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Group homes · Home health

The software handles the clinical side. Nobody handles the binder the surveyor asks for.

Compliance systems for Washington group care facilities, residential substance use disorder treatment and withdrawal management programs, supported living providers, and home health agencies.

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The problem

It is not a clinical problem. It is a documentation problem.

Licensing shows up. The surveyor asks for the training file on the staff member who worked last Tuesday night. Twenty minutes later somebody is still digging through a shared drive.

That is the one that generates citations. Most agencies in this sector have invested in EHR and scheduling software. Very few have invested in the layer around it: policy that matches the current rule, personnel files that survive review, training records that can be produced on demand, and an audit trail that shows the system worked before anyone asked.

What gets cited

Six places the paperwork comes apart.

These are the categories that generate findings, with the governing rule for each. Group care citations are to chapter 110-145 WAC, rewritten effective May 1, 2026. Behavioral health and substance use disorder programs are to chapter 246-341 WAC. Home health is chapter 246-335 WAC and, for Medicare-certified agencies, 42 CFR part 484.

Personnel file completeness

The first thing asked for and the most common place a file is short a document.

  • WAC 110-145-2710: Personnel records. Eleven enumerated contents, including a background check log showing the date each check was requested and completed.
  • WAC 246-335-530: Personnel, contractor, and volunteer records. Nursing assistant certification within twelve months of hire; evidence of initial and subsequent background checks.
  • WAC 246-341-0510: Personnel, agency record requirements. Includes a signed, dated commitment to maintain individual confidentiality, and orientation within 90 days of hire.
  • 42 CFR 484.115: Personnel qualifications, and 42 CFR 484.110 for clinical records, retained five years after discharge.

Training documentation and refresh intervals

Where the hour counts are explicit, a shortfall is arithmetic, not judgment. It is not arguable.

  • WAC 110-145-2740: Preservice training. At least 16 hours before providing direct care.
  • WAC 110-145-2750: In-service training. At least 24 hours annually; behavior management within the first 60 calendar days.
  • WAC 110-145-2770: First aid and CPR, within the first 90 calendar days. CPR must be completed in person.
  • WAC 246-341-1100: Withdrawal management. All staff other than credentialed professionals need a documented minimum 40 hours of training covering substance use disorder, infectious disease, and withdrawal and trauma screening.
  • 42 CFR 484.80: Home health aide services. 75 hours total training, at least 16 classroom before 16 supervised practical, and at least 12 hours of in-service in each 12-month period.

Worth knowing: chapter 246-335 WAC requires orientation and ongoing training but sets no hour count. An agency holding itself to a number it invented is a different conversation from one out of compliance.

Background check timing and re-check cycles

Two rule sets, two different triggers. Agencies running both license types routinely apply the wrong one.

  • WAC 110-145-2650: Group care. No one works at the facility until the department issues a background check clearance authorization.
  • WAC 246-335-525: Home health. Checks renewed within two years of the previous check, processed through the Washington State Patrol.

Note the difference in trigger: group care ties clearance to working at the facility, home health to independently providing patient care. Part 484 imposes no federal background screening at all. That requirement is entirely state law.

Medication administration and records

Storage, administration and documentation are separate requirements, and are separately citable.

  • WAC 110-145-2970: Accepting, storing, and disposing of medication.
  • WAC 110-145-2980: Medication administration and documentation. Requires at least one direct care staff member with department-approved medication training present when children are in care.
  • WAC 246-335-520 and WAC 246-335-550: Delivery of services, and patient records including documented response to medications ordered.
  • 42 CFR 484.55: The drug regimen review inside the comprehensive assessment.

Incident reporting timelines

Group care has a hard clock. The home health rules do not, which surprises people who work in both.

  • WAC 110-145-2780: Reporting incidents. Immediately, but no later than 48 hours after.
  • WAC 110-145-2790: Reporting children and youth missing from care.
  • WAC 246-341-0420: Behavioral health agencies. Critical incidents reported to the department within 48 hours, along with the actions taken. Note this is a policy requirement, not a separately titled reporting section, so agencies looking for one do not find it.
  • 42 CFR 484.50: Patient rights. Findings of abuse or neglect reported immediately, with no hour figure attached.

Chapter 246-335 WAC contains no incident reporting section with a deadline. Agencies that assume one exists tend to have no internal clock either, which is its own exposure.

Policy currency against the current rule

The quiet one. A policy binder that was correct in 2024 can be non-compliant today without anyone touching it.

  • WAC 110-145-2360: License application requirements, including policies covering staff qualifications, duties and ongoing training.
  • WAC 110-145-3190: Behavior management policies, which must be approved by the department.
  • WAC 246-335-515: Plan of operation. Current written policies accessible to staff during hours of operation, and a plan updated to reflect current practice and current law.
  • WAC 246-341-0420: Agency policies and procedures, the section that carries most of a behavioral health agency's written-policy obligations.
  • 42 CFR 484.105: Organization and administration, including a patient acceptance-to-service policy maintained through annual review.

This is live right now. Chapter 110-145 WAC was substantially rewritten and took effect May 1, 2026. Any group care policy set that has not been reviewed since then is being measured against a rule it was not written for.

Admissions, house rules and fair housing

The documents that decide who gets in are the ones nobody reviews.

Intake criteria, house rules, and tenancy agreements are usually written once and then inherited. They are also where disability and fair housing questions land. We read them against the rules below and tell you what we see. What any of it means for your organization is a question for your counsel, and we will tell you when you have reached one.

Prescribed medication is not illegal drug use

The most common provision we are asked to look at, and the one with the most rules pointing at it.

  • WAC 246-341-1108: amended effective June 29, 2025. An agency may not deny admission based solely on an individual taking FDA-approved medications for substance use disorder under a medical provider's supervision, or require titration of dosages to be admitted or remain in the program.
  • 42 U.S.C. 12210: the ADA excludes current illegal drug use from protection. Subsection (d) puts medication taken under a licensed health care professional's supervision outside that exclusion.
  • 28 CFR 35.131 and 28 CFR 36.209: the implementing rules. Both also confirm that a treatment program may deny participation to someone engaging in illegal drug use while in the program. The two provisions do different work and are easy to conflate.

The Department of Justice put it plainly in its 2022 guidance on opioid use disorder: “illegal use does not include taking a medication, including an opioid or medication used to treat OUD, under the supervision of a licensed health care professional.” DOJ has resolved matters on these facts against residential and skilled nursing providers, including the Ready to Work settlement in March 2022 and North End Rehabilitation in November 2023.

A recovery housing statute that has not moved since 2003

The one worth sitting down with. It is the only Washington statute written specifically for this housing type.

  • RCW 59.18.550: Drug and alcohol free housing. It contemplates tenants abstaining from alcohol and illegal drugs, landlord-conducted drug testing, participation in a program of recovery, and quarterly written verification, with termination on three days' notice.

Its history line reads 2003 c 382 s 1. It has not been amended since, so it predates the current medication standard entirely. House rules drafted from its language, and then applied to a resident taking prescribed medication, are reaching a place the rules above address differently. That tension is worth understanding before it is tested, and it is the first thing we look for in a recovery residence's paperwork.

Washington's disability definition is not the ADA's

Organizations that scope their policies to the federal standard alone are working from a narrower rule than the one that applies here.

  • RCW 49.60.040: defines disability as an impairment that is medically cognizable or diagnosable, or exists as a record or history, or is perceived to exist. A disability exists mitigated or unmitigated. The “substantially limiting” test appears only in the employment accommodation subsection.
  • RCW 49.60.222: Unfair practices with respect to real estate transactions, facilities, or services. Carries the state reasonable accommodation and reasonable modification obligations.
  • 42 U.S.C. 3604: the federal Fair Housing Act equivalents, including the reasonable accommodation provision at 3604(f)(3)(B).

Chapter 49.60 RCW contains no counterpart to the ADA's current-use exclusion at 42 U.S.C. 12210 or the Fair Housing Act's at 42 U.S.C. 3602(h). We have not found a Washington appellate decision resolving how that plays out for substance use disorder, and we will not tell you it is settled. We will tell you the texts differ, which is enough reason to have looked.

Two licenses, and neither chapter mentions the other

A structural gap rather than a drafting one. It catches providers who have read their own chapter carefully.

  • WAC 246-341-1105: a behavioral health agency providing residential or inpatient services must be, among the listed options, a residential treatment facility licensed under chapter 71.12 RCW.
  • WAC 246-337-001: chapter 246-337 WAC is the rule that implements chapter 71.12 RCW for residential treatment facilities.

Read together, a non-hospital residential program is looking at a facility license under chapter 246-337 WAC alongside its behavioral health agency license and service certification under chapter 246-341 WAC. Neither chapter cites the other by WAC number; the link runs through the RCW. Where a provider's configuration is genuinely unclear, the answer comes from the Department of Health, and we will help you ask rather than guess on your behalf.

Two deadlines that moved, and one that surprises people

Dates are the cheapest thing to get wrong and the easiest to check.

  • 45 CFR 84.84: the Section 504 web and mobile accessibility requirement. Originally May 11, 2026; an interim final rule at 91 FR 25496 moved it to May 11, 2027 for recipients with fifteen or more employees and May 10, 2028 for smaller ones. Because it rests on an interim rule, we re-check it rather than quoting it from memory.
  • WAC 246-337-065: reporting serious or undesirable outcomes by the end of the next business day. It sits inside a section titled “Safety and security,” which is why providers looking for an incident reporting section do not find it.
Substance use disorder programs

42 CFR Part 2 is a different standard, and it is already being enforced.

Feb 16
2026

The compliance date has passed. The 2024 Final Rule aligning 42 CFR part 2 with HIPAA took effect April 16, 2024 with a compliance date of February 16, 2026. HHS Office for Civil Rights opened its civil enforcement program the same day and began accepting Part 2 complaints and breach notifications.

For a program that has not yet revisited its consents, redisclosure notices, patient notice, breach response, and safeguards policy, this is no longer preparation for a future deadline. The obligations are in force, and the enforcement scheme behind them is borrowed from HIPAA. Where that leaves any particular program is a question for that program and its counsel.

Who this applies to. A part 2 program is a federally assisted program that holds itself out as providing substance use disorder diagnosis, treatment, or referral (42 CFR 2.11). Federal assistance is defined broadly at 42 CFR 2.12: DEA registration, Medicare or Medicaid participation, block grant funds passed through the state, or 501(c)(3) status each satisfy it independently. In practice nearly every Washington residential substance use disorder provider is covered.

The common mistake

“Part 2 just follows HIPAA now.” It does not.

The 2024 rule made Part 2 consent reusable. It did not make it optional. Six places the two regimes still diverge, and each one is a live exposure:

Consent is still required for treatment, payment and operations

The single biggest operational gap, and the one most often gotten wrong.

  • 42 CFR 2.31: Consent requirements. HIPAA permits treatment, payment and health care operations disclosures with no authorization at all. Part 2 requires written consent meeting the elements of this section first.
  • 42 CFR 2.33: Uses and disclosures permitted with written consent. A single consent can now cover all future TPO uses until the patient revokes it in writing. That is the change. The consent itself is not optional.

Records cannot be used against the patient in proceedings

There is no HIPAA analogue for this, and it is the one that surprises counsel.

  • 42 CFR 2.13: Confidentiality restrictions and safeguards. Records may not be used or disclosed in any civil, criminal, administrative or legislative proceeding conducted by any federal, state or local authority.
  • 42 CFR 2.12: Applicability. That restriction applies to any person who obtains the record, not only to the program that created it.
  • 42 CFR 2.33: The bar survives lawful redisclosure. A covered entity that receives the record may pass it on under HIPAA, except for proceedings against the patient.

A subpoena is not enough

Under HIPAA a qualifying court order generally suffices. Under Part 2 the order has to meet Part 2's own criteria.

  • 42 CFR 2.64: Orders authorizing uses and disclosures for noncriminal purposes.
  • 42 CFR 2.65: Orders authorizing use and disclosure of records to criminally investigate or prosecute patients.
  • 42 CFR 2.66: Orders authorizing use and disclosure to investigate or prosecute a part 2 program.

Every disclosure carries a notice

HIPAA has no equivalent. It is a small requirement that generates findings because nobody built it into the workflow.

  • 42 CFR 2.32: Notice and copy of consent to accompany disclosure. Each disclosure travels with either the long-form notice or the short form, plus a copy of the consent or a clear explanation of its scope.

Breach notification and penalties now run on HIPAA rails

This is what changed the stakes. The obligations are stricter than HIPAA, and the consequences are now the same size.

  • 42 CFR 2.16: Security for records and notification of breaches. The HIPAA Breach Notification Rule at 45 CFR part 164 subpart D applies to part 2 programs in the same manner as it applies to a covered entity.
  • 42 CFR 2.3: Civil and criminal penalties for violations. Part 2 violations now carry HIPAA's civil money penalties and criminal penalties, and 45 CFR part 160 subparts C, D and E govern noncompliance.

Even acknowledging the patient is there requires consent

Front desk, phone, visitor log. This is a training problem more than a policy problem.

  • 42 CFR 2.13: Presence at a facility publicly identified as providing only substance use disorder services may be acknowledged only with the patient's written consent. HIPAA's facility directory rule is an opt-out regime; this is opt-in.
  • 42 CFR 2.14: Minor patients. Where state law lets a minor obtain treatment on their own, the consent may be given only by the minor.

Where the state rule hands off to the federal one. WAC 246-341-0425 requires a behavioral health agency to keep individual service records for six years after the most recent discharge, and to release them only in compliance with applicable state and federal law. For a federally assisted substance use disorder program, the release standard that sentence points to is 42 CFR part 2, not the WAC. An agency whose release policy stops at the state rule has not answered the question.

How Bright Rowan helps

Five ways in, depending on where you are.

Templates and tools

Policy sets, personnel file checklists, and training trackers built for this license type. Buy once, use them yourself.

System setup

A build of your compliance infrastructure from the ground up. Files, policies, calendars, and the tracking that keeps them current.

Fractional compliance oversight

Monthly retainer. Someone who owns audit readiness without a full-time salary attached.

Mock audits, on site

A walkthrough before the state does one. Findings written the way a surveyor would write them.

Crisis response

A citation landed and a plan of correction is due. We help you draft it and build the underlying fix. The response is yours, filed by you, and we will tell you if it needs counsel first.

Who this is for

Licensed residential and in-home providers.

Group care facilities licensed under chapter 110-145 WAC, including programs operating as Behavior Rehabilitation Services or as a Qualified Residential Treatment Program under Family First. Behavioral health agencies licensed and certified under chapter 246-341 WAC, including residential and inpatient substance use disorder treatment and withdrawal management services. Home health and home care agencies licensed under chapter 246-335 WAC. Supported living providers.

Currently serving Washington, with Oregon and Idaho by arrangement. California providers know this license type as an STRTP; the work is the same, the rule citations are not.

Bright Rowan is led by Christie Clutter, CCEP, PHR, CRCMP, based in Vancouver, Washington. We advise, audit, and build systems you own and operate. We do not act as your compliance officer of record, we do not run your operations, and we do not provide legal advice. Where a question turns on how a rule applies to your organization, that is a question for your counsel, and we will say so.

Get in touch

Find out what a surveyor would find first.

A compliance review is a scoped, flat-fee piece of work, quoted in writing before it begins.

service@brightrowan.com · Vancouver, WA