About Hospice

Program Overview
Hospice focuses on improving the quality of life for people and their families faced with a life-limiting illness. The primary goals of hospice care are to provide comfort, relieve physical, emotional, and spiritual suffering and promote the dignity of terminally ill people.

Although typically provided in a person’s home, hospice care can also be provided in freestanding hospice centers, hospitals, nursing homes and other long-term care facilities. Hospice services are available to patients of any age, religion, race or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs and other managed-care organizations.

Hospice agencies provide the following types of services:

• Hospice agency staff members work with the family or nursing home staff to provide patient care. Goals of care are established with the patient and family and a care plan developed to help meet these goals.
• The hospice team provides the patient with medical care to relieve pain and other symptoms arising from a life-limiting illness.
• Medications are ordered by the primary physician or hospice doctor but are usually picked up by family members at a designated pharmacy.
• Counseling is available to patients to help them cope with their illness, address depression, grief, and anxiety, as well as spiritual issues, such as loss of meaning and fear of death.
• Counseling services to help with caregiver stress, role changes, depression, anxiety, family conflict, grief and spiritual concerns.
• Education to help family provide hands-on care to patients, proper usage of medications, knowledge about disease progression, signs and symptoms of dying, normal grief response and coping with stress, etc.
• Religious care is available either directly by the hospice chaplain or through community resources.
• Assistance with cremation/burial arrangements and with funeral/memorial services.

The Department of Health licenses hospice agencies to assure care is provided within health and safety standards established by statute and rule. Hospice services may also include the provision of home health and home care services. The department enforces the standards by periodically conducting unannounced on-site surveys of these agencies.

Medicare may pay for services provided by hospice agencies who voluntarily seek and are approved for certification by the federal Centers for Medicare & Medicaid Services (CMS). CMS contracts with the department to evaluate compliance with the federal hospice regulations by periodically conducting unannounced on-site surveys of these agencies.

Applications & Forms

• License Application Packet (PDF)
• Full-Time Equivalent (FTE) Worksheet (PDF)

License Requirements

For hospice agency licensing, submit the following:

• Copy of In-home Services Orientation Class “certificate of completion.” Applications will not be processed unless a certificate of completion has been submitted.
• Completed in-home services application (PDF), along with the initial licensing fee.
• Proof of current commercial general liability insurance according to WAC 246-335-320(2)(b).
• Disclosure statements for the on-site administrator and director of clinical services according to WAC 246-335-320(2)(d) dated within three months of the application date.
• Criminal history background checks processed through the Washington State Patrol for the on-site administrator and director of clinical services according to WAC 246-335-320(2)(d) dated within three months of the application date.
• Copy of any and all current government-issued business licenses for each office location; this may include state, county, or city licenses.
• Completed full-time equivalent worksheet.
• A description of the agency’s organizational structure listing; for example, the names of the officers, administrator, director of clinical services, and other key positions.
• A description of how the agency will provide management and supervision of hospice services throughout all requested service areas.
• A description of the services the agency will offer directly and those offered under contract.

Submit all of the above to the address shown in the application packet above.

After review and acceptance of the application materials, the department’s Office of Investigation and Inspection will contact the applicant and schedule an initial survey. Applicants must pass the survey process in order for their license to be issued.

Important notice: According to WAC 246-335-320(4), the department may close out an application, with no refund of licensing fees being issued, if an applicant has not completed all steps required for licensure within nine months.

For the federal Medicare-certified hospice agency application, continue on to the Department of Health’s website.

In-Home Services Survey Program

The Department of Health’s Office of Investigation and Inspection (OII) is responsible for ensuring that licensed in-home services agencies comply with all applicable state and federal requirements. The OII survey and investigation teams conduct routine state and federal surveys as well as complaint investigations. Washington State licenses more than 400 in-home services agencies to provide home-based personal care and health services to clients and patients within the minimum health and safety standards established in chapter WAC 246-335. The OII survey team is required to survey applicants as part of the initial licensing process, and to survey licensees once during each licensure period. Initial surveys are scheduled and announced; on-going surveys are unannounced.

Our survey team consists of registered nurses who have experience and training in home care, home health, and hospice services. Initial licensure surveys focus primarily on reviewing and approving an applicant’s policies and procedures, sample employee and client/patient files, and demonstrated knowledge of the in-home services rules and client/patient delivery of care. On-going surveys of licensed agencies focus primarily on the delivery of client/patient care, interviewing client/patients about the services they receive, interviewing agency employees about training and knowledge of agency policies and procedures, and a review of randomly selected client/patient and employee files.

After a survey is completed, the agency may be provided with documentation indicating non-compliance with chapter WAC 246-335 and chapter RCW 70.127. If so, the agency is required to submit an acceptable plan of correction addressing the areas of non-compliance.

How to prepare for your survey:
Surveyors use the following tools and checklists to systematically guide them through the survey process to determine an agency’s compliance with the minimum health and safety standards in chapter WAC 246-335. Agencies are encouraged to review the below tools and checklists to help them prepare for their next survey.

Home care survey resources

• Home care deficiency checklist (PDF)
• Home care policy and procedure checklist (PDF)
• Home care bill of rights checklist (PDF)
• Home care personnel checklist (PDF)
• Home care client record review (PDF)
• Long-term care worker checklist (PDF)

Home health survey responses

• Home health deficiency checklist (PDF)
• Home health policy and procedure checklist (PDF)
• Home health bill of rights checklist (PDF)
• Home health personnel checklist (PDF)

Hospice and hospice care center survey resources

• Hospice deficiency checklist (PDF)
• Hospice policy and procedure checklist (PDF)
• Hospice state record review (PDF)
• Hospice personnel checklist (PDF)

Policies and procedures
Chapter WAC 246-335 require agencies to develop and put into operation various policies and procedures (P&Ps) related to delivery of services. P&Ps provide framework and structure for the agency, the services it provides and its employees. Well-written P&Ps allow employees to clearly understand their roles and responsibilities within predefined limits. P&Ps allow agency administration to define and guide operations without constant management intervention. When consistently enforced, they contribute to the development of the company culture. P&Ps may not consist of the WAC or RCW copied word for word, nor may they refer to Medicare certification or accreditation prior to an agency officially gaining Medicare certification or accreditation. Agencies have the option to develop P&Ps themselves or to hire an industry consultant to create a P&P manual for them. Agencies that want to develop P&Ps themselves may find the below example helpful in regards to structure and wording:

• Hand hygiene policy and procedure example (PDF)

Statement of deficiencies and plan of correction
If non-compliance with chapter WAC 246-335 is identified during the on-site survey process, surveyors will compile all areas of noncompliance and may issue a statement of deficiencies document. The statement of deficiencies will include brief statements of what is required for agencies to achieve compliance, the date by which the department requires compliance to be achieved, contact information for any technical assistance services the department provides, and the process to request an extension of time for good cause to achieve compliance.

Agencies that are not Medicare certified must submit a written plan of correction (POC) within 10 working days after receiving the statement of deficiencies to address deficiencies that are determined not to be significant, broadly systemic, or recurring. The POC must describe: How each deficiency will be or was corrected; what measures or monitors will be put in place to ensure the deficiencies do not recur; who is responsible for correcting each deficiency; and when each deficiency will be or has been corrected.

Agencies must complete all corrections within 60 days, unless the department authorizes a different time frame for correcting some of the deficiencies. Implementation of the plan of correction is subject to verification by the department. Agencies needing to submit a plan of correction may find the below resource helpful:

• Plan of correction instructions (PDF)

Updated Rules – Information, Resources, and Guidance

The in-home services licensing rules, chapter 246-335 WAC, have been updated and took effect April 6, 2018. This page offers applicants and licensees various resources and guidance pertaining to the updated rules.

CR-103 – filed on March 6, 2018
The filing of the CR-103 (WSR 18-06-093) (PDF) signifies the conclusion of the department’s in-home services rule updating activities. The CR-103 form identifies new sections added to the rules, old sections that have been repealed, and amended sections. The updated rules are attached to the CR-103, page 4 through 78.

Significant rule changes
The department has created a “significant rule changes” document (PDF) that highlights the more substantial in-home services rule changes for applicants and licensees. In addition to these changes, there are many other updates throughout the rules. We encourage applicants and licensees to read the revised rules thoroughly.

Survey grace period ended on October 6, 2018
The department provided in-home services licensees a six-month survey-related grace period, which ended October 6, 2018, in order to perform necessary administrative updates and to become familiar with the various new and revised rule requirements in chapter 246-335 WAC. Any licensee surveyed after October 6, 2018, is expected to be in compliance with the updated rules.

New orientation class requirement for applicants
WAC 246-335-320(1) requires applicants to complete an in-home services orientation class before submitting a licensing application. The class’s purpose is to provide prospective applicants an overview of the state licensing process, explain the differences between home care, home health, and hospice service categories, and describe department expectations of licensees providing care to vulnerable persons. This half-day orientation class is free of charge and offered at the department’s Tumwater campus. Applications submitted without an orientation class certificate of completion will not be processed. For class registration information and dates, see our Orientation Class webpage.

Note: The orientation class isn’t required for change of ownership applications, agencies adding a service category to their license, or Medicare-certified agencies that choose to establish a new state license for a recently approved county through Certificate of Need.

New Full-time Equivalent (FTE) Worksheet)
WAC 246-335-320(2)(c) and 246-335-325(3) requires applicants and licensees to complete, sign and submit a Full-time Equivalent Worksheet (PDF) along with their initial and renewal applications. The worksheet is designed to assist agencies in calculating their FTEs. The FTEs noted on initial and renewal applications should match the FTEs on the worksheet. A separate FTE worksheet is required for each services category (e.g., home care, home health, and hospice). Agency administrators must sign the completed form, attesting that the information is accurate. For your convenience, here are two examples of completed FTE worksheets:

• FTE worksheet for initial applications – example (PDF)
• FTE worksheet for renewal applications – example (PDF)

New criminal history background check requirements
WAC 246-335-425(6), 246-335-525(6), and 246-335-625(6) requires home care, home health, and hospice agencies to request criminal history background checks and disclosure statements for the administrator, supervisor of direct care services, director of clinical services, and all employees who provide care to clients and patients. Background checks are required upon hire and then every two years. The department supports client and patient safety by requiring agencies to periodically re-run background checks on their workers to verify that no disqualifying charges or convictions have taken place since their previous check.

Home health and hospice agencies must process initial and subsequent background checks through the Washington State Patrol (WSP). Home care agencies must process initial hiring background checks through the Washington State Department of Social and Health Services Background Check Central Unit (DSHS BCCU) and subsequent two-year checks through WSP. Processing background checks through the BCCU satisfies the requirement in WAC 246-335-425(6). BCCU is required to provide only initial background checks for long-term care workers and certified home care aides at no charge to the home care agency.

Note 1: DSHS-contracted home care agencies are required by their contract to process all background checks, initial and subsequent, through the BCCU system.

New character, competency, and suitability determination requirement
WAC 246-335-425(7), 246-335-525(7), and 246-335-625(7) requires home care, home health, and hospice agencies to develop policies and procedures for conducting a character, competence, and suitability (CCS) determination for personnel, contractors, volunteers, and students whose background check results reveal non-disqualifying convictions, pending charges, or negative actions. Agencies are required to process Washington State Patrol (WSP) criminal history background checks upon hire and then every two years. The WSP background check results will either indicate “No Record Found” or “Record Found.” If the results say “Record,” agencies must review the crimes listed to determine if there are any disqualifying crimes per RCW 43.43.830. If there are no disqualifying crimes, but other non-disqualifying crimes, pending charges, or negative actions are listed, agencies must conduct a CCS review to determine if the person should have unsupervised access to vulnerable adults or children.

Guidance on using the Tuberculosis (TB) Risk Assessment form WAC 246-335-425(13), 246-335-525(16), and 246-335-625(15) requires home care, home health, and hospice agencies to conduct TB risk assessments for new employees and annually for all employees. Agencies must use the department’s Adult TB Risk Assessment form (PDF) and conduct TB testing if any of the three boxes are checked.

The department recognizes that agencies have limited resources and complying with these new regulations translates into increased costs. If agencies with limited fiscal resources are unable to test all employees who indicate they are foreign-born, the risk assessment form contains an option to focus testing efforts on higher risk persons who have identified they also have one or more medical risks. Persons who were born in countries that have elevated TB rates have an increased risk of TB infection. These persons who also have certain medical risks have an even higher risk of progressing to TB disease. Focusing testing and treatment efforts on higher-risk employees will allow agencies with limited resources to provide the most protection to public health.

Here is an example of a completed risk assessment form (PDF) and one way that agencies can document that their foreign-born employee will not be tested because they don’t have additional medical risks.

Note 1: If the “Immunosuppression” or “Close contact” boxes are checked, testing is required.

Note 2: Medicare-certified home health and hospice agencies and hospice care centers may have additional requirements in their conditions of participation related to TB testing.