training in assessment and competency testing.

(1) A class on adult education must include content, student practice, and evaluation of student skills by the instructor in:

(a) Adult education theory and practice principles;

(b) Instructor facilitation techniques;

(c) Facilitating learning activities for adults;

(d) Administering competency testing; and

(e) Working with adults with special training needs like limited English as a second language proficiency, learning disabilities, or both.

(2) Instructors who request approval to teach either core basic training, specialty training as described in chapter 388-112A, or both, must complete the DSHS adult education class or an adult education class that meets the criteria in subsection (1) of this section and provide a copy of the certificate of completion.

(1) The minimum qualifications for community instructors for mental health specialty training, in addition to the general qualifications in WAC 388-71-1055 (1) and (2), include:

(a) The instructor must be experienced in mental health caregiving practices and capable of demonstrating competency in the entire course content;

(b) Education:

(i) Bachelor's degree, registered nurse, or mental health specialist, with at least one year of education in seminars, conferences, continuing education, or accredited college classes, in subjects directly related to mental health, including, but not limited to, psychology (one year of education equals 24 credits in a semester system, 36 credits in a quarter system, or at least 80 hours of seminars, conferences, and continuing education); and

(ii) Successful completion of the mental health specialty training class before the instructor trains others;

(c) Work experience: Two years full-time equivalent direct work experience with people who have a mental illness; and

(d) Teaching experience:

(i) 200 hours experience teaching long-term care related subjects;

(ii) Successful completion of an adult education class that meets the requirements of WAC 388-71-1066;

(iii) Successful completion of the DSHS instructor qualification/demonstration process; and

(iv) The instructor has been approved and contracted by the department as a community instructor;

(e) Instructors who will administer tests must have experience or training in assessment and competency testing; and

(2) Five years of full-time equivalent direct work experience with people who have a mental illness may substitute for either:

(a) The credential described in subsection (1)(b)(i) of this section; or

(b) The one year of education in college classes or 80 hours in seminars, conferences, continuing education described in subsection (1)(b)(i) of this section.

(3) If your status is an approved instructor for mental health specialty training, you may instruct a new mental health specialty training curriculum after submitting to the department a copy of a certificate of completion for that curriculum and a copy of a certificate of completion of an adult education class that meets the requirements of WAC 388-71-1066.