Chapter 246-322 WAC
Last Update: 7/30/24PRIVATE PSYCHIATRIC AND ALCOHOLISM HOSPITALS
WAC Sections
| HTMLPDF | 246-322-010 | Definitions. |
| HTMLPDF | 246-322-020 | Licensure—Initial, renewal, modifications. |
| HTMLPDF | 246-322-025 | Responsibilities and rights—Licensee and department. |
| HTMLPDF | 246-322-030 | Criminal history, disclosure, and background inquiries. |
| HTMLPDF | 246-322-035 | Policies and procedures. |
| HTMLPDF | 246-322-040 | Governing body and administration. |
| HTMLPDF | 246-322-050 | Staff. |
| HTMLPDF | 246-322-100 | Infection control. |
| HTMLPDF | 246-322-120 | Physical environment. |
| HTMLPDF | 246-322-140 | Patient living areas. |
| HTMLPDF | 246-322-150 | Clinical facilities. |
| HTMLPDF | 246-322-160 | Bathrooms, toilet rooms and handwashing sinks. |
| HTMLPDF | 246-322-170 | Patient care services. |
| HTMLPDF | 246-322-180 | Patient safety and seclusion care. |
| HTMLPDF | 246-322-190 | Provisions for patients with tuberculosis. |
| HTMLPDF | 246-322-200 | Clinical records. |
| HTMLPDF | 246-322-210 | Pharmacy and medication services. |
| HTMLPDF | 246-322-220 | Laboratory services. |
| HTMLPDF | 246-322-230 | Food and dietary services. |
| HTMLPDF | 246-322-240 | Laundry. |
| HTMLPDF | 246-322-250 | Construction. |
| HTMLPDF | 246-322-260 | Adverse health events reporting requirements. |
| HTMLPDF | 246-322-500 | Exemptions. |
| HTMLPDF | 246-322-990 | Private psychiatric hospital fees. |
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
| 246-322-001 | Purpose and scope. [Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-001, filed 10/20/95, effective 11/20/95.] Repealed by WSR 97-20-101, filed 9/29/97, effective 10/30/97. Statutory Authority: RCW 43.70.040. |
| 246-322-060 | HIV/AIDS education and training. [Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-060, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-060, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 70.24.310. WSR 89-21-038 (Order 3), § 248-22-017, filed 10/12/89, effective 11/12/89.] Repealed by WSR 21-02-002, filed 12/23/20, effective 1/23/21. Statutory Authority: RCW 18.19.050, 18.29.130, 18.29.210, 18.34.120, 18.46.060, 18.55.095, 18.84.040, 18.88B.060, 18.89.050, 18.130.050, 18.138.070, 18.155.040, 18.200.050, 18.205.060, 18.215.040, 18.230.040, 18.240.050, 18.250.020, 18.290.020, 18.360.030, 18.360.070, 70.41.030, 70.230.020, 71.12.670, and 18.108.085. |
| 246-322-070 | Patient care services. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-070, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-021, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-021, filed 12/30/80.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
| 246-322-080 | Food and dietary services. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-080, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-026, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-026, filed 12/30/80.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
| 246-322-090 | Pharmaceutical services. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-090, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-031, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-031, filed 12/30/80.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
| 246-322-110 | Clinical records. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-110, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-041, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-041, filed 12/30/80.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
| 246-322-130 | Laboratory services. [Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-130, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-051, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-051, filed 12/30/80.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
| 246-322-991 | Alcoholism hospital fees. [Statutory Authority: RCW 43.70.250, 43.70.110 and 43.20B.020. WSR 95-12-097, § 246-322-991, filed 6/7/95, effective 7/8/95. Statutory Authority: RCW 43.70.250. WSR 92-12-028 (Order 273), § 246-322-991, filed 5/28/92, effective 6/28/92. Statutory Authority: RCW 43.70.040. WSR 91-02-050 (Order 122), § 246-322-991, filed 12/27/90, effective 1/31/91.] Repealed by WSR 95-22-012, filed 10/20/95, effective 11/20/95. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. |
PDF246-322-010
Definitions.
The definitions in this section apply throughout the chapter unless the context clearly requires otherwise. For the purposes of this chapter, the following words and phrases have the following meanings unless the context clearly indicates otherwise:
(1) "Abuse" means an act by any individual which injures, exploits or in any way jeopardizes a patient's health, welfare, or safety including, but not limited to:
(a) Physically damaging or potentially damaging nonaccidental acts;
(b) Emotionally damaging verbal behavior and harassment or other actions which may result in emotional or behavioral problems; and
(c) Sexual use, exploitation and mistreatment through inappropriate touching, inappropriate remarks or encouraging participation in pornography or prostitution.
(2) "Administrator" means the individual responsible for the day-to-day operation of the hospital.
(3) "Advanced registered nurse practitioner" means a registered nurse authorized to practice specialized and advanced nursing according to the requirements in RCW 18.79.250.
(4) "Authenticate" means to authorize or validate an entry in a record by:
(a) A signature including first initial, last name, and professional title/discipline; or
(b) A unique identifier which clearly indicates the responsible individual.
(5) "Bathing fixture" means a bathtub, shower, or combination bathtub shower.
(6) "Bathroom" means a room containing one or more bathing fixtures.
(7) "Child psychiatrist" means an individual licensed as a physician under chapter 18.71 or 18.57 RCW who is board-certified or board-eligible with a specialty in child psychiatry by:
(a) The American Board of Psychiatry and Neurology; or
(b) The Bureau for Osteopathic Specialists, American Osteopathic Neurology and Psychiatry.
(8) "Clinical record" means a file maintained by the licensee for each patient containing all pertinent psychological, medical, and clinical information.
(9) "Comprehensive treatment plan" means a written plan of care developed by a multidisciplinary treatment team for an individual patient, based on an assessment of the patient's developmental, biological, emotional, psychological, and social strengths and needs, which includes:
(a) Treatment goals with specific time frames;
(b) Specific services to be provided;
(c) The name of each individual responsible for each service provided;
(d) Behavior management; and
(e) Discharge criteria with estimated time frames.
(10) "Construction" means:
(a) A new building to be used as a hospital or part of a hospital;
(b) An addition, modification or alteration which changes the approved use of a room or area; and
(c) An existing building or portion thereof to be converted for use as a hospital.
(11) "Department" means the Washington state department of health.
(12) "Dietitian" means an individual certified under chapter 18.138 RCW.
(13) "Document" means to record, with authentication, date and time.
(14) "Drug administration" means the act of an authorized individual giving a single dose of prescribed drug or biological to a patient according to the laws and regulations governing such acts.
(15) "Drug dispensing" means interpreting a prescription and, pursuant to that prescription, selecting, measuring, labeling, packaging, and issuing the prescribed medication to a patient or service unit of the facility.
(16) "Exemption" means a written authorization from the department which releases a licensee from meeting a specific requirement or requirements in this chapter.
(17) "Family" means an individual or individuals:
(a) Designated by the patient, who may or may not be related to the patient; or
(b) Legally appointed to represent the patient.
(18) "Governing body" means the person legally responsible for the operation and maintenance of the hospital.
(19) "Health care professional" means an individual who provides health or health-related services within the individual's authorized scope of practice, who is:
(a) Licensed, certified or registered under Title 18 RCW; or
(b) A recreational therapist as defined in this section.
(20) "Licensed bed capacity" means the patient occupancy level requested by the applicant or licensee and approved by the department.
(21) "Licensee" means the person to whom the department issues the hospital license.
(22) "Maximum security window" means a security window which, if operable, opens only with a key or special tool.
(23) "Mental health professional" means:
(a) A psychiatrist, psychologist, psychiatric nurse or social worker; or
(b) An individual with:
(i) A masters degree in behavioral science, nursing science, or a related field from an accredited college or university; and
(ii) Two years experience directly treating mentally ill individuals under the supervision of a mental health professional.
(24) "Multidisciplinary treatment team" means a group of individuals from various clinical services who assess, plan, implement and evaluate treatment for patients under care.
(25) "Neglect" means conduct which results in deprivation of care necessary to maintain a patient's minimum physical and mental health including, but not limited to:
(a) Physical and material deprivation;
(b) Lack of medical care;
(c) Inadequate food, clothing or cleanliness;
(d) Refusal to acknowledge, hear or consider a patient's concerns;
(e) Lack of social interaction and physical activity;
(f) Lack of personal care; and
(g) Lack of supervision appropriate for the patient's level of functioning.
(26) "Occupational therapist" means an individual licensed under chapter 18.59 RCW.
(27) "Patient-care staff" means employees, temporary employees, volunteers, or contractors, who provide direct care services for patients.
(28) "Person" means any individual, firm, partnership, corporation, company, association, joint stock association, and the legal successor thereof.
(29) "Pharmacist" means an individual licensed as a pharmacist under chapter 18.64 RCW.
(30) "Pharmacy" means the central area in a hospital where prescriptions are filled, or drugs are stored and issued to hospital departments.
(33) "Private psychiatric hospital" or "hospital" means a privately owned and operated establishment or institution which:
(a) Provides accommodations and services over a continuous period of twenty-four hours or more; and
(b) Is expressly and exclusively for observing, diagnosing, or caring for two or more individuals with signs or symptoms of mental illness, who are not related to the licensee.
(34) "Professional staff" means health care professionals appointed by the governing body to practice within the parameters of the professional staff bylaws.
(35) "Psychiatric advanced registered nurse practitioner" means a person who is licensed as an advanced registered nurse practitioner under chapter 18.79 RCW and who is board certified in advanced practice psychiatric and mental health nursing.
(36) "Psychiatric nurse" means a registered nurse with:
(a) A bachelor's degree from an accredited college or university and two years experience directly treating mentally ill or emotionally disturbed individuals under the supervision of a psychiatrist or psychiatric nurse; or
(b) Three years experience directly treating mentally ill or emotionally disturbed individuals under the supervision of a psychiatrist or psychiatric nurse.
(37) "Psychiatrist" means an individual licensed as a physician under chapter 18.71 or 18.57 RCW who is board-certified or board-eligible with a specialty in psychiatry by:
(a) The American Board of Psychiatry and Neurology; or
(b) The Bureau for Osteopathic Specialists, American Osteopathic Neurology and Psychiatry.
(38) "Psychologist" means an individual licensed under chapter 18.83 RCW.
(39) "Recreational therapist" means an individual:
(a) With a bachelor's degree with a major or option in therapeutic recreation or in recreation for the ill and handicapped; or
(b) Certified or certification-eligible under Certification Standards for Therapeutic Recreation Personnel, June 1, 1988, National Council for Therapeutic Recreation Certification, 49 South Main Street, Suite 005, Spring Valley, New York 10977.
(40) "Referred outpatient diagnostic service" means a diagnostic test or examination performed outside the hospital which:
(a) Is ordered by a member of the professional staff legally permitted to order such tests and examinations, to whom the findings and results are reported; and
(b) Does not involve a parenteral injection, local or general anesthesia, or a surgical procedure.
(41) "Registered nurse" means an individual licensed under chapter 18.88 RCW.
(42) "Restraint" means any apparatus or chemical used to prevent or limit volitional body movements.
(43) "Seclusion room" means a small room designed for maximum security and patient protection, with minimal sensory stimuli, for the temporary care of one patient.
(44) "Security room" means a patient sleeping room designed, furnished and equipped to provide maximum safety and security.
(45) "Security window" means a window designed to inhibit exit, entry and injury to a patient, with safety glazing or other security feature to prevent breakage.
(46) "Self-administration" means the act of a patient taking the patient's own medication from a properly labeled container while on hospital premises, with the hospital responsible for appropriate medication use.
(47) "Sink" means a properly trapped plumbing fixture, with hot and cold water under pressure, which prevents back passage or return of air.
(48) "Social worker" means an individual registered or certified as a counselor under chapter 18.19 RCW with a master's degree in social work from an accredited school of social work.
(49) "Special services" means clinical and rehabilitative activities or programs including, but not limited to:
(a) Educational and vocational training;
(b) Dentistry;
(c) Speech therapy;
(d) Physical therapy;
(e) Occupational therapy;
(f) Language translation; and
(g) Training for individuals with hearing or visual impairment.
(50) "Staff" means employees, temporary employees, volunteers, and contractors.
(51) "Toilet" means a fixture fitted with a seat and flushing device used to dispose of bodily waste.
(52) "Useable floor space" means the total floor surface area excluding area used for closets, wardrobes and fixed equipment.
[Statutory Authority: Chapter 71.12 RCW. WSR 16-03-062, § 246-322-010, filed 1/19/16, effective 2/19/16. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-010, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-010, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-001, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-001, filed 12/30/80; Regulation .22.001, effective 3/11/60.]
PDF246-322-020
Licensure—Initial, renewal, modifications.
(1) A person shall have a current license issued by the department before operating or advertising a private psychiatric hospital.
(2) An applicant for initial licensure shall submit to the department, forty-five days or more before commencing business:
(a) A completed application on forms provided by the department;
(b) Certificate of need approval according to the provisions of chapter 246-310 WAC for the number of beds indicated on the application;
(c) Verification of department approval of facility plans submitted for construction review according to the provisions of WAC 246-322-250;
(d) A criminal history background check in accordance with WAC 246-322-030(2);
(e) Verification of approval as a private psychiatric hospital from the state director of fire protection according to RCW 71.12.485;
(f) The fee specified in WAC 246-322-990; and
(g) Other information as required by the department.
(3) The licensee shall apply for license renewal annually at least thirty days before the expiration date of the current license by submitting to the department:
(a) A completed application on forms provided by the department;
(b) The fee specified in WAC 246-322-990; and
(c) Other information as required by the department.
(4) At least sixty days prior to transferring ownership of a currently licensed hospital:
(a) The licensee shall submit to the department:
(i) The full name and address of the current licensee and prospective owner;
(ii) The name and address of the currently licensed hospital and the name under which the transferred hospital will operate;
(iii) Name of the new administrator; and
(iv) Date of the proposed change of ownership; and
(b) The prospective owner shall apply for licensure according to subsection (2) of this section.
[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-020, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-020, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 34.05 RCW, RCW 34.05.220 (1)(a) and 1989 1st ex.s. c 9 § 106. WSR 90-06-019 (Order 039), § 248-22-005, filed 2/28/90, effective 3/1/90. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-005, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-005, filed 12/30/80.]
PDF246-322-025
Responsibilities and rights—Licensee and department.
(1) The licensee shall:
(a) Comply with the provisions of chapter 71.12 RCW and this chapter;
(b) Post the private psychiatric hospital license in a conspicuous place on the premises;
(c) Maintain the bed capacity at or below the licensed bed capacity;
(d) Cooperate with the department during on-site surveys and investigations;
(e) Respond to a statement of deficiencies by submitting to the department, according to the dates specified on the statement of deficiencies form:
(i) A written plan of correction for each deficiency stated in the report and date to be completed; and
(ii) A progress report stating the dates deficiencies were corrected.
(f) Obtain department approval before changing the bed capacity;
(g) Obtain department approval before starting any construction or making changes in department-approved plans or specifications;
(h) Notify the department immediately upon a change of administrator or governing body;
(i) When assuming ownership of an existing hospital, maintain past and current clinical records, registers, indexes, and analyses of hospital services, according to state law and regulations; and
(j) Obtain department approval of a plan for storing and retrieving patient records and reports prior to ceasing operation as a hospital.
(2) An applicant or licensee may contest a disciplinary decision or action of the department according to the provisions of RCW 43.70.115, chapter 34.05 RCW and chapter 246-10 WAC.
(3) The department shall:
(a) Issue or renew a license when the applicant or licensee meets the requirements in chapter 71.12 RCW and this chapter;
(b) Conduct an on-site inspection of the hospital prior to granting an initial license;
(c) Conduct on-site inspections at any time to determine compliance with chapter 71.12 RCW and this chapter;
(d) Give the administrator a written statement of deficiencies of chapter 71.12 RCW and this chapter observed during on-site surveys and investigations; and
(e) Comply with RCW 43.70.115, chapter 34.05 RCW and chapter 246-10 WAC when denying, suspending, modifying, or revoking a hospital license.
(4) The department may deny, suspend, or revoke a private psychiatric hospital license if the department finds the applicant, licensee, its agents, officers, directors, or any person with any interest therein:
(a) Is unqualified or unable to operate or direct operation of the hospital according to chapter 71.12 RCW and this chapter;
(b) Makes a misrepresentation of, false statement of, or fails to disclose a material fact, to the department:
(i) In an application for licensure or renewal of licensure;
(ii) In any matter under department investigation; or
(iii) During an on-site survey or inspection;
(c) Obtains or attempts to obtain a license by fraudulent means or misrepresentation;
(d) Fails or refuses to comply with the requirements of chapter 71.12 RCW or this chapter;
(e) Compromises the health or safety of a patient;
(f) Has a record of a criminal or civil conviction for:
(i) Operating a health care or mental health care facility without a license;
(ii) Any crime involving physical harm to another individual; or
(iii) Any crime or disciplinary board final decision specified in RCW 43.43.830;
(g) Had a license to operate a health care or mental health care facility denied, suspended or revoked;
(h) Refuses to allow the department access to facilities or records, or fails to promptly produce for inspection any book, record, document or item requested by the department, or interferes with an on-site survey or investigation;
(i) Commits, permits, aids or abets the commission of an illegal act on the hospital premises;
(j) Demonstrates cruelty, abuse, negligence, assault or indifference to the welfare and well-being of a patient;
(k) Fails to take immediate appropriate corrective action in any instance of cruelty, assault, abuse, neglect, or indifference to the welfare of a patient;
(l) Misappropriates the property of a patient;
(m) Fails to exercise fiscal accountability and responsibility toward individual patients, the department, or the business community; or
(n) Retaliates against a staff person, patient or other individual for reporting suspected abuse or other alleged improprieties.
(5) The department may summarily suspend a license pending proceeding for revocation or other action if the department determines a deficiency is an imminent threat to a patient's health, safety or welfare.
(6) The department may assess civil fines on a psychiatric hospital according to RCW 71.12.710.
(a) The department may assess a civil fine of up to $10,000 per violation, not to exceed a total fine of $1,000,000, on a psychiatric hospital when:
(i) The psychiatric hospital has previously been subject to an enforcement action for the same or similar type of violation of the same statute or rule; or
(ii) The psychiatric hospital has been given any previous statement of deficiency that included the same or similar type of violation of the same or similar statute or rule; or
(iii) The psychiatric hospital failed to correct noncompliance with a statute or rule by a date established or agreed to by the department.
(b) The department will assess a civil fine in accordance with Table 1 of this section:
Table 1
Fine Amounts in Relation to the Severity of the Violation | |||
Impact of Potential or Actual Harm | |||
Scope | Low | Moderate | High |
Limited | Up to $1,000 | $1,000 - $4,000 | $2,000 - $8,000 |
Pattern | Up to $2,000 | $2,000 - $5,500 | $3,500 - $9,000 |
Widespread | Up to $3,000 | $3,000 - $7,000 | $6,500 - $10,000 |
(c) The "severity of the violation" will be considered when determining fines. Levels of severity are categorized as low, moderate, or high, and defined as:
(i) "Low" means harm could happen but would be rare. The violation undermines safety or quality or contributes to an unsafe environment but is very unlikely to directly contribute to harm;
(ii) "Moderate" means harm could happen occasionally. The violation could cause harm directly, but is more likely to cause harm as a continuing factor in the presence of special circumstances or additional failures. If the deficient practice continues, it would be possible that harm could occur but only in certain situations or patients;
(iii) "High" means harm could happen at any time or did happen. The violation could directly lead to harm without the need for other significant circumstances or failures. If the deficient practice continues, it would be likely that harm could happen at any time to any patient.
(d) Factors the department will consider when determining the severity of the violation include, but are not limited to:
(i) Whether harm to the patient has occurred, or could occur including, but not limited to, a violation of patient's rights;
(ii) The impact of the actual or potential harm on the patient;
(iii) The degree to which the hospital failed to meet the patient's highest practicable physical, mental, and psychosocial well-being;
(iv) Whether a fine at a lower severity has been levied and the condition or deficiency related to the violation has not been adequately resolved; and
(v) Whether the hospital has been offered, or requested, and received and implemented technical assistance from the department.
(e) The scope of the violation is the frequency, incidence or extent of the occurrence of the violation(s). The levels of scope are defined as follows:
(i) "Limited" means a unique occurrence of the deficient practice that is not representative of routine or regular practice and has the potential to impact only one or a very limited number of patients, visitors, or staff. It is an outlier. The scope of the violation is limited when one or a very limited number of patients are affected or one or a very limited number of staff are involved, or the deficient practice occurs in a very limited number of locations.
(ii) "Pattern" means multiple occurrences of the deficient practice, or a single occurrence that has the potential to impact more than a limited number of patients, visitors, or staff. It is a process variation. The scope of the violation becomes a pattern when more than a very limited number of patients are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same patient(s) have been affected by repeated occurrences of the same deficient practice.
(iii) "Widespread" means the deficient practice is pervasive in the facility or represents a systemic failure or has the potential to impact most or all patients, visitors, or staff. It is a process failure. Widespread scope refers to the entire organization, not just a subset of patients or one unit.
(f) When determining the scope of the violation, the department will also consider the duration of time that has passed between violations that relate to the same or similar circumstances.
(g) A hospital may appeal the department's action of assessing civil fines under RCW 43.70.095.
PDF246-322-030
Criminal history, disclosure, and background inquiries.
(1) The licensee or license applicant shall require a disclosure statement as defined in RCW 43.43.834 for each prospective employee, volunteer, contractor, student, and any other individual associated with the hospital having direct contact with vulnerable adults as defined under RCW 43.43.830.
(2) The license applicant having direct contact with vulnerable adults shall obtain a Washington state patrol criminal history background disclosure statement and submit it to the department with the initial application for licensure.
(3) The licensee or license applicant shall:
(a) Require a Washington state patrol criminal history background inquiry, as specified in RCW 43.43.842(1), from the Washington state patrol or the department of social and health services for each:
(i) Staff person, student, and any other individual currently associated with the hospital having direct contact with vulnerable adults, when engaged on or since July 22, 1989; and
(ii) Prospective staff person, student, and individual applying for association with the hospital prior to allowing the individual direct contact with vulnerable adults, except as allowed by subsection (4) of this section;
(b) Inform each individual identified in (a) of this subsection of the requirement for a background inquiry;
(c) Require the individual to sign an acknowledgement statement that a background inquiry will be made;
(d) Verbally inform the individual of the background inquiry results within seventy-two hours of receipt; and
(e) Offer to provide a copy of the background inquiry results to the individual within ten days of receipt.
(4) The licensee may conditionally employ, contract with, accept as a volunteer or associate, an individual having direct contact with vulnerable adults pending a background inquiry, provided the licensee:
(a) Immediately obtains a disclosure statement from the individual; and
(b) Requests a background inquiry within three business days of the conditional acceptance of the individual.
(5) Except as provided in RCW 43.43.842 and in subsection (4) of this section, a licensee shall not hire or retain, directly or by contract, any individual having direct contact with vulnerable adults, if that individual has been:
(a) Convicted of a crime against individuals as defined in RCW 43.43.830;
(b) Convicted of a crime relating to financial exploitation as defined in RCW 43.43.830;
(c) Found in any disciplinary board final decision to have abused a vulnerable adult under RCW 43.43.830; or
(d) The subject in a protective proceeding under chapter 74.34 RCW.
(6) The licensee shall establish and implement procedures ensuring that all disclosure statements and background inquiry responses are:
(a) Maintained in a confidential and secure manner;
(b) Used for employment purposes only;
(c) Not disclosed to any individual except:
(i) The individual about whom the licensee made the disclosure or background inquiry;
(ii) Authorized state and federal employees; and
(iii) The Washington state patrol auditor; and
(d) Retained and available for department review:
(i) During the individual's employment or association with a facility; and
(ii) At least two years following termination of employment or association with a facility.
(7) The department shall:
(a) Review records required under this section;
(b) Investigate allegations of noncompliance with RCW 43.43.830 through 43.43.842, when necessary, in consultation with law enforcement personnel; and
(c) Use information collected under this section solely for the purpose of determining eligibility for licensure or relicensure as required under RCW 43.43.842.
(8) The department may require licensees to complete additional disclosure statements or background inquiries for an individual associated with the licensed hospital having direct contact with vulnerable adults if the department has reason to believe that offenses specified under RCW 43.43.830 have occurred since completion of the previous disclosure statement or background inquiry.
PDF246-322-035
Policies and procedures.
(1) The licensee shall develop and implement the following written policies and procedures consistent with this chapter and services provided:
(a) Criteria for admitting and retaining patients;
(b) Methods for assessing each patient's physical and mental health prior to admission;
(c) Providing or arranging for the care and treatment of patients;
(d) Assuring patient rights according to chapters 71.05 and 71.34 RCW, including posting those rights in a prominent place for the patients to read;
(e) Protecting against abuse and neglect and reporting suspected incidents according to the provisions of chapters 71.05, 71.34, 74.34 and 26.44 RCW;
(f) Fire and disaster plans, including;
(i) Accessing patient-occupied sleeping rooms, toilet rooms and bathrooms;
(ii) Summoning internal or external resource agencies or persons, such as a poison center, fire department, and police;
(g) Emergency medical care, including:
(i) Physician orders;
(ii) Staff actions in the absence of a physician; and
(iii) Storing and accessing emergency supplies and equipment;
(h) Managing assaultive, self-destructive, or out-of-control behavior, including:
(i) Immediate actions and conduct;
(ii) Use of seclusion and restraints consistent with WAC 246-322-180 and other applicable state standards; and
(iii) Documenting in the clinical record;
(i) Pharmacy and medication services consistent with WAC 246-322-210;
(j) Infection control as required by WAC 246-322-100;
(k) Staff actions upon:
(i) Patient elopement;
(ii) A serious change in a patient's condition, and immediately notifying family according to chapters 71.05 and 71.34 RCW;
(iii) Accidents or incidents potentially harmful or injurious to patients, and documentation in the clinical record; and
(iv) Patient death;
(l) Smoking on the hospital premises;
(m) Responsibility for patients' personal property, including recording any valuables left on deposit with the hospital;
(n) Allowing patients to work on the premises, according to WAC 246-322-180;
(o) Maintenance and housekeeping functions, including schedules;
(p) Cleaning, inspecting, repairing and calibrating electrical, biomedical and therapeutic equipment, and documenting actions;
(q) Transporting patients for:
(i) Diagnostic or treatment activities;
(ii) Hospital connected business and programs; and
(iii) Medical care services not provided by the hospital;
(r) Transferring patients to other health care facilities or agencies;
(s) Obtaining and retaining criminal history background checks and disclosure statements consistent with WAC 246-322-030.
(t) Research involving patients;
(u) Clinical records consistent with WAC 246-322-200, the Uniform Medical Records Act, chapter 70.02 RCW and Title 42 C.F.R., chapter 1, Part 2, 10/1/89;
(v) Food service consistent with chapter 246-215 WAC and WAC 246-322-230.
(2) The licensee shall review and update the policies and procedures annually or more often as needed.
PDF246-322-040
Governing body and administration.
The governing body shall:
(1) Adopt written policies concerning the purposes, operation and maintenance of the hospital, and the safety, care and treatment of patients;
(2) Provide staff, facilities, equipment, supplies and services to meet the needs of patients within the purposes of the hospital;
(3) Establish and maintain a current written organizational plan delineating positions, responsibilities, authorities, and relationships of positions within the hospital;
(4) Appoint an administrator responsible for implementing the policies adopted by the governing body;
(5) Appoint a psychiatrist as medical director responsible for directing and supervising medical treatment and patient care twenty-four hours per day;
(6) Maintain an organized professional staff accountable to the governing body;
(7) Appoint and periodically reappoint the professional staff;
(8) Require and approve professional staff bylaws and rules concerning, at a minimum:
(a) Organization of the professional staff;
(b) Delineation of privileges;
(c) Requirements for membership;
(d) Specific mechanisms for appointing and reappointing members;
(e) Granting, renewing and revising clinical privileges, including temporary ward privileges for community psychiatrists;
(f) Self-government;
(g) Required functions;
(h) Accountability to the governing body; and
(i) Mechanisms to monitor and evaluate quality of care and clinical performance; and
(9) Require that each person admitted to the hospital is under the care of a professional staff member with clinical privileges.
[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-040, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-040, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-011, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-011, filed 12/30/80.]
PDF246-322-050
Staff.
The licensee shall:
(1) Employ sufficient, qualified staff to:
(a) Provide adequate patient services;
(b) Maintain the hospital free of safety hazards; and
(c) Implement fire and disaster plans;
(2) Develop and maintain a written job description for the administrator and each staff position;
(3) Maintain evidence of appropriate qualifications and current credentials prior to hiring, or granting or renewing clinical privileges or association of any health care professional;
(4) Verify work references prior to hiring staff;
(5) Assure all patient-care staff including those transporting patients and supervising patient activities, except licensed staff whose professional training exceeds first-responder training, have within thirty days of employment:
(a) Current cardiopulmonary resuscitation cards from instructors certified by the American Red Cross, American Heart Association, United States Bureau of Mines, or Washington state department of labor and industries; and
(b) Current first-aid cards from instructors certified as in (a) of this subsection;
(6) Provide and document orientation and appropriate training for all staff, including:
(a) Organization of the hospital;
(b) Physical layout of hospital, including buildings, departments, exits, and services;
(c) Fire and disaster plans, including monthly drills;
(d) Infection control;
(e) Specific duties and responsibilities;
(f) Policies, procedures, and equipment necessary to perform duties;
(h) Managing patient behavior; and
(i) Appropriate training for expected duties;
(7) Make available an ongoing, documented, in-service education program including, but not limited to:
(a) For each staff person, training to maintain and update competencies needed to perform assigned duties and responsibilities; and
(b) For patient care staff, in addition to (a) of this subsection, the following training:
(i) Methods of patient care;
(ii) Using the least restrictive alternatives;
(iii) Managing assaultive and self-destructive behavior;
(v) Special needs of the patient population, such as children, minorities, elderly, and individuals with disabilities;
(vi) Cardiopulmonary resuscitation; and
(vii) First-aid training;
(8) When volunteer services are used within the hospital:
(a) Designate a qualified employee to be responsible for volunteer services;
(b) Provide and document orientation and training according to subsections (6) and (7) of this section for each volunteer; and
(c) Provide supervision and periodic written evaluations of each volunteer working directly with patients;
(9) In addition to following WISHA requirements, protect patients from tuberculosis by requiring each staff person to have upon employment or starting service, and each year thereafter during the individual's association with the hospital:
(a) A tuberculin skin test by the Mantoux method, unless the staff person:
(i) Documents a previous positive Mantoux skin test, which is ten or more millimeters of induration read at forty-eight to seventy-two hours;
(ii) Documents meeting the requirements of this subsection within the six months preceding the date of employment; or
(iii) Provides a written waiver from the department or authorized local health department stating the Mantoux skin test presents a hazard to the staff person's health;
(b) A second test one to three weeks after a negative Mantoux skin test for staff thirty-five years of age or older; and
(c) A chest X-ray within seven days of any positive Mantoux skin test;
(10) Report positive chest X-rays to the appropriate public health authority, and follow precautions ordered by a physician or public health authority;
(11) Restrict a staff person's contact with patients when the staff person has a known communicable disease in the infectious stage which is likely to be spread in the hospital setting or by casual contact; and
(12) Maintain a record on the hospital premises for each staff person, during employment and for two years following termination of employment including, but not limited to:
(a) An employment application;
(b) Verification of required education, training and credentials;
(c) Documentation of contacting work references as required by subsection (4) of this section;
(d) Criminal history disclosure and background checks as required in WAC 246-322-030;
(e) Tuberculin test results, reports of X-ray findings, exceptions, physician or public health official orders, and waivers; and
(f) Annual performance evaluations.
[Statutory Authority: RCW 18.19.050, 18.29.130, 18.29.210, 18.34.120, 18.46.060, 18.55.095, 18.84.040, 18.88B.060, 18.89.050, 18.130.050, 18.138.070, 18.155.040, 18.200.050, 18.205.060, 18.215.040, 18.230.040, 18.240.050, 18.250.020, 18.290.020, 18.360.030, 18.360.070, 70.41.030, 70.230.020, 71.12.670, and 18.108.085. WSR 21-02-002, § 246-322-050, filed 12/23/20, effective 1/23/21. Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-050, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-050, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-016, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-016, filed 12/30/80.]
PDF246-322-100
Infection control.
The licensee shall:
(1) Establish and implement an effective hospital-wide infection control program, which includes at a minimum:
(a) Written policies and procedures describing:
(i) Types of surveillance used to monitor rates of nosocomial infections;
(ii) Systems to collect and analyze data; and
(iii) Activities to prevent and control infections;
(b) A review process, using definitions and criteria established by the infection control committee, to determine if staff and patient infections are nosocomial;
(c) A system for reporting communicable diseases consistent with chapter 246-100 WAC, Communicable and certain other diseases;
(d) A procedure for reviewing and approving infection control aspects of policies and procedures used in each area of the hospital;
(e) A procedure to monitor the physical environment of the hospital for situations which may contribute to the spread of infectious diseases;
(f) Provisions for:
(i) Providing consultation regarding patient care practices, equipment and supplies which may influence the risk of infection;
(ii) Providing consultation regarding appropriate procedures and products for cleaning, disinfecting and sterilizing;
(iii) Providing infection control information for orientation and in-service education for staff providing direct patient care;
(iv) Making recommendations, consistent with federal, state, and local laws and rules, for methods of safe and sanitary disposal of:
(A) Sewage;
(B) Solid and liquid wastes; and
(C) Infectious wastes including safe management of sharps;
(g) Identifying specific precautions to prevent transmission of infections; and
(h) Coordinating employee activities to control exposure and transmission of infections to or from employees and others performing patient services;
(2) Assign one or more individuals to manage the infection control program with documented qualifications related to infection surveillance, prevention, and control, including:
(a) Education;
(b) Training;
(c) Certification; or
(d) Supervised experience;
(3) Designate an infection control committee, comprised of the individual or individuals assigned to manage the program and multidisciplinary representatives from the professional staff, nursing staff and administrative staff, to:
(a) Oversee the program;
(b) Develop a committee-approved description of the program, including surveillance, prevention, and control activities;
(c) Delegate authority, approved in writing by administrative and professional staff, to institute surveillance, prevention, and control measures when there is reason to believe any patient or staff may be at risk of infection;
(d) Meet at regularly scheduled intervals, at least quarterly;
(e) Maintain written minutes and reports of findings presented during committee meetings; and
(f) Develop a method for forwarding recommendations to the professional staff, nursing, administration, and other committees and departments as appropriate.
[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-100, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-100, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 83-10-079 (Order 1960), § 248-22-036, filed 5/4/83; WSR 82-23-003 (Order 1898), § 248-22-036, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-036, filed 12/30/80.]
PDF246-322-120
Physical environment.
The licensee shall:
(1) Provide a safe and clean environment for patients, staff and visitors;
(2) Provide ready access and equipment to accommodate individuals with physical and mental disabilities;
(3) Provide adequate lighting in all areas;
(4) Provide natural or mechanical ventilation sufficient to remove odors, smoke, excessive heat and condensation from all habitable rooms;
(5) Provide a heating system operated and maintained to sustain a comfortable, healthful temperature in all habitable rooms;
(6) Provide an adequate supply of hot and cold running water under pressure meeting the standards in chapters 246-290 and 246-291 WAC, with:
(a) Devices to prevent backflow into the potable water supply system; and
(b) Water temperature not exceeding 120°F automatically regulated at all plumbing fixtures used by patients;
(7) Implement current, written policies, procedures, and schedules for maintenance and housekeeping functions;
(8) Provide housekeeping and service facilities on each floor, including:
(a) One or more service sinks, designed for filling and emptying mop buckets;
(b) Housekeeping closets:
(i) Equipped with shelving;
(ii) Ventilated to the out-of-doors; and
(iii) Kept locked; and
(c) A utility service area designed and equipped for washing, disinfecting, storing, and housing medical and nursing supplies and equipment; and
(9) Provide equipment and facilities to collect and dispose of all sewage, garbage, refuse and liquid waste in a safe and sanitary manner.
[Statutory Authority: Chapter 71.12 RCW and RCW 43.60.040. WSR 95-22-012, § 246-322-120, filed 10/20/95, effective 11/20/95. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-322-120, filed 12/27/90, effective 1/31/91. Statutory Authority: Chapter 71.12 RCW. WSR 82-23-003 (Order 1898), § 248-22-046, filed 11/4/82. Statutory Authority: RCW 43.20.050. WSR 81-02-004 (Order 205), § 248-22-046, filed 12/30/80.]
PDF246-322-140
Patient living areas.
The licensee shall:
(1) Provide patient sleeping rooms with:
(a) A minimum of eighty square feet of useable floor space in a single bedroom;
(b) A minimum of seventy square feet of useable floor space per bed in a multipatient room;
(c) A minimum ceiling height of seven feet six inches over the required floor area;
(d) A maximum capacity of four patients;
(e) A floor elevation no lower than three feet six inches below grade, with grade extending horizontally ten or more feet from the building;
(f) A clear window area on an outside wall equal to or greater than one-tenth the floor area with a minimum of ten square feet;
(g) Only security or maximum security windows;
(h) Direct access to and from a corridor, common-use activity room, or other common-use area;
(i) Sufficient room furnishings maintained in safe and clean condition including:
(i) A bed for each patient at least thirty-six inches wide or appropriate to the special needs and size of the patient;
(ii) A cleanable, firm mattress; and
(iii) A cleanable or disposable pillow; and
(j) At least three feet between beds, and adequate space between furnishings to allow easy entrance, exit, and traffic flow within the room;
(k) A means to assure patient privacy when appropriate;
(2) Provide, in addition to the requirements in subsection (1) of this section, when security rooms are used:
(a) Security or maximum security windows appropriate to the area and program;
(b) Furnishings, equipment and design for maximum safety and security;
(c) Shielded and tamper-resistant lighting fixtures and electrical outlets;
(d) A door lockable from the outside; and
(e) Provisions for authorized staff to observe occupants;
(3) Provide an enclosed space within the patient sleeping room, or nearby, suitable for each patient to hang garments, and store clothing and personal belongings;
(4) Provide secure storage for each patient's valuables in the patient sleeping room or conveniently available elsewhere in the hospital;
(5) Provide a dining area for patients in a community setting with furnishings appropriate for dining;
(6) Provide and maintain a safe area or areas for patient recreation and physical activity equal to or greater than twenty square feet for each licensed bed space;
(7) Provide a visiting area allowing privacy for patients and visitors;
(8) Provide a readily available telephone for patients to make and receive confidential calls; and
(9) Provide a "nonpay" telephone or equivalent communication device readily accessible on each patient occupied floor for emergency use.
PDF246-322-150
Clinical facilities.
The licensee shall provide:
(1) An adequate number of counseling or treatment rooms for group or individual therapy programs with reasonable soundproofing to maintain confidentiality;
(2) One or more seclusion rooms, with or without an exterior window, intended for short-term occupancy, with:
(a) Staff-controlled locks and relites in the door, or equivalent;
(b) Provisions for authorized staff to observe the occupant at all times;
(c) A minimum of eighty square feet of floor space, exclusive of fixed equipment, with a minimum room dimension of eight feet; and
(d) Shielded, tamper-proof lighting fixtures;
(3) One or more physical examination rooms, with or without an exterior window, equipped with:
(a) An examination table;
(b) Examination light;
(c) Storage for medical supplies and equipment; and
(d) A readily accessible handwashing sink, soap dispenser, and acceptable single-use hand-drying device; and
(4) Secure areas to properly store and handle medical supplies and medications.
PDF246-322-160
Bathrooms, toilet rooms and handwashing sinks.
The licensee shall provide:
(1) One toilet, handwashing sink and bathing fixture for each six patients, or fraction thereof, on each patient-occupied floor of the hospital, with:
(a) Provisions for privacy during toileting, bathing, showering, and dressing;
(b) Separate toilet rooms for each sex if the toilet room contains more than one toilet;
(c) Separate bathrooms for each sex if the bathroom contains more than one bathing fixture; and
(d) One or more grab bars at each toilet and bathing fixture appropriate to the needs of patients; and
(2) Toilet rooms and bathrooms directly accessible from patient rooms or corridors, without passing through any kitchen, pantry, food preparation, food storage, or dishwashing area or from one bedroom through another bedroom.
PDF246-322-170
Patient care services.
(1) The licensee shall:
(a) Provide an initial physical and mental health assessment by a physician, advanced registered nurse practitioner, or physician assistant. The initial mental status exam may be conducted by a mental health professional;
(b) Admit only those patients for whom the hospital is qualified by staff, services and equipment to give adequate care; and
(c) Provide appropriate transfer and acceptance of a patient needing medical care services not provided by the hospital, by:
(i) Transferring relevant data with the patient;
(ii) Obtaining written or verbal approval by the receiving facility prior to transfer; and
(iii) Immediately notifying the patient's family.
(2) The licensee shall provide medical supervision and treatment, transfer, and discharge planning for each patient admitted or retained, including but not limited to:
(a) Admittance by a member of the medical staff as defined by the staff bylaws;
(b) An initial treatment plan upon admission incorporating any advanced directives of the patient;
(c) A physical examination and medical history completed and recorded by a physician, advanced registered nurse practitioner, or physician assistant within twenty-four hours following admission, unless the patient had a physical examination and medical history completed within fourteen days prior to admission, and the information is recorded in the clinical record;
(d) A psychiatric evaluation, including provisional diagnosis, completed and documented within seventy-two hours following admission;
(e) A comprehensive treatment plan developed within seventy-two hours following admission:
(i) Developed by a multidisciplinary treatment team with input, when appropriate, by the patient, family, and other agencies;
(ii) Reviewed and modified by a mental health professional as indicated by the patient's clinical condition;
(iii) Interpreted to staff, patient, and, when possible and appropriate, to family; and
(iv) Implemented by persons designated in the plan;
(f) Physician orders for drug prescriptions, medical treatments and discharge;
(g) Current written policies and orders signed by a physician to guide the action of staff when medical emergencies or threat to life arise and a physician is not present;
(h) A discharge plan including a review of the patient's hospitalization, condition upon discharge, and recommendations for follow-up and continuing care;
(i) Patient education pertaining to the patient's illness, prescribed medications, and health maintenance; and
(j) Referrals to appropriate resources and community services during and after hospitalization.
(3) The licensee shall provide, or arrange for, diagnostic and therapeutic services prescribed by the attending professional staff, including:
(a) Medical services, including:
(i) A physician on call at all times; and
(ii) Provisions for emergency medical services when needed;
(b) Psychiatric services, including:
(i) A staff psychiatrist available for consultation daily and visits as necessary to meet the needs of each patient; and
(ii) A child psychiatrist for regular consultation when hospital policy permits the admission of children or adolescents;
(c) Nursing services, including:
(i) A psychiatric nurse, employed full time, responsible for directing nursing services twenty-four hours per day; and
(ii) One or more registered nurses on duty within the hospital at all times to supervise nursing care;
(d) Social work services coordinated and supervised by a social worker with experience working with psychiatric patients, responsible for:
(i) Reviewing social work activities;
(ii) Integrating social work services into the comprehensive treatment plan; and
(iii) Coordinating discharge with community resources;
(e) Psychological services coordinated and supervised by a psychologist with experience working with psychiatric patients;
(f) Occupational therapy services coordinated and supervised by an occupational therapist with experience working with psychiatric patients, responsible for integrating occupational therapy functions into the patient's comprehensive treatment plan;
(g) Recreational therapy services coordinated and supervised by a recreational or occupational therapist with experience working with psychiatric patients, responsible for integrating recreational therapy functions into the comprehensive treatment plan; and
(h) Special services, within the hospital or contracted outside the hospital, as specified in the comprehensive treatment plan.
PDF246-322-180
Patient safety and seclusion care.
(1) The licensee shall assure seclusion and restraint are used only to the extent and duration necessary to ensure the safety of patients, staff, and property, as follows:
(a) Staff shall not inflict pain or use restraint and seclusion for retaliation or personal convenience;
(b) Staff shall document all assaultive incidents in the clinical record and review each incident with the appropriate supervisor;
(c) Staff shall observe any patient in restraint or seclusion at least every fifteen minutes, intervening as necessary, and recording observations and interventions in the clinical record;
(d) Staff shall notify, and receive authorization by, a physician, physician assistant, or psychiatric advanced registered nurse practitioner within one hour of initiating patient restraint or seclusion;
(e) A physician, physician assistant, or psychiatric advanced registered nurse practitioner shall examine each restrained or secluded patient and renew the order for every twenty-four continuous hours of restraint and seclusion; and
(f) A mental health professional or registered nurse shall evaluate the patient when secluded or restrained more than two continuous hours, and reevaluate the patient at least once every eight continuous hours of restraint and seclusion thereafter.
(2) The licensee shall provide adequate emergency supplies and equipment, including airways, bag resuscitators, intravenous fluids, oxygen, sterile supplies, and other equipment identified in the policies and procedures, easily accessible to patient-care staff.
(3) When research is proposed or conducted involving patients, the licensee shall:
(a) Document an initial and continuing review process by a multidisciplinary treatment team;
(b) Require approval by the patient prior to participation;
(c) Allow the patient to discontinue participation at any time; and
(d) Ensure policies and procedures are in accordance with Title 42 Code of Federal Regulations, chapter 1, Part 2, 10/1/89 edition.
(4) The licensee shall prohibit the use of any patient for basic maintenance of the hospital or equipment, housekeeping, or food service in compliance with the Federal Fair Labor Standards Act, 29 U.S.C., paragraph 203 et al., and 29 C.F.R., section 525 et al., except:
(a) Cleaning or maintaining the patient's private living area, or performing personal housekeeping chores; or
(b) Performing therapeutic activities:
(i) Included in and appropriate to the comprehensive treatment plan;
(ii) As agreed to with the patient;
(iii) Documented as part of the treatment program; and
(iv) Appropriate to the age, physical, and mental condition of the patient.
(5) The licensee shall assure the safety and comfort of patients when construction work occurs in or near occupied areas.
PDF246-322-190
Provisions for patients with tuberculosis.
A licensee providing inpatient services for mentally ill patients with suspected or known infectious tuberculosis shall:
(1) Design patient rooms with:
(a) Ventilation to maintain a negative pressure condition in each patient room relative to adjacent spaces, except bath and toilet areas, with:
(i) Air movement or exhaust from the patient room to the out-of-doors with the exhaust grille located over the head of the bed;
(ii) Exhaust at the rate of six air changes per hour;
(iii) Make-up or supply air from adjacent ventilated spaces for four or less air changes per hour, and tempered outside air for two or more air changes per hour; and
(iv) Ultraviolet generator irradiation as follows:
(A) Use of ultraviolet fluorescent fixtures with lamps emitting wave length of 253.7 nanometers;
(B) The average reflected irradiance less than 0.2 microwatts per square centimeter in the room at the five foot level;
(C) Wall-mount type of fixture installed over the head of the bed, as close to the ceiling as possible to irradiate the area of the exhaust grille and the ceiling; and
(D) Lamps changed as recommended by the manufacturer; and
(b) An adjoining bathroom and toilet room with bedpan washer; and
(2) Provide discharge information to the health department of the patient's county of residence.
PDF246-322-200
Clinical records.
(1) The licensee shall establish and maintain an organized clinical record service, consistent with recognized principles of record management, directed, staffed, and equipped to:
(a) Ensure timely, complete and accurate identification, checking, processing, indexing, filing, and retrieval of records;
(b) Facilitate compilation, maintenance, analyses, and distribution of patient care statistics; and
(c) Protect records from undue deterioration and destruction.
(2) The licensee shall develop and maintain an individual clinical record for each person receiving care, treatment, or diagnostic service at the hospital.
(3) The licensee shall ensure prompt entry and filing of the following data into the clinical record for each period a patient receives inpatient or outpatient services:
(a) Identifying information;
(b) Assessment and diagnostic data including history of findings and treatment provided for the psychiatric condition for which the patient is treated in the hospital;
(c) Psychiatric evaluation including:
(i) Medical and psychiatric history and physical examination; and
(ii) Record of mental status;
(d) Comprehensive treatment plan;
(e) Authenticated orders for:
(i) Drugs or other therapies;
(ii) Therapeutic diets; and
(iii) Care and treatment, including standing medical orders used in the care and treatment of the patient, except standing medical emergency orders;
(f) Significant observations and events in the patient's clinical treatment;
(g) Any restraint of the patient;
(h) Databases containing patient information;
(i) Original reports or durable, legible, direct copies of original reports, of all patient tests, diagnostic procedures and examinations performed on or for the patient;
(j) Description of therapies administered, including drug therapies;
(k) Nursing services;
(l) Progress notes recorded by the professional staff responsible for the care of the patient or others significantly involved in active treatment modalities; and
(m) A discharge plan and discharge summary.
(4) The licensee shall ensure each entry includes:
(a) Date;
(b) Time of day;
(c) Authentication by the individual making the entry; and
(d) Diagnosis, abbreviations and terminology consistent with:
(i) Fourth edition revised 1994 The American Psychiatry Association Diagnostic and Statistical Manual of Mental Disorders; and
(ii) International Classification of Diseases, 9th edition, 1988.
(5) The licensee shall provide designated areas, designed to assure confidentiality, for reading, recording, and maintaining patient clinical records and for patients to review their own records.
(6) The licensee shall share and release information relating to patients and former patients only as authorized by statute and administrative code, and shall protect patient confidentiality according to confidentiality requirements in chapters 70.02, 71.05, and 71.34 RCW.
(7) The licensee shall retain and preserve:
(a) Each patient's clinical records, excluding reports on referred outpatient diagnostic services, for:
(i) Adult patients, a minimum of ten years following the most recent discharge; or
(ii) Patients who are minors at the time of care, treatment, or diagnosis, a minimum of three years following the patient's eighteenth birth date, or ten years following the most recent discharge, whichever is longer;
(b) Reports on referred outpatient diagnostic services for at least two years;
(c) A master patient index card or equivalent for at least the same period of time as the corresponding clinical records; and
(d) Patients' clinical records, registers, indexes, and analyses of hospital service in original form or in photographic form in accordance with the provisions of chapter 5.46 RCW.
PDF246-322-210
Pharmacy and medication services.
The licensee shall:
(1) Maintain the pharmacy in the hospital in a safe, clean, and sanitary condition;
(2) Provide evidence of current approval of pharmacy services by the pharmacy quality assurance commission under chapter 18.64 RCW;
(3) Develop and implement procedures for prescribing, storing, and administering medications according to state and federal laws and rules, including:
(a) Assuring professional staff who prescribe are authorized to prescribe under chapter 69.41 RCW;
(b) Assuring orders and prescriptions for medications administered and self-administered include:
(i) Date and time;
(ii) Type and amount of drug;
(iii) Route of administration;
(iv) Frequency of administration; and
(v) Authentication by professional staff;
(c) Administering drugs;
(d) Self-administering drugs;
(e) Receiving and recording or transcribing verbal or telephone drug orders by authorized staff;
(f) Authenticating verbal and telephone orders by prescriber in a timely manner, not to exceed forty-eight hours for inpatients;
(g) Use of medications and drugs owned by the patient but not dispensed by the hospital pharmacy, including:
(i) Specific written orders;
(ii) Identification and administration of drug;
(iii) Handling, storage and control;
(iv) Disposition; and
(v) Pharmacist and physician inspection and approval prior to patient use to ensure proper identification, lack of deterioration, and consistency with current medication profile;
(h) Maintaining drugs in patient care areas of the hospital including:
(i) Hospital pharmacist or consulting pharmacist responsibility;
(ii) Legible labeling with generic and/or trade name and strength as required by federal and state laws;
(iii) Access only by staff authorized access under hospital policy;
(iv) Storage under appropriate conditions specified by the hospital pharmacist or consulting pharmacist, including provisions for:
(A) Storing medicines, poisons, and other drugs in a specifically designated, well-illuminated, secure space;
(B) Separating internal and external stock drugs; and
(C) Storing Schedule II drugs in a separate locked drawer, compartment, cabinet, or safe;
(i) Preparing drugs in designated rooms with ample light, ventilation, sink or lavatory, and sufficient work area;
(j) Prohibiting the administration of outdated or deteriorated drugs, as indicated by label;
(k) Restricting access to pharmacy stock of drugs to:
(i) Legally authorized pharmacy staff; and
(ii) Except for Schedule II drugs, to a registered nurse designated by the hospital when all of the following conditions are met:
(A) The pharmacist is absent from the hospital;
(B) Drugs are needed in an emergency, and are not available in floor supplies; and
(C) The registered nurse, not the pharmacist, is accountable for the registered nurse's actions;
(4) The appropriate professional staff committee shall approve all policies and procedures on drugs, after documented consultation with:
(a) The pharmacist or pharmacist consultant directing hospital pharmacy services; and
(b) An advisory group comprised of representatives from the professional staff, hospital administration, and nursing services;
(5) When planning new construction of a pharmacy:
(a) Follow the general design requirements for architectural components, electrical service, lighting, call systems, hardware, interior finishes, heating, plumbing, sewerage, ventilation/air conditioning, and signage in WAC 246-318-540;
(b) Provide housekeeping facilities within or easily accessible to the pharmacy;
(c) Locate pharmacy in a clean, separate, secure room with:
(i) Storage, including locked storage for Schedule II controlled substances;
(ii) All entrances equipped with closers;
(iii) Automatic locking mechanisms on all entrance doors to preclude entrance without a key or combination;
(iv) Perimeter walls of the pharmacy and vault, if used, constructed full height from floor to ceiling;
(v) Security devices or alarm systems for perimeter windows and relites;
(vi) An emergency signal device to signal at a location where twenty-four-hour assistance is available;
(vii) Space for files and clerical functions;
(viii) Break-out area separate from clean areas; and
(ix) Electrical service including emergency power to critical pharmacy areas and equipment;
(d) Provide a general compounding and dispensing unit, room, or area with:
(i) A work counter with impermeable surface;
(ii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;
(iii) Storage space;
(iv) A refrigeration and freezing unit; and
(v) Space for mobile equipment;
(e) If planning a manufacturing and unit dose packaging area or room, provide with:
(i) Work counter with impermeable surface;
(ii) Corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter; and
(iii) Storage space;
(f) Locate admixture, radiopharmaceuticals, and other sterile compounding room, if planned, in a low traffic, clean area with:
(i) A preparation area;
(ii) A work counter with impermeable surface;
(iii) A corrosion-resistant sink, suitable for handwashing, mounted in counter or integral with counter;
(iv) Space for mobile equipment;
(v) Storage space;
(vi) A laminar flow hood in admixture area; and
(vii) Shielding and appropriate ventilation according to WAC 246-318-540 (3)(m) for storage and preparation of radiopharmaceuticals;
(g) If a satellite pharmacy is planned, comply with the provisions of:
(i) Subsection (5)(a), (5)(c)(i), (ii), (iii), (iv), (v), and (vi) of this section when drugs will be stored;
(ii) Subsection (5)(c)(vii), (viii), and (ix) of this section, if appropriate; and
(iii) Subsections (5)(d) and (f) of this section if planned;
(h) If a separate outpatient pharmacy is planned, comply with the requirements for a satellite pharmacy including:
(i) Easy access;
(ii) A conveniently located toilet meeting accessibility requirements in WAC 51-20-3100; and
(iii) A private counseling area.
PDF246-322-220
Laboratory services.
The licensee shall:
(1) Provide access to laboratory services to meet emergency and routine needs of patients;
(2) Ensure laboratory services are provided by licensed or waivered medical test sites in accordance with chapter 70.42 RCW and chapter 246-338 WAC; and
(3) Maintain each medical test site in the hospital in a safe, clean, and sanitary condition.
PDF246-322-230
Food and dietary services.
The licensee shall:
(2) Designate an individual responsible for managing and supervising dietary/food services twenty-four hours per day, including:
(a) Incorporating ongoing recommendations of a dietitian;
(b) Serving at least three meals a day at regular intervals with fifteen or less hours between the evening meal and breakfast, unless the licensee provides a nutritious snack between the evening meal and breakfast;
(c) Providing well-balanced meals and nourishments that meet the current recommended dietary allowances of the National Research Council, 10th edition, 1989, adjusted for patient age, sex and activities unless contraindicated;
(d) Making nourishing snacks available as needed for patients, and posted as part of the menu;
(e) Preparing and serving therapeutic diets according to written medical orders;
(f) Preparing and serving meals under the supervision of food service staff;
(g) Maintaining a current diet manual, approved in writing by the dietitian and medical staff, for use in planning and preparing therapeutic diets;
(h) Ensuring all menus:
(i) Are written at least one week in advance;
(ii) Indicate the date, day of week, month and year;
(iii) Include all foods and snacks served that contribute to nutritional requirements;
(iv) Provide a variety of foods;
(v) Are approved in writing by the dietitian;
(vi) Are posted in a location easily accessible to all patients; and
(vii) Are retained for one year;
(3) Substitute foods, when necessary, of comparable nutrient value and record changes on the menu;
(4) Allow sufficient time for patients to consume meals;
(5) Ensure staff from dietary/food services are present in the hospital during all meal times;
(6) Keep policies and procedures pertaining to food storage, preparation, and storage, and cleaning food service equipment and work areas in the food service area for easy reference by dietary staff at all times.
PDF246-322-240
Laundry.
The licensee shall provide:
(1) Laundry and linen services, on the premises or by commercial laundry;
(2) Storage and sorting areas for soiled laundry in well-ventilated areas, separate from clean linen handling areas;
(3) A clean area with an adequate supply of clean linen;
(4) When laundry is washed on the premises:
(a) An adequate water supply and a minimum water temperature of 140°F in washing machines; and
(b) Laundry facilities in areas separate from food preparation and dining; and
(5) Facilities for patients who wear their own clothing during hospitalization to do personal laundry.
PDF246-322-250
Construction.
(1) The applicant or licensee shall comply with chapter 31 of the Washington State Building Code for all construction.
(2) Prior to starting construction, the applicant or licensee shall submit the following documentation to the department:
(a) A completed application form, a copy of which is provided in the Submissions Guide for Health and Residential Facility Construction Projects, which may be obtained from the department;
(b) The fee specified in chapter 246-314 WAC;
(c) A functional program which describes the services and operational methods affecting the hospital building, premises, and patients;
(d) One set of preliminary documents including, when applicable:
(i) Plot plans drawn to scale showing:
(A) Streets, driveways, parking, vehicle and pedestrian circulation;
(B) Site utilities, water service system, sewage disposal system, electrical service system, elevations; and
(C) Location of existing and new buildings and other fixed equipment;
(ii) Building plans drawn to scale showing:
(A) Floor plans designating function of each room and fixed equipment;
(B) Typical building sections and exterior elevations;
(iii) Outline specifications generally describing the construction and materials including mechanical and electrical systems; and
(e) Three sets of final construction drawings, stamped by a Washington state licensed architect or engineer, complying with the requirements of this chapter including, when applicable:
(i) Plot plans drawn to scale showing all items required in the preliminary plan in final form;
(ii) Building plans drawn to scale showing:
(A) Floor plans designating function of each room and fixed equipment;
(B) Interior and exterior elevations;
(C) Building sections and construction details;
(D) Schedules of room finishes, doors, finish hardware and windows;
(E) Mechanical, including plumbing, heating, venting and air conditioning; and
(F) Electrical, including lighting, power and communication systems; and
(iii) Specifications fully describing the workmanship and finishes;
(f) One copy of specifications and the radiant panel test report for each carpet type used in corridors and exitways;
(g) Three copies of fire sprinkler system shop drawings, hydraulic calculations and equipment specifications, stamped by the fire sprinkler contractor; and
(h) Three copies of fire alarm system shop drawings and equipment specifications.
(3) The licensee shall:
(a) Obtain department approval of final construction documents prior to starting construction;
(b) Conform with the approved plans during construction;
(c) Consult with the department prior to deviating from approved documents;
(d) Provide a written construction project completion notice to the department indicating:
(i) The expected completion date; and
(ii) Compliance with the approved construction documents, requirements of chapter 18.20 RCW and this chapter;
(e) Make adequate provisions for the health, safety, and comfort of patients during construction projects;
(f) Obtain authorization from the department prior to occupying or using new construction; and
(g) Obtain approval of the Washington state fire protection services division prior to construction, modification, and alteration consistent with RCW 18.20.130.
PDF246-322-260
Adverse health events reporting requirements.
The National Quality Forum identifies and defines twenty-nine serious reportable events (adverse health events) as updated and adopted in 2011.
(1) Psychiatric hospitals must report adverse health events to the department.
(2) Psychiatric hospitals must comply with the reporting requirements under chapter 246-302 WAC.
(3) Adverse health events are listed in chapter 246-02 WAC.
[Statutory Authority: Chapter 70.56 RCW. WSR 12-16-057, § 246-322-260, filed 7/30/12, effective 10/1/12; WSR 09-07-051, § 246-322-260, filed 3/11/09, effective 4/11/09.]
PDF246-322-500
Exemptions.
(1) A licensee wishing to request an exemption from a requirement in this chapter shall submit a written request to the department, including:
(a) A description of the requested exemption;
(b) Reason for the exemption; and
(c) Impact of the exemption on patient or public health and safety.
(2) If the department determines the exemption will not jeopardize patient or public health or safety, and is not contrary to the intent of chapter 71.12 RCW and this chapter, the department may:
(a) Exempt the licensee from meeting a specific requirement in this chapter; or
(b) Allow the licensee to use another method of meeting the requirement.
(3) The licensee shall retain a copy of each approved exemption in the hospital.
PDF246-322-990
Private psychiatric hospital fees.
This section establishes the initial licensure and annual renewal fees for private psychiatric hospitals licensed under chapter 71.12 RCW.
(1) Applicants and licensees shall:
(a) Submit to the department an initial licensure fee for each bed space within the licensed bed capacity of the hospital;
(b) Submit to the department an annual renewal fee for each bed space within the licensed bed capacity of the hospital to the department;
(c) Include all bed spaces and rooms complying with physical plant and movable equipment requirements of this chapter for 24-hour assigned patient rooms;
(d) Include bed spaces assigned for less than 24-hour patient use as part of the licensed bed capacity when:
(i) Physical plant requirements of this chapter are met without movable equipment; and
(ii) The private psychiatric hospital currently possesses the required movable equipment and certifies this fact to the department.
(e) Limit licensed bed spaces as required under chapter 70.38 RCW;
(f) Submit applications for bed additions to the department for review and approval under chapter 70.38 RCW subsequent to department establishment of the private psychiatric hospital's licensed bed capacity;
(g) Set up 24-hour assigned patient beds only within the licensed bed capacity approved by the department.
(2) Refunds. The department shall refund fees paid by the applicant for initial licensure if:
(a) The department has received the application but has not conducted an on-site survey or provided technical assistance, the department will refund two-thirds of the fees paid, less a refund processing fee.
(b) The department has received the application and has conducted an on-site survey or provided technical assistance, the department will refund one-third of the fees paid, less a refund processing fee.
(c) The department will not refund fees if:
(i) The department has performed more than one on-site visit for any purpose;
(ii) One year has elapsed since an initial licensure application is received by the department, and the department has not issued the license because the applicant has failed to complete the requirements for licensure; or
(iii) The amount to be refunded as calculated by (a) or (b) of this subsection is $10 or less.
(3) Between November 1, 2024, and October 31, 2025, the following fees will apply:
Fee Type | Fee |
Initial Licensure Fee per bed | $1,700.00 |
Renewal Licensure Fee per bed | $1,700.00 |
Refund Processing Fee | $50.00 |
(4) On and after November 1, 2025, the following fees apply:
Fee Type | Fee |
Initial Licensure Fee per bed | $1,450.00 |
Renewal Licensure Fee per bed | $1,450.00 |
Refund Processing Fee | $50.00 |
[Statutory Authority: RCW 43.70.110 and 43.70.250. WSR 24-16-045, § 246-322-990, filed 7/30/24, effective 11/1/24. Statutory Authority: RCW 43.70.250, 43.70.110, 71.12.670, 71.12.470 and 2020 c 115. WSR 21-11-107, § 246-322-990, filed 5/19/21, effective 7/1/21. Statutory Authority: RCW 43.70.250. WSR 19-16-049, § 246-322-990, filed 7/30/19, effective 10/1/19. Statutory Authority: RCW 70.41.080 and 71.12.485. WSR 17-18-109, § 246-322-990, filed 9/6/17, effective 11/30/17. Statutory Authority: RCW 43.70.250. WSR 07-17-174, § 246-322-990, filed 8/22/07, effective 9/22/07; WSR 05-18-073, § 246-322-990, filed 9/7/05, effective 10/8/05. Statutory Authority: RCW 43.70.250, 18.46.030, 43.70.110, 71.12.470. WSR 04-19-141, § 246-322-990, filed 9/22/04, effective 10/23/04. Statutory Authority: RCW 43.70.250 and 70.38.105(5). WSR 03-22-020, § 246-322-990, filed 10/27/03, effective 11/27/03. Statutory Authority: RCW 43.70.250. WSR 02-13-061, § 246-322-990, filed 6/14/02, effective 7/15/02. Statutory Authority: RCW 71.12.470, 43.70.110 and 43.70.250. WSR 01-15-092, § 246-322-990, filed 7/18/01, effective 8/18/01. Statutory Authority: RCW 43.70.250 and 43.20B.020. WSR 99-24-060, § 246-322-990, filed 11/29/99, effective 12/30/99. Statutory Authority: RCW 43.70.250, 43.70.110 and 43.20B.020. WSR 95-12-097, § 246-322-990, filed 6/7/95, effective 7/8/95. Statutory Authority: RCW 43.70.250. WSR 92-12-028 (Order 273), § 246-322-990, filed 5/28/92, effective 6/28/92. Statutory Authority: RCW 43.70.040. WSR 91-02-050 (Order 122), § 246-322-990, filed 12/27/90, effective 1/31/91.]