All the following documents are strictly an archive of the DSHS database as of December 31, 2015.

Transcription

1 In an effort to preserve institutional knowledge, the Washington Health Care Association has created an archive of all Dear Administrators from the year 2012 and earlier. We attempted to retain as many links and enclosures as possible however, some links are broken and some enclosures are no longer available. WHCA is unable to correct or fix issues. All the following documents are strictly an archive of the DSHS database as of December 31, 2015.

2 December 15, 2011 ADSA: NH # S&C 12-04: Smoking Safety in Long-term Care Facilities The purpose of this letter is to let you know that the Centers for Medicare & Medicaid Services (CMS) has issued a survey and certification (S&C) memorandum on smoking safety in long term care facilities. The CMS information applies to those nursing homes that have a designated area for smoking at their facility. Please remember that state law, under Chapter Revised Code of Washington (RCW), prohibits smoking in public places and within a minimum distance of twenty-five feet from entrances and exits. According to this state law, nursing homes are considered a public place. If you have a designated smoking area, please note the following highlights from the CMS memorandum. Facilities must assess each smoking resident s capabilities and deficits and determine whether or not supervision is required. A resident assessed as incapable of independent smoking should have this information current and updated and documented in the care plan. Facility policy must describe the methods by which residents are assessed as safe to smoke without supervision. Facilities should provide supervision when unsure of whether or not the resident is safe to smoke unsupervised. Oxygen use is prohibited in smoking areas for the safety of residents. A change in facility s policy to prohibit smoking does not affect current residents who smoke. Residents admitted after policy change must be informed, during the admission process, of the policy prohibiting smoking. Facilities are obligated to ensure the safety of designated smoking areas including protecting residents from weather conditions and non-smoking residents from second hand smoke. Facilities are required to provide portable fire extinguishers and noncombustible ashtrays. Electronic cigarettes are not considered smoking devices. To read the details of the memorandum online, please use the following link: D=0&sortByDID=4&sortOrder=descending&itemID=CMS &intNumPerPage=10 Please contact your local RCS Field Manager if you have any questions.

3 November 10, 2011 ADSA: NH # FINAL AMENDMENTS RELATED TO CHAPTER WAC In June and August 2011, (RCS) informed you of possible changes to the Nursing Home licensing rules. The Department recently filed the final Rule-Making Order CR-103 for amendments to Chapter WAC, Nursing Homes, with the Office of the Code Reviser. The rule becomes effective December 2, 2011 and will be published in the Washington State Register as WSR Amending the rules was necessary as a result of legislative activity during session and to be consistent with federal regulations and newly passed state laws. Highlights of the changes are: Changes to terms in the definition section; Reference changes to the correct appeals WACs and name of Medicaid agency; Clarification of refusal of certain transfers section; Changes to per bed license fee language; and Clarification of whom a license must be issued to and when a license expires, including in situations of change of ownership. Enclosed is the CR-103. We will not mail a printed copy of the final rule; however, you can access this from a link on the ADSA internet, nursing home professional page at: Thank you for your continued commitment to the care of long-term care residents of our state. If you have questions, please contact your local RCS Field Manager.

4 October 26, 2011 ADSA: NH # CR-103E FILED to extend expiration date of emergency rules The purpose of this memo is to inform you that the department filed an emergency rule extension in order to comply with Engrossed Substitute House Bill (ESHB) As you may recall, at the end of June, the Department sent a letter (NH # ) informing you about Section 401 of ESHB 1277 that required nursing home license fees to be set in the State Omnibus Appropriations Act, effective July 1, The June letter also notified you that the department filed emergency rules and started the permanent rule making process. To read the details of this legislation its entirety online, visit: scroll down to Available Documents/Bill Documents and select the link, Session Law. Emergency rules are temporary in nature and expire in 120 days. RCS has taken steps to adopt the emergency rules as permanent rules. However, the department needed to file an emergency rule extension since the permanent rules will not take effect in time. The CR-103E document is enclosed for your convenience. The document and the rule text are available electronically athttp:// under NH Rule Filings.

5 October 25, 2011 ADSA: NH # Nursing Assistant Certification Alternative Program Dear Nursing Home/Facility Administrator and Interested Parties: The 2010 Legislature passed a bill relating to nursing assistant certification. This was codified in Revised Code of Washington (RCW) 18.88A.087 and in recently adopted Department of Health (DOH) rules, Washington Administrative Code (WAC) through 585. The law specifically allows certified home care aides and certified medical assistants to take the competency evaluation for nursing assistant certified as long as they have successfully completed an additional twenty-four hours of training that the nursing commission determined is necessary. The DOH approved additional training must be on topics not addressed in the training specified for certification as a home care aide or medical assistant. Because individuals who are certified under this program also meet the certified nursing assistant requirement under federal law, please become familiar with the provisions of the alternative training. You may receive applications from individuals who may have become a certified nursing assistant through this program. In addition, you may also receive applications from individuals who completed a bridge program but have not yet tested and desire to work under the 120 day rule. In order to make it clearer for everyone, DOH may consider requiring the Certificate of Completion from the alternative program to clearly indicate that it is a bridge to nursing assistant certified. If you have any questions, please contact Mindy Schaffner, PhD, MSN, CNS, RN, Nursing Education Advisor at (360) , or at:mindy.schaffner@doh.wa.gov.

6 September 28, 2011 ADSA: NH # S&C 11-38: compliance with food procurement requirements for gardens The purpose of this letter is to let you know that the Centers for Medicare & Medicaid Services (CMS) has issued a survey and certification (S&C) memorandum on compliance with food procurement requirements for nursing homes (NHs) with gardens producing foods for residents. Highlights of the memorandum: Facilities with nursing home gardens are compliant with the food procurement requirements at 42 CFR (i), Sanitary Conditions, Tag F 371 as long as the facilities have and follow policies and procedures for maintaining the gardens. The facility should immediately report any outbreaks of food borne illnesses, from any cause, to their local health department. To read the details of the memorandum online, please visit: &sortbydid=4&sortorder=descending&itemid=cms &intnumperpage=10 If you have a facility garden that provides food to residents, you will need to provide your related policies and procedures to the surveyors: If there is an outbreak of food-borne illness; and Your primary source of food procurement has been ruled out as a source of the illness. Please contact your local RCS Field Manager if you have any questions.

7 September 15, 2011 ADSA: NH # Influenza and pneumonia shot reminders Nursing homes must meet federal and state requirements related to flu and pneumonia shots. is partnering with the Department of Health to remind providers about the benefits of: Vaccinating residents and employees against flu and pneumonia Flu and pneumonia shots can reduce the rate of hospitalizations and deaths in people 65 and older. Using the Child Profile Immunization Registry to keep track of your residents and staff s vaccinations. For more information or to register, contact Child Profile Help Desk at or Get ready for flu! Help keep your residents and staff healthier this flu season by: Encouraging all residents and employees to get the seasonal flu vaccination this fall. Encouraging pneumonia vaccine for all your residents, especially those 65 and older and those with certain medical conditions. Taking measures to minimize transmission in your facility such as washing hands or using hand sanitizers frequently. More information about infection control is available at: Reporting flu outbreaks in your facility to your local health department (LHD). They can help with advice about testing, treatment, prophylaxis and infection control. The Centers for Disease Control and Prevention (CDC) defines an outbreak as a sudden increase of acute febrile respiratory illness cases or when any resident tests positive for influenza. There are many websites that provide information on flu and pneumonia. We encourage you to check these websites often for new information: Department of Health: Centers for Disease Control and Prevention: We have also updated our internet website under Professionals & Providers to include the above links and other resources. Seehttp:// Department of Social and Health Services Janna Bardi, MPH, Director Immunization and Child Profile Office Washington State Department of Health

8 September 6, 2011 ADSA: NH # REVISIONS TO RAI USER S MANUAL This letter contains important information for facility staff responsible for completing the Minimum Data Set (MDS) assessments. The Centers for Medicare and Medicaid Services (CMS) recently announced the release of the third set of updates to the Long Term Care Facility Resident Assessment Instrument User s Manual Version 3.0. The primary focus of these updates is related to the implementation of the SNF/PPS Final Rule FY2012 and the related Medicare PPS assessment processes. There are also some changes to selected chapters and chapter sections not related to Medicare PPS issues that reflect clarifications of existing policies, addition of coding tips and examples, and changes in item definitions. The updates include a Track Changes document that describes the chapter, section and page number of the changes as well as the old language and the newly changed language. The second document is the newly revised section, chapter or appendix with the effective month and year noted on the bottom left of each page. Not all sections/chapters are updated with this release. The updated chapters/sections are dated October Highlights of this update include the following: Chapter 1: Revision to the explanation of the regulatory requirements for the RAI process. Chapter 2: The entire chapter has been revised including definitions, correction of existing examples and addition of new examples, management tips, description of a new PPS assessment type (Change of Therapy OMRA:COT-OMRA), new process for EOT OMRA when a resident resumes therapy at the identical previous level (EOT-R), new Medicare PPS schedule. Chapter 3: Changes to item definitions, clarifications, coding tips and examples for sections C, I, K, M, and N. Section O has a new MDS item related to the new End of Therapy Resumption process: Item O0450 A & B. Chapter 4: Revised information on the care planning process and key steps. Chapter 6: Major revisions to this chapter related to the changes outlined in Chapter 2 for PPS assessments, including the new Change of Therapy Assessment, allocation of group therapy minutes, supervision of therapy students and the End of Therapy Resumption. New examples are included and billing information. Appendix A (glossary) has some modifications to several item definitions. Appendix C has minor editing to CAA items. These updates are now available for download on the CMS website at:

9 New MDS item sets reflecting the addition of the new PPS processes have also been developed. The new items are: A0301C: PPS Other Medicare Required Assessment-OMRA Selection #4. Change of therapy assessment O0450: Resumption of Therapy A = Has a previous rehabilitation therapy regimen ended, as reported on this End of Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline? B = Date on which therapy regimen resumed (if above answer is Yes) X0900: Reasons for Modification Selection E. End of Therapy-Resumption date (EOT-R) The updated item sets are available for download on the CMS technical website at: It is the responsibility of the individuals who complete the MDS to have the most current RAI manual instructions in order to accurately complete the required assessments. If you have any questions or need further information, please contact Marjorie Ray, RN, Washington State RAI Coordinator, at (360) or at rayma@dshs.wa.gov

10 August 26, 2011 ADSA: NH # FORMAL PHASE OF PROPOSED AMENDMENTS TO CHAPTER WAC Dear Nursing Home/Facility Administrator and Interested Parties: In June 2011, the department filed a CR-101 to begin the rule adoption process for changes to Washington Administrative Code (WAC) , Nursing Homes. Recently, the department filed the CR-102, a more formal phase of the rule making process. The CR- 102, including draft rule language, is available on the ADSA website at: under the heading, NH Rule Filings: Chapter WAC The formal hearing for the proposed rules is scheduled: Date: October 11, 2011 Time: 10: 00 a.m. Location: Office Building 2 - Auditorium (DSHS Headquarters) 1115 Washington Olympia, WA You may either submit any comments in person at the public hearing listed above, or in writing to the department s Rules and Policies Assistance Unit (RPAU) by 5:00 p.m. on October 11, 2011 to the following address or by to Jennisha Johnson at: DSHSRPAURulesCoordinator@dshs.wa.gov DSHS Rules Coordinator /RPAU PO Box Olympia WA, Public parking is available at 11th and Jefferson. The link for directions to Office Building 2 is: If you have any questions about the proposed rules, please contact Lisa Yanagida, Program Manager at (360) or atyanagln2@dshs.wa.gov.

11 August 11, 2011 ADSA: NH # S&C 11-30: REPORTING REASONABLE SUSPICION OF A CRIME IN A LONG-TERM CARE FACILITY The 2010 federal health care legislation adopted new requirements for the reporting of possible crimes in long-term care facilities, including nursing facilities and skilled nursing facilities. Covered individuals, including facility employees, must report any reasonable suspicion of a crime against a resident of a long-term care facility, or against an individual receiving care from the facility. The purpose of this letter is to let you know that the Centers for Medicare & Medicaid Services (CMS) has issued a survey and certification (S&C) memorandum describing facilities obligations under the new law. Some requirements of the law are new and some of them already existed under state law. Please review the CMS memorandum for important details by accessing the link provided at the end of this letter. A few highlights are provided below. REQUIRED FACILITY RESPONSIBILITIES New requirements, the facility must: Determine once a year whether the facility is required to comply with the law; Annually notify each individual covered by the law of that individual s reporting obligations; Post, in an appropriate location, a notice for its employees describing the employee s rights, including the right to file a complaint under this law. Current requirements, the facility must not: Retaliate against an individual who lawfully reports a reasonable suspicion of a crime. ADVISABLE FACILITY FUNCTIONS New guideline, the facility should: Coordinate with law enforcement to determine what actions are considered crimes in their political subdivision. Current guidelines, the facility should: Review existing facility policies and procedures to ensure compliance with existing federal and state laws and regulations, and CMS and state policies and procedures for reporting incidents and complaints. Develop and maintain policies and procedures that ensure compliance with the new reporting requirements. DIFFERENCES BETWEEN FEDERAL AND STATE REQUIREMENTS

12 If there is a difference between federal and state reporting requirements, you must follow whichever law is the most stringent. For example: RCW requires mandated reporters to immediately make a report when there is reason to suspect that a sexual or physical assault has occurred. Depending upon the circumstances, the federal law requires reporting of a reasonable suspicion of a crime within two or twenty-four hours. In this situation, the state law is more stringent, so it must be followed. RCW has an exception to the law enforcement reporting requirements for certain resident-to-resident incidents. The federal law does not include the same exception; therefore, the federal law is more stringent and must be followed. To read nursing facilities/skilled nursing facilities responsibilities and other details of the memorandum online, please visit: sortbydid=3&sortorder=descending&itemid=cms &intnumperpage=10 Please contact your local RCS Field Manager if you have any questions.

13 July 26, 2011 ADSA: NH # MEDICAID-RELATED TRANSFER AND DISCHARGE APPEALS IN ACTIVE HEARING STATUS This letter specifically addresses residents who are in active appeal status regarding a facility initiated transfer or discharge. We recently informed you that the legislature passed Second Engrossed Second Substitute (2E2SHB) 1738 which transferred the single state Medicaid agency from the Department of Social and Health Services (DSHS) to Washington Health Care Authority (HCA). DSHS and the HCA have developed a cooperative agreement that leaves much of the work Aging and Disability Services Administration does with DSHS. However, the transfer to HCA has necessitated a change to Medicaid related appeals. HCA has developed a new Washington Administrative Code (WAC) chapter to cover appeal rights, Chapter WAC. HCA has also developed the enclosed fact sheet explaining the change that took effect July 1, 2011 regarding the appeal process rules for medical services programs from Chapter WAC to Chapter WAC. It is important that you share this fact sheet with the resident who is in active status of appeal related to your initiated transfer and discharge. If you have any questions, please contact the HCA Hearing Representative. Enclosure

14 Fact Sheet: Health Care Authority s New Administrative Hearing Rules for Medical Services Programs On July 1, 2011, a new law gave the Washington Health Care Authority (HCA) responsibility for Medicaid-related medical services programs. Previously, the Department of Social and Health Services (DSHS) had this responsibility. This change will not affect your ability to get an administrative hearing ( fair hearing ) relating to these medical service programs. New hearing rules were needed to carry out the transfer of responsibility. This fact sheet explains the major differences between the DSHS hearing rules in Chapter WAC and the HCA emergency hearing rules in Chapter WAC. You may have received a brochure titled Your Hearing Rights in a DSHS Case from the Office of Administrative Hearings, a separate state agency. Much of the information relating to the general hearing process is accurate, even though it refers to DSHS and not HCA. Please contact your case worker, the HCA Hearing Representative, or the Coordinated Legal Education Advice and Referral ( CLEAR ) Line if you have questions. What rules govern hearings relating to medical service programs found in Title RCW? Before July 1, 2011, the rules in Chapter WAC applied to administrative hearings for medical service programs. Starting on July 1, 2011, the rules in Chapter WAC apply. Who represents HCA in these hearings? Who is an authorized agent of HCA? What program rules apply to these hearings? May I still send hearing requests to DSHS? The HCA Hearing Representative will represent HCA in your hearing. The HCA Hearing Representative may be an HCA employee, an authorized agent of HCA (such as a DSHS employee or contractor who is authorized to act as a representative), or an assistant attorney general for Washington State. An authorized agent is a person or agency which may act on behalf of HCA through an agreement between HCA and DSHS. Authorized agent(s) may include employees of DSHS, or its contractors. Program rules are the agency s rules that say how benefit programs, like Healthy Options, and Apple Health For Kids, are run. Program rules tell you who are eligible for a program, how you apply for benefits, and how HCA decides what benefits you get. You can find the program rules for medical service programs in Title 182 WAC or Title 388 WAC. HCA is in the process of moving many of its medical services program rules from Title 388 WAC to Title 182 WAC. Yes. After July 1, 2011, you may send a request for a hearing to either DSHS or HCA. You may also contact the Office of Administrative Hearings to request a hearing. If you decide to request a hearing, please follow the instructions in the agency s notice when submitting your request for a hearing. HCA/DLS/OHAv1

15 What happens if I request a hearing that involves decisions made by DSHS and HCA? Where can I find the new hearing rules? If you ask for an administrative hearing about actions taken by more than one state agency (for example, DSHS denied a request for food assistance and HCA denied a request for medical assistance), the Office of Administrative Hearings will schedule one hearing so you can appeal both agencies actions at the same time. This can be helpful by reducing the number of hearings and documents required to resolve all the issues you have appealed. But combining appeals of both agencies actions into one case can sometimes delay the hearing, be confusing, or otherwise cause problems in the way the hearings are handled. Any party in a hearing that deals with both agencies decisions may ask the Administrative Law Judge (ALJ) to split the hearing into two or more hearings. HCA s new hearing rules are in Chapter WAC. Below is a list of resources to help you: 1. Visit the website at: pdf to obtain a copy of the new hearing rules; or 2. Contact the assigned Hearing Representative or your case worker to explain the new rules. How do I file Petitions for Review and where is the HCA Review Judge located? How do I appeal a final order by HCA? How do I seek legal assistance? If you disagree with the ALJ s decision (the initial order ), you or any party may ask the Review Judge to review and change the decision. HCA s new hearing rules have not changed the review process. You may contact the HCA Review Judge at the same location as the DSHS Board of Appeals; this information is listed in WAC If you do not agree with a final decision (the final order ) in your case, you can ask the ALJ or the Review Judge who wrote the order to reconsider it. You can also file a petition for judicial review in Superior Court, asking the court to change the agency s final order. There are strict deadlines and other rules for requesting reconsideration and for filing a petition for judicial review. If you do not meet those deadlines, or you do not follow one of the other rules, you may lose your right to appeal the agency s final order. Call weekdays from 9:15 a.m. until 12:15 p.m. CLEAR works with a language line to provide interpreters as needed at no cost to callers. If you are deaf or hard of hearing, please call using your preferred TTY or Video relay service. If you are 60 years or older, CLEAR has a separate hotline: HCA/DLS/OHAv1

16 July 26, 2011 ADSA: NH # CHANGES TO MDS 3.0 ASSESSMENT MODIFICATION & FORMATTING POLICIES & NURSING HOME COMPARE The purpose of this letter is to let you know the Centers for Medicare & Medicaid Services (CMS) has issued a Survey and Certification Memorandum (S&C ) providing information on changes being made to the Minimum Data Set Version 3.0 (MDS 3.0) Assessment Modification & Formatting Policies & Nursing Home Compare as a result of MDS 3.0 Implementation. Highlights of the memorandum: Effective April 1, 2011, nursing home and swing bed providers may not modify existing MDS 3.0 records to correct an event date or a reason for assessment. The corrections will need to be made by inactivating the incorrect record in the data base and creating a new MDS 3.0 record with the correct information and then submitting that new correct record Effective February 1, 2011, CMS issued version of jraven, the CMS data entry software application that can be used by nursing homes or swing beds to collect, maintain, and submit MDS 3.0 assessment information. This version provides more signature lines in Section Z of the MDS. In addition, CMS made a decision that the print format provided by jraven for a MDS 3.0 assessment is acceptable for review in the nursing home survey process. For providers who use other software programs, the printed copies of MDS 3.0 are acceptable as long as they display information similarly to jraven. Effective April 23, 2011, CMS froze Quality Measure (QM) data and the QM ratings currently on Nursing Home Compare website for a period of six months. The data currently displayed reflects MDS 2.0 data and MDS 3.0 data will not be available until early You may access the Survey and Certification letter issued by CMS at: Please contact your local RCS Field Manager if you have any questions.

17 June 28, 2011 ADSA: NH # ESSB RESHAPING THE DELIVERY OF LONG-TERM CARE SERVICES The purpose of this letter is to let you know that the Governor recently signed Engrossed Substitute Senate Bill (ESSB) 5708 into law, affecting nursing homes. ESSB 5708 is an act relating to reshaping the delivery of long-term care services. The effective date of this bill is July 22, Sections 7 and 8 of this bill involve nursing homes. Section 7 adds a new section to chapter RCW and allows nursing facilities to provide telephone or web-based transitional care management services to persons discharged from the facility to a home. If these services are provided, the nursing facility is required to discuss with the client options for care or other services and must coordinate the care and service needs with in-home agencies and other authorized care providers. The nursing facility is also required to notify the client s primary care physician if concerns are identified. Since this section involves nursing facility activity related to postdischarge, the department does not intend to adopt rules and cannot assist you with related questions. In Section 8, the legislation requires the department to convene a workgroup, adopt rules and develop a report to the legislature on identifying mechanisms to incentivize nursing facilities to close or to eliminate licensed beds from active service. The department is already working with providers on aspects of Section 8. To read the details of the newly passed legislation in its entirety online, visit: scroll down to Available Documents/Bill Documents and select the link, Session Law.

18 June 28, 2011 ADSA: NH # SSB 5042: PROTECTION OF VULNERABLE ADULTS; AND 2E2SHB 1738: CHANGING THE DESIGNATION OF THE MEDICAID SINGLE STATE AGENCY The purpose of this letter is to let you know the Governor recently signed two bills into law that affect nursing homes. Substitute Senate Bill (SSB) 5042 is an act relating to protection of vulnerable adults and Second Engrossed Second Substitute (2E2SHB) 1738 is an act relating to changing the designation of the Medicaid single state agency. Bill Information Highlights of SSB 5042: Becomes effective July 22, 2011 and makes changes to statute, chapter Revised Code Washington (RCW) on Abuse of Vulnerable Adult. Expands the definition of financial exploitation to include improper control over or withholding of a vulnerable adult s resources by another person or entity. Adds specific examples of financial exploitation including the use of deception, intimidation, or undue influence by a person or entity to obtain or use a vulnerable adult s resources for the benefit of a person or entity other than the vulnerable adult. Adds breach of fiduciary duty as an example of financial exploitation when it results in the unauthorized appropriation, sale or transfer of a vulnerable adult s resources for the benefit of a person or entity other than the vulnerable adult. To read the details of the newly passed legislation in its entirety online, visit: scroll down to Available Documents/Bill Documents and select the link, Session Law. Highlights of 2E2SHB 1738: Becomes effective July 1, Designates the Health Care Authority (HCA) as the single state agency for the purposes of the Medicaid program. Assigns all responsibilities of the Department of Social and Health Services (DSHS) for medical services programs to HCA. The passage of this law means that all appeal rights under Title XIX (Medicaid) will be held under an HCA WAC chapter for appeal rights. (Appeal rights under state law, will continue to be held under chapter WAC). To read the details of the newly passed legislation in its entirety online, visit: scroll down to Available Documents/Bill Documents and select the link, Session Law.

19 Rule Making CR-101 Permanent Rules: recently filed a CR-101 with the Office of the Code Reviser to start the rule making process for amending sections of Chapter Washington Administrative Code (WAC). Technical changes will be made, such as amending the financial exploitation definition and clarifying hearing rights for medical services programs under Title XIX, so that the WACs are consistent with the newly passed laws. In addition to changes in SSB 5042 and 2E2HB 1738, the CR-101 proposes amending WAC sections related to other newly passed legislation. (See NH # and NH # ) The CR-101 is also available electronically on the ADSA website at under NH Rule Filings. Please check the ADSA website often as we will be posting draft language for review and comment before filing the CR-102. Thank you for your continued commitment to the long-term care residents of our state.

20 June 28, 2011 ADSA: NH # ESHB 1277: Oversight of Licensed Long-term Care Settings The purpose of this letter is to let you know about a bill the Governor recently signed into law that affects nursing homes. Engrossed Substitute House Bill (ESHB) 1277 is an act relating to oversight of licensed long-term care settings. Bill Information Section 401 of ESHB 1277 involves nursing homes as it amends Revised Code of Washington (RCW) , License Issuance, renewal fee Display. It requires that nursing home license fees be set in the State Omnibus Appropriations Act. It also requires that the license must be issued only to the person who applied for the license and provides details on the expiration date of a license. The law directs that the effective date of these changes is July 1, To read the details of the newly passed legislation in its entirety online, visit: scroll down to Available Documents/Bill Documents and select the link, Session Law. Rule Making CR-103 Emergency Rules: Since Section 401 requires the effective date to be July 1, 2011, this does not allow the Department enough time to adopt rules through the regular rule adoption process. has filed a CR-103, Emergency Rule Filing, on Chapter Washington Administrative Code (WAC) with the Office of the Code Reviser. The CR-103E document, including rule changes, is enclosed for your convenience. In addition, this information is available electronically on the ADSA website at under NH Rule Filings. CR-101 Permanent Rules: Since emergency rules are not permanent, has also filed a related CR- 101 to start the regular rule adoption process on these emergency rules. In addition to changes in ESHB 1277, the CR-101 proposes amending WAC sections related to other newly passed legislation. (See NH # and NH # ) The CR 101 document is enclosed for your convenience. You can also access this document electronically on the ADSA website mentioned on page one of this letter.

21 Please check the ADSA website as we will be posting draft language for review and comment before filing the CR-102. Aging & Disability Services Administration, Office of Rates Management, will also be sending you a letter shortly with details on the fee amounts.

22 June 16, 2011 ADSA: NH # SUBSTITUTE HOUSE BILL EMPLOYMENT OF PHYSICIANS The purpose of this letter is to let you know that the Governor recently signed into law Substitute House Bill 1315, an act relating to employment of physicians by nursing homes. The effective date of this bill is July 22, Highlights of this recently passed legislation follows. The nursing home: May employ physicians to provide professional services to residents of the nursing home under these conditions: Nursing homes may not supplant, diminish or regulate any employed physician s judgment, directly or indirectly, concerning the practice of medicine or diagnosis and treatment of any patient; and The employed physicians may provide professional services only to residents of the nursing home or a related living facility as defined in the bill. Licensee still is ultimately responsible for the daily operations of the nursing home. Must continue to comply with applicable federal and state resident rights laws and rules. To ensure that the hiring facility is in compliance with applicable federal and state resident rights laws and rules the department will monitor nursing homes during survey and complaint investigations. To read the newly passed legislation, please go to this link: The legislation also requires the department to submit a report to the legislature by January 1, 2013 on consumer satisfaction and medical cost implications. If you choose to hire physicians, please keep the following information: hire date, end date (if applicable), total capacity of your facility and the number of residents who have chosen to be served by the hired physician. In August 2012, we will send a letter requesting that you provide this information to us so that it can be included in the report. If you have any questions, please contact your RCS Field Manager.

23 June 8, 2011 ADSA: NH # REVISIONS TO RAI USER S MANUAL This letter contains important information for facility staff responsible for completing the Minimum Data Set (MDS) assessments. The Centers for Medicare and Medicaid Services (CMS) recently announced the release of the first set of updates to the Long Term Care Facility Resident Assessment Instrument User s Manual Version 3.0. The changes, which include clarifications of existing policy, addition of coding tips and examples, revision of certain documents, changes in definitions and correction of typographical errors are found in the MDS 3.0 RAI Manual May 25, 2011 download. The updates include a Track Changes document that describes the chapter, section and page number of the changes as well as the old language and the newly changed language. The second document is the newly revised section, chapter or appendix with the effective month and year noted on the bottom left of each page. Not all sections/chapters are updated with this release. Highlights of this update include the following: Chapter 1: The Privacy Act Statement has been changed Chapter 2: Clarifications on the requirements for entry and discharge reporting r/t change of ownership, more examples of what constitutes an unplanned discharge and completing a significant change vs admission assessment for residents admitted on Hospice Chapter 3: Coding Conventions-how to code items that require a count or measurement that exceeds the available number of boxes Chapter 3: Section D-Change in what constitutes a successful interview for the PHQ-9- OV (was 7 out of 10 responses, now it is 8 out of 10). The total severity score range also changed for the PHQ-9 from 0-4 to 1-4. This is now consistent with the severity score range for the staff interview (PHQ-9-OV) Chapter 3: Section G- clarified who were considered facility staff for coding ADL assistance Chapter 3: Section J- The definition for coding J1440 Prognosis changed from requiring a physician to document a life expectancy of less than 6 months to providing documentation that the resident is terminally ill or that the resident is receiving hospice services. Medicare Hospice still requires the physician to have documentation in the record that states the resident has a life expectancy of less than 6 months. Chapter 3: Section K- The definition of therapeutic diet was clarified and two additional coding tips were added. Chapter 3: Section M-Clarified when to code a healed ulcer for M0210; Identified when to use a dash for coding the most severe tissue type in a pressure ulcer wound bed (M0700); Clarified M0800 r/t worsened ulcer; M1040 Other skin conditions had 2 clarifications about open lesions

24 on the foot and adding the word healed to the description of surgical wound as it relates to stomas Chapter 3: Section O0100- Added that any treatment, program and/or procedure that a residents does themselves can now be coded, including putting on, adjusting or removing their own oxygen cannula, self suctioning, self tracheostomy care, etc. The facility, however, will have to educate the resident on the proper procedures, safety, and use of equipment and monitor the resident for appropriate use and continued ability to self perform the procedures. Chapter 3: Item O0100M, Isolation-significant changes in coding instructions and definitions. Chapter 3: Item O0250C, Influenza Vaccine- Removed the words in this facility. The intent is to capture whether or not a resident received the flu shot, not where. Chapter 3: Section Q- Added some new examples and expanded coding tips Chapter 5 (submission and error correction) was rewritten to reflect changes in what can be modified and inactivated. They also added language that instructs facilities NOT to submit Managed Care Medicare assessments to the CMS data base, only OBRA required and PPS Medicare Part A assessments. Chapter 6 had some additions and changes Appendix A- (the glossary) Several items were changed/added Appendix B- The list of state RAI and automation coordinators and Regional coordinators was removed and replaced with the website address where this list will now be maintained Appendix C- (the CAA list) A signature line and date line was added to all of the CAA example forms. The CAA for community referral had a couple of minor additions also. Appendix E-The CPS chart was removed along with references to it being used to determine cognitive performance. These updates are now available for download on the CMS website at: OfPage. It is the responsibility of the individuals who complete the MDS to have the most current RAI manual instructions in order to accurately complete the required assessments. If you have any questions or need further information, please contact Marjorie Ray, RN, Washington State RAI Coordinator, at (360) or at rayma@dshs.wa.gov

25 April 19, 2011 ADSA: NH # DSHS REGIONAL CONSOLIDATION: RCS TRI-DISTRICT STRUCTURE The Department of Social and Health Services is currently transitioning its regional structure from six to three regions for all programs across the state. The work of DSHS is centered around integrated case management and community outreach. is unique in that our work is regulatory in nature; we support the work of DSHS through the licensing, certification and oversight of long-term care facilities Because our work is regulatory in nature, our structure is a bit different. Effective immediately, will adopt a 3 district (instead of regional) structure, comprised of the following counties: District 1: Adams Asotin, Benton, Chelan, Columbia, Douglas, Ferry, Franklin, Garfield, Grant, Lincoln, Klickitat, Kittitas, Okanogan, Pend Oreille, Spokane, Stevens, Walla Walla, Whitman & Yakima District 2: Island, King, San Juan, Skagit, Snohomish & Whatcom District 3: Clallam, Clark, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Mason, Pacific, Pierce, Skamania, Thurston & Wahkiakum Each District will have a District Administrator for Regulatory Programs and Field Managers. The core work of RCS has not changed. The Field Managers will continue to supervise staff that work with your facility. The Field Manager remains your primary contact. I am enclosing a crosswalk that shows your previous region/unit and current district/unit and respective contacts. RCS contacts and a map showing the new district boundaries are also available online at Thank you for your patience during this transition. Please feel free to contact your RCS Field Manager or District Administrator should you have any questions.

26 RCS Regional Consolidation Crosswalk Old Region/Unit Region 1A New District/Unit District 1A District Administrator Region 1B District 1B Lori Heiner Shirlee Steiner (509) 323- (509) Region 2A District 1C Robert Gutierrez (509) Region 2B District 1D Robert Gutierrez (509) Region 3A District 2A Field Field Office Manager Elena Madrid (509) W Boone Lynne Dasher (360) Region 3B District 2B Roberta Linda Moss Crawford (360) 651- (360) Region 4A District 2C Delores Usea (253) Region 4B District 2D Lois Rasmussen (253) Region 4C District 2E Bennetta Shoop (253) Region 4D District 2F Susan Hajek (253) Region 5A District 3A Janice Jiles (253) Suite 170 Spokane, WA River Road, Suite 200 Yakima, WA nd St. NE Suite 100 Arlington, WA nd Ave S, Suite 400 Kent, WA Mailing Address Same Same Same Same

27 Region 5B District 3B Nancy Tyson (360) Loida Baniqued (253) Region 6B District 3C Maureen Mead (360) Region 6A District 3D Dahl Kim (360) Lakewood Dr. SW. Lakewood, WA th Ave SE Lacey, WA East Mill Plain Blvd, Suite 203 Vancouver, WA South State Street Tacoma, WA PO Box Olympia, WA

28 April 11, 2011 ADSA: NH # DEATH WITH DIGNITY Dear Nursing Home/Facility Administrator: Recently we received information that some nursing homes/facilities may not have been providing care and services around death and dying issues, as required. Some specific issues raised were: Failure to provide, or allow a resident to obtain, physician prescribed medical marijuana. Failure to provide pain medication as ordered resulting in a resident suffering a very painful death. Failure to provide residents with information about death and dying, including the Death with Dignity law, when asked. Discouraging resident use of the Hospice benefit. There are a number of requirements related to resident rights and choices. WAC states the resident has the right to participate in planning care and treatment or changes in care and treatment. WAC also gives the resident the right to choose health care consistent with his or her interests, assessments, and plan of care. In 2008 the public passed Initiative 1000, the Death with Dignity Act. It has been codified in chapter Revised Code of Washington, and the Department of Health has written related rules at chapter Washington Administrative Code (WAC). Please refer to DOHs website atwww.doh.wa.gov/dwda for more information. The Act allows individuals who meet certain criteria to request a prescription for medication to selfadminister to end his or her own life in a humane and dignified manner. The action is between the individual and the attending and consulting physicians. Under the law, nursing homes/facilities are allowed to opt out of participating in the process but must have a policy stating such and inform residents and prospective residents of the policy. Regardless of policy, the nursing home/facility should provide residents, and those providing support to residents, access to information about the Act and other related information as requested. See WAC (4) for more detail about nursing home/facility responsibilities related to a facility policy that may be in conflict with a resident s health care directive. Death and dying issues are sensitive but are issues that you and your residents deal with every day. Please keep informed on requirements related to informed consent, resident choice, and death and dying so that you can best serve your residents. For questions, please contact your local RCS Field Manager.

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30 Not Available April 7, 2011 April and July 2011 Changes to Nursing Home Compare Website

31 March 10, 2011 ADSA: NH # TRANSFERS AND ROOM/ROOMMATE CHANGES This letter is to clarify current requirements for a resident s refusal of certain transfers and the notice required before a resident s room or roommate is changed. In the long term, some clarifications will require a change in the Washington Administrative Code (WAC) but because of the Governor s executive order 10-06, Suspending Non-critical Rule Development and Adoption, non-critical rule making cannot be done at this time. Refusal of Certain Transfers: Federal law at 42 Code of Federal Regulations (CFR) (o) allows a resident to refuse a transfer from a dually certified (Medicare/Medicaid) bed to a nursing facility (Medicaid only) bed, or vice versa, if the purpose of the transfer is to obtain Medicare or Medicaid eligibility. WAC mirrors the refusal language but does not include the language of the purpose. Notice before room or roommate changes: Federal law at 42 CFR (e)(2) gives each resident the right to receive notice before the resident s room or roommate is changed. While the regulation does not include a specific timeframe for the notice, the interpretive guidelines clarify that the facility is to lessen resident trauma associated with the change, and accommodate the resident as much as possible. WAC in general requires three (3) days notice before a room or roommate change, unless a longer or shorter notice is necessary. Conclusion: Nursing facilities/homes may transfer residents between a dually certified Medicare/Medicaid bed and a Medicaid only bed, unless the purpose of the transfer is to obtain Medicare or Medicaid eligibility; and Residents have the right to receive notice before a room or roommate change, and the facility/home should be accommodating as possible including allowing the resident to visit the room and meet a new roommate. Survey staff have been instructed to only consider citing F177 Refusal of Certain Transfers, if the facility has transferred a resident for the purposes of obtaining Medicare or Medicaid eligibility. Staff have also been instructed to determine if notice was given prior to resident transfers as required. We hope this clarification gives residents, eligible for post-acute care, access to more beds, whether under Medicare or Medicaid. If you have questions, please contact your local RCS Field Manager.

32 ADSA: NH # MEDICAID PROGRAM CUTS As you have heard, due to the current conditions of the economy, the state cannot afford to continue all the programs and services that are in place today. Recently, Medicaid Purchasing Administration (MPA) announced a list of anticipated reductions in programs and services designed to reduce the expenditure of state funds. MPA has already sent out notices to Medicaid recipients. Most of the program and service reductions have taken effect January 1, 2011, although some would not take effect until March 2011, because they require legislative approval. Details about the proposed cutbacks are outlined on MPA s website at Please check there regularly to see if there are any updates. By statutes and regulations, nursing homes are still required to meet the identified needs of the residents. Nursing homes will need to: Try to help the resident obtain the service/items (such as arranging appointments and/or transportation); and Contact the resident s case manager to see if they can help. If you have Medicaid questions, please contact the Washington State Medicaid Customer Service at: or the MPA website link above. For questions on the implementation of the requirements, please contact your local RCS Field Manager.