(5) Accreditation or certification. Within three hundred sixty-five calendar days of the effective date of this rule, a physician who performs a procedure under this rule must ensure that the procedure is performed in a facility that is appropriately equipped and maintained to ensure patient safety through accreditation or certification and in good standing from one of the following:

(a) The Joint Commission;

(b) The Accreditation Association for Ambulatory Health Care;

(c) The American Association for Accreditation of Ambulatory Surgery Facilities;

(d) The Centers for Medicare and Medicaid Services; or

(e) Planned Parenthood Federation of America or the National Abortion Federation, for facilities limited to office-based surgery for abortion or abortion-related services.

(2) An ambulatory surgical facility certified by the Centers for Medicare and Medicaid Services or accredited by the Joint Commission, Accreditation Association for Ambulatory Health Care or American Association for Accreditation of Ambulatory Surgery Facilities must:

(a) Notify the department of a certification or an accreditation survey within two business days following completion of the survey; and

(b) Notify the department in writing of the accreditation decision and any changes in accreditation status within thirty calendar days of receiving the accreditation report.

(5) ‘Health care institution‘ or ‘medical facility‘ includes the following:

(a) Adult residential rehabilitation centers regulated under chapter 71.12 RCW;

(b) Alcohol and drug treatment facilities and hospitals regulated under chapter 70.96A RCW;

(c) Emergency medical care and transportation services regulated under chapter 18.73 RCW;

(d) Boarding homes regulated under chapter 18.20 RCW;

(e) Childbirth centers regulated under chapter 18.46 RCW;

(f) Community mental health centers regulated under chapter 71.05 or 71.24 RCW;

(g) Home health agencies, home care agencies, hospice care centers, and hospice agencies regulated under chapter 70.127 RCW;

(h) Medical test sites regulated under chapter 70.42 RCW; (i) Nursing homes regulated under chapter 18.51 RCW;

(j) Pharmacies regulated under chapter 18.64 RCW;

(k) Private psychiatric hospitals and residential treatment facilities for psychiatrically impaired children and youth regulated under chapter 71.12 RCW;

(l) Rural health care facilities regulated under chapter 70.175 RCW; (m) Organizations that provide designated trauma care services individually or jointly under chapter 70.168 RCW;(n) Facilities owned and operated by a political subdivision or instrumentality of the state, including, but not limited to:

(i) Public health departments;

(ii) Fire districts and departments;

(iii) Soldiers' and veterans' homes;

(iv) State mental health institutions;

(v) Health clinics operated by educational institutions;

(vi) Department of corrections health care facilities;

(vii) A health care entity seeking department approval of an alternative program shall submit to the department, in addition to the items specified in WAC 246-50-030(1), verification of certification or accreditation by an organization approved by the department.

(1) A home health or hospice licensee that is certified by the federal Medicare program, or accredited by the community health accreditation program, or the joint commission on accreditation of health care organizations is not subject to a state licensure survey when exempt under subsection (3) of this section or the department has granted deemed status under subsection (6) of this section.

(1) The department will recognize the accreditation organizations granted deemed status by CMS. (2) The CMS-approved accreditation organizations are: (f) Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (3) The accreditation organizations must: (a) Allow the department to have jurisdiction to investigate complaints, do random on-site validation inspections, and take disciplinary action against a medical test site if indicated; (b) Notify the department within fifteen days of any medical test site that: (i) Has had its accreditation withdrawn, revoked, or limited; (ii) Is sanctioned as a result of a routine inspection or complaint investigation; or (iii) When adverse action has been taken for unsuccessful proficiency testing performance; (c) Notify the department within five days of any deficiency that jeopardizes the public health, safety, or welfare; and (d) Provide the department with a list of inspection schedules, as requested, for the purpose of conducting on-site validation inspections.

(1) Surveys. The department will:

(a) Conduct on-site surveys of each hospital on average at least every eighteen months or more often using the health and safety standards in this chapter and chapter 70.41 RCW;

(b) Coordinate the on-site survey with other agencies, including local fire jurisdictions, state fire marshal, state pharmacy board, and report the survey findings to those agencies;

(c) Notify the hospital in writing of the survey findings following each on-site survey;

(d) Require each hospital to submit a corrective action plan addressing each deficient practice identified in the survey findings;

(e) Notify the hospital when the hospital submitted plan of correction adequately addresses the survey findings; and

(f) Accept on-site surveys conducted by the Joint Commission or American Osteopathic Association as meeting the eighteen-month survey requirement in accordance with RCW 70.41.122.

(15) “Licensed service provider” means an entity licensed according to this chapter or chapter 71.05 RCW or an entity deemed to meet state minimum standards as a result of accreditation by a recognized behavioral health accrediting body recognized and having a current agreement with the department, that meets state minimum standards or persons licensed under chapter 18.57, 18.71, 18.83, or 18.79 RCW, as it applies to registered nurses and advanced registered nurse practitioners

(1) By January 1, 2011, the department shall endeavor to enhance and support an emergency cardiac and stroke care system through:

(b) Giving a hospital “deemed status” and designating it as a primary stroke center if it has received a certification of distinction for primary stroke centers issued by the nonprofit organization known as the joint commission. When available, a hospital shall demonstrate its cardiac or stroke level through external, national certifying organizations, including, but not limited to, primary stroke center certification by the joint commission

(1) Notwithstanding the provisions of RCW 70.127.080(1)(c), an in-home services agency that is certified by the federal Medicare program, or accredited by the community health accreditation program, or the joint commission on accreditation of health care organizations as a home health or hospice agency is not subject to a state licensure survey if:

(a) The department determines that the applicable survey standards of the certification or accreditation program are substantially equivalent to those required by this chapter;

(b) An on-site survey has been conducted for the purposes of certification or accreditation during the previous twenty-four months; and

(c) The department receives directly from the certifying or accrediting entity or from the licensee applicant copies of the initial and subsequent survey reports and other relevant reports or findings that indicate compliance with licensure requirements.

1) To apply to become a department-approved long-term acute care (LTAC) hospital, the department requires a hospital to provide documentation that confirms the hospital is:

(ii) Accredited by the joint commission on accreditation of healthcare organizations (JCAHO);

(5) Accreditation or certification. Within three hundred sixty-five calendar days of the effective date of this rule, a physician who performs a procedure under this rule must ensure that the procedure is performed in a facility that is appropriately equipped and maintained to ensure patient safety through accreditation or certification and in good standing from one of the following:

(a) The Joint Commission;

(b) The Accreditation Association for Ambulatory Health Care;

(c) The American Association for Accreditation of Ambulatory Surgery Facilities;

(d) The Centers for Medicare and Medicaid Services; or

(e) Planned Parenthood Federation of America or the National Abortion Federation, for facilities limited to office-based surgery for abortion or abortion-related services.

Note:   Rules were finalized on 8/18/2010