For residents with medicaid as a payor, in addition to the requirements in WAC 388-76-10616, the adult family home must do the following when issuing a written notice of transfer or discharge:

(1) Include in the notice contact information provided by the department for the legal services agencies assigned to provide legal counsel;

(2) Clearly state in the notice that, subject to legislative appropriation, legal counsel at public expense is available to represent the resident's interests in the transfer or discharge process. This language must be substantially in the following form: "Subject to legislative appropriation you have a right to a free lawyer to help you respond to a notice of transfer or discharge. If you want a free lawyer to help you, please call the long-term care discharge defense screening line at [phone number].";

(3) Within three calendar days of issuing the notice, provide a copy of the notice to the resident's assigned department case manager;

(4) Within three calendar days of issuing the notice, provide a copy of the notice to the Washington state long-term care ombudsman program; and

(5) Issue the transfer and discharge notice in substantially the following form:

(a) Resident information;

(i) Resident name;

(ii) Resident address;

(b) Facility information;

(i) Facility name;

(ii) Facility address;

(iii) Contact person's name;

(c) Date notice given;

(d) Effective date: Effective date must be at least 30 days from the date notice is given unless an exception applies according to RCW 70.129.110;

(e) Location to where resident is transferred or discharged:

(i) Name;

(ii) Address;

(iii) Phone;

(f) Reason for transfer or discharge: The specific reason for the transfer or discharge must be one or more of the reasons in (i)-(v) of this subsection:

(i) Transfer or discharge is necessary for the resident's welfare and the residents' needs cannot be met in the facility;

(ii) The safety of individuals in the facility is endangered;

(iii) The health of individuals in the facility would otherwise be endangered;

(iv) The resident has failed to make the required payment for their stay;

(v) The facility ceases to operate.

(g) Copy of notice given within three days to:

(i) Department case manager;

(ii) Washington state long-term care ombudsman program;

(h) Your rights and resources.

(i) Legal counsel: Subject to legislative appropriation, you have a right to a free lawyer to help you respond to a notice of transfer or discharge. If you want a free lawyer to help you, please call the long-term care discharge defense screening line at [phone number].

(ii) Washington state ombuds: The Washington state long-term care ombudsman program is available to answer questions and provide assistance regarding this notice and your health, safety, welfare, and rights as a long-term care resident. If you wish to find out more about the long-term care ombuds, call 1-800-562-6028. You may also contact a long-term care ombuds in writing, by fax at (253) 815-8173, email at ltcop@mschelp.org, or mail at PO Box 23699, Federal Way, WA 98093-0699.

(iii) Disability rights Washington: If you have a diagnosis of a mental illness or an intellectual disability, you may contact disability rights Washington 1-800-562-2702 or (206) 324-1521. You may also make your request in writing by fax at (206) 957-0729, email at info@dr-wa.org or mail at Disability rights Washington, 315 5th Ave S, Suite 850, Seattle WA, 98104.

(iv) DSHS home and community living administration (HCLA): You have the right to make a complaint to the complaint resolution unit (CRU/complaint hotline) 1-800-562-6078.