State Assisted Living Policy: 1998. Washington



Boarding homes Chapter 246-316 WAC

Assisted living (Medicaid) Chapter 388-110 WAC

General Approach

The state initiated its assisted living program as a pilot program under Medicaid in one site in 1989. Effective June 8, 1996, the Aging and Adult Services Administration issued regulations for licensed boarding homes who contract with Medicaid for residential care services that covered assisted living, enhanced adult residential care and adult residential care. Enhanced residential care facilities provide limited nursing services and personal care while adult residential care facilities provide only personal care. Boarding homes are licensed by the Health Department.

The number of facilities contracting with Medicaid has risen from 14 in 1995, to 77 in September 1996 and 104 in 1998. The number of units occupied by Medicaid clients has increased from 847 in July 1996 to 1,500 in 1998. Medicaid contracts with 243 facilities providing residential care and enhanced residential care to 1,366 beneficiaries.


Boarding home means any home or other institution, however, named, which is advertised, announced or maintained for the express or implied purpose of providing board and domiciliary care to three or more aged persons not related by blood or marriage to the operator.

Medicaid "Assisted living services is a package of services, including personal care and limited nursing services, that the department contracts with a licensed boarding home to provide in accordance with Parts I and II of this chapter. Assisted living services include housing for the residents in a private apartment-like unit."

The contract previously defined assisted living as "a coordinated array of personal care, health services and other supportive services available 24-hours per day to residents who have been assessed to need these services. Assisted living promotes resident self-direction and participation in decisions that emphasize independence, individuality, privacy, dignity, choice and residential surroundings."

Unit Requirements

Boarding home Rooms must offer 80 square feet for single occupancy and 70 square feet per person in multiple occupancy rooms. No more than four residents may occupy a room. One toilet and sink is required for every eight residents and one bathing fixture is required for every twelve residents.

Medicaid To contract with Medicaid, facilities must provide individual units with 220 square feet including counters, closets and built-ins, and excluding the bathroom. Existing facilities may have a minimum of 180 square feet. The kitchen area must have a refrigerator, microwave or stove top and a counter or table for food preparation. New facilities must also have a sink and counter area and storage area. Units must have lockable entry doors and a living area wired for telephone and television service, where available. The physical environment is supposed to enhance autonomy in ways which reflect the personal and social values of dignity, privacy, independence, individuality, choice and decision-making of residents. Facilities must provide a home-like environment enhancing the dignity, independence, individuality, privacy, choice and decision-making ability of residents.

Two people may occupy a unit but only by choice. Facilities are prohibited from offering a shared unit at a lower cost per month. Medicaid will reimburse facilities a separate full rate for a qualified second occupant.

Tenant Policy

Boarding home Generally, homes may not provide respiratory ventilation, intravenous procedures, suctioning, feeding tube insertion or site maintenance and care of residents who are bed bound more than 14 consecutive days as a result of a medical condition. However, residents may arrange for these services if they reside in lockable quarters with a private toilet, sink, bathing fixture and emergency power if necessary for life support equipment.

Medicaid Residents may be required to move when their needs exceed the services provided through the contract with the state agency; the residents places themselves or others at an unreasonable risk; the residents have failed to make proper payments for services; or the residents require a level of nursing care that exceeds what is allowed by the boarding home license. Case managers must approve all discharges from facilities.


Boarding homes provide basic domiciliary care, general health supervision and assistance with self-administration of medications, following prescribed diets and activity regimes, making and keeping appointments for health care services, maintain personal hygiene, obtaining and maintaining functional aids, arranging for social, recreational and religious activities, resident mobility and incontinence care. Homes may apply for a limited nursing license and employ or contract with an RN or physician to provide or supervise limited nursing services (not continuous nursing care) such as insertion of catheters, routine ostomy care, enemas, uncomplicated routine colostomy and urethral care, care of superficial wounds, and assistance with glucomoter testing.

Medicaid Facilities contracting with Medicaid must obtain a limited nursing license. The negotiated service plan format has been changed. A specified form is no longer required. A formal written negotiated plan, which involves the resident, appropriate staff, AASA case manager and family or others if chosen by the residents, must be completed within 30 days of move-in. The services must meet a range of needs and preferences of residents and facilitate aging in place by being flexible. Services must support managed risk and allow the resident to take responsibility for risks associated with decision-making. A negotiated plan to reduce the probability of a poor outcome when the resident's decision or preference creates risk must be developed.

The service plan should decrease the probability of a poor outcome when a resident's decision or preference places the resident or others at risk, leads to adverse consequences, or conflicts with other residents' rights or preferences. This negotiated services planning process is now required for boarding homes and adult family care programs.

Facilities must provide personal care services based on the resident's negotiated service agreement and provide the range of services required to meet the increasing or changing needs of residents as they age-in-place to the maximum extent permitted by boarding home regulations. Contractors have to provide or arrange for limited nursing services at no additional cost.

Facilities must also assist the resident to arrange, obtain and coordinate services such as transportation to medical appointments and recreational activities, ancillary services related to medical care (physician, pharmacist, mental health, physical or occupational therapy, hospice, home health care, podiatry), barber/beauty services and others necessary to support and assist the resident in maintaining independence.

In 1995, amendments to the state's nurse practice act were passed which allow RNs to delegate tasks to nursing assistants in licensed boarding homes, assisted living facilities and adult family homes. Nursing assistants must complete a core training program. Nurses may delegate the following tasks: oral and topical medications and ointments; nose, ear, eye drops and ointments; dressing changes and catheterization; suppositories, enemas and ostomy care; blood glucose monitoring and gastronomy feeding in established and healed condition. Delegation is at the discretion of the nurse and only for people whose conditions are stable and predictable.


The reimbursement methodology and rate for Medicaid recipients who meet the nursing home level of care criteria has been revised. AASA developed three rate levels and three geographic areas. The rates are based on components for nursing staff, operations and capital costs. Residents without any other income apply $14.82 per day from their SSI check to the room and board costs. Services costs are reimbursed by Medicaid. (See narrative for a discussion of the rate structure.)



Level 1

Level 2

Level 3

MSA Counties




Non-MSA counties




King County




A capital add-on is available for newly constructed facilities whose capital costs exceed the allowance. The add-on ranges from $4.08 to $4.49.


Medication administration is covered under the boarding homes rules. The boarding home rules allow for reminders, assistance with self-administration and administration of medications by licensed staff. Changes in the nurse practice act to allow nurse delegation is pending in the legislature.


Boarding home Staff must be sufficient to furnish services and care needed by residents, maintain the home free of safety hazards and implement fire and disaster plans.

Medicaid RNs or LPNs are required to be available on-site five hours a day, seven days a week and on call 24-hours a day to provide services listed in the negotiated service agreements. Other staff must be sufficient to deliver services identified in service agreements. New staff must receive five hours of training and monthly in-service sessions on assisted living values and principles.



Boarding home Administrators must be 21 and have a high school degree and two years experience or an advanced degree, or certification.

Medicaid Administrators must complete 40 hours of training regarding assisted living services, resident rights and the social model of services within the first six months of employment. All administrators shall have 10 hours of continuing education credits per calendar year.


Boarding homes must provide staff orientation and appropriate training for expected duties, including: organization of the boarding home; physical boarding home layout; specific duties and responsibilities; and policies, procedures and equipment necessary to perform duties. Other sections require training in CPR, first aid, infection control, and HIV/AIDs.

Medicaid Caregivers must complete the department designated fundamentals of caregiving training. Contractors who meet the prescribed criteria may be approved to provide this training. Caregivers who are RNs, LPNs, nursing assistants, or who have successfully completed personal care training from an area agency on aging are exempt.

Caregivers must complete 10 hours of in-service training a year. Topics include but are not limited to: resident rights; personal care; dementia; mental illness; developmental disabilities; depression; medication assistance; communication skills; alternatives to restraints; and activities for residents.

Contractors must provide a minimum of five hours of training for all staff regarding assisted living services, resident rights, the social model of services and service planning for residents.

Background Checks

Boarding home The licensee and administrator must file a disclosure statement as defined in RCW 43.43.824-hour. The licensee must obtain a Washington state patrol criminal history (RCW 43.43.842(1) for all staff having direct contact with residents. Staff may not be hired who have a conviction of a crime against individuals, financial exploitation or abuse.


The licensing agency makes periodic inspection and survey visits. Case managers are a primary source of monitoring for quality assurance for Medicaid beneficiaries. During regular visits, the case manager checks to see if the client is satisfied, the negotiated service plan is being carried out and that the plan is appropriate for the resident.


Facilities are charged $54 per licensed bed. An additional $150 is payable for facilities receiving a third site visit because of failure to respond adequately to deficiencies or a complete on-site review resulting from a complaint.

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