Washington home health vs home care: the license categories

Home care services are "Personal care such as assistance with dressing, feeding, and personal hygiene to facilitate self-care; homemaker assistance with household tasks, such as housekeeping, shopping, meal planning and preparation, and transportation; respite care assistance and support provided to the family; or other nonmedical services or delegated tasks of nursing under RCW 18.79.260(3)(e)." RCW 70.127.010(6) DOH’s rule then defines nonmedical services as "ADL and IADL tasks which do not require clinical judgment and are ordinarily performed by the client or patient, which if not for the client or patient’s functional, physical, or mental limitation(s), would be completed independently by the client or patient, or family." WAC 246-335-310(24)

Nursing as such. Nursing services are a home health service. RCW 70.127.010(8) The statute lets an agency that provides nursing services only choose to be designated a home health agency for licensure. RCW 70.127.010(7) The only nursing tasks in the definition of home care are tasks delegated under RCW 18.79.260(3)(e), so by our reading a home care agency gives nursing tasks only through nurse delegation, never as nursing services of its own. RCW 70.127.010(6) If your plan sits near the line, ask DOH before you start.

CareRulebook’s manual sets out each task and limit for your workers in Policy 2.3, home care services and the tasks workers do and do not do, written from the services you choose.

A home care agency’s policies must set out what staff, contractors and volunteers may do in "medication self-administration with assistance". WAC 246-335-420(4) DOH’s rule defines it as "reminding or coaching the client or patient to take their medication, handing the medication container to the client or patient, opening the medication container, using an enabler, or placing the medication in the hand of the client or patient", and other help the pharmacy commission (PQAC) defines. WAC 246-335-310(22)

• The pharmacy commission’s list. The pharmacy commission’s rule also allows setting up a diabetic device, handing over injectables for self-administration, and (only on a practitioner’s direction) transferring medication between containers and altering it (crushing, cutting). No hand-over-hand administration. WAC 246-945-714 The statute frames it as help "by a nonpractitioner to an individual residing in a community-based care setting or in-home care setting to facilitate the individual’s self-administration of a legend drug". RCW 69.41.010(15)
• Only for clients who know. "Medication assistance must only be provided if the individual is cognitively aware they are receiving medications." Otherwise a person legally authorized must administer it. WAC 246-945-718
• Injections. Handing a client an injectable to use themselves is on the pharmacy commission’s list. Giving the injection is not: certified home care aides may accept a delegated injection only for insulin. WAC 246-980-130(8) So, by our reading, a home care worker gives an insulin injection only through nurse delegation, below.

The manual’s Policy 2.4, medication self-administration with assistance, sets out the level of help you choose.

Delegation keeps you in home care. "A home care agency that provides delegated tasks of nursing under RCW 18.79.260 (3)(e) is not considered a home health agency for purposes of this chapter." WAC 246-335-410(4) In home settings, the nursing law lets a registered nurse delegate only to registered or certified nursing assistants or certified home care aides. RCW 18.79.260(3)(e) And "Home care agencies are not required to provide nurse delegation services and do not need a policy if they do not provide these services". WAC 246-335-420(14)(b)

Vital signs for information are not delegation. The rule names no nurse for the informational help in WAC 246-335-420(12)(a); only readings that decide medication bring in a contracted registered nurse (our reading of subsection (12) as a whole). WAC 246-335-420(12)

In CareRulebook’s manual, help with vital signs for information (Policy 2.9) and passive range of motion (Policy 2.10) are options you choose. Nurse delegation and vital signs that decide medication are recorded as not offered (Policy 2.11), with what workers do if asked and the steps the agency would take before ever offering them.

The statute’s definition of home care services is open-ended: it ends with "other nonmedical services". RCW 70.127.010(6) Housework, meal preparation, essential shopping and travel to medical services are instrumental activities of daily living in DOH’s rule, WAC 246-335-310(18) and none of the 22 exemptions in RCW 70.127.040 covers a companion-only or homemaker-only agency, so by our reading a companion business whose staff do those tasks needs the home care category. RCW 70.127.040; WAC 246-335-410(5)

Companionship with no ADL or IADL task at all is not addressed. DOH’s rule defines nonmedical services as ADL and IADL tasks and does not mention companionship. WAC 246-335-310(24) We found no DOH statement either way. Ask DOH (360-236-2957) before you plan on running without a license. DOH, Contact Information

For the DOH license: "A certificate of need under chapter 70.38 RCW is not required for licensure except for the operation of a hospice care center." RCW 70.127.080(2)

Under the certificate of need law, though, a separate chapter applies. It lists home health agencies, hospices and hospice care centers among health care facilities, RCW 70.38.025(6) and establishing a new health care facility is subject to review: "No person shall engage in any undertaking which is subject to certificate of need review under subsection (4) of this section without first having received from the department either a certificate of need or an exception granted in accordance with this chapter." RCW 70.38.105(3), (4)(a)

DOH’s certificate of need rules limit which agencies count: a home health agency or hospice is one that "is, or has declared its intent to become, certified" in the Medicaid or Medicare program. WAC 246-310-010(30)-(31) DOH’s certificate of need page lists "Medicare or Medicaid home health agencies", Medicare or Medicaid hospice agencies and hospice care centers among the facilities that need review. DOH, Certificate of Need For those agencies, serving a new county on a regular and ongoing basis counts as developing a new agency. WAC 246-310-020(1)(a)(ii)

What that means, by our reading: home care does not need a certificate of need. A home health agency licensed by DOH that is not and does not plan to be Medicare or Medicaid certified does not need one either. A home health agency or hospice that plans to bill Medicare or Medicaid does, and so does a hospice care center. We have not reviewed how DOH decides those applications or what it charges; if your plan depends on it, contact DOH’s Certificate of Need program first.