Washington - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Washington State, an Assisted Living Facility (ALF) is a licensed congregate residential setting that provides housing, basic services, personal care, and intermittent nursing services to seven or more residents. Governed by the Department of Social and Health Services (DSHS) Aging and Long-Term Support Administration (ALTSA), these facilities serve private-pay individuals as well as Medicaid beneficiaries enrolled in programs like the Community Options Program Entry System (COPES) waiver or Community First Choice (CFC). Medicaid reimburses the facility for personal care and supervision, while the resident is responsible for paying a state-mandated room and board rate from their own income.

The single biggest structural barrier to entry for a new ALF provider in Washington is securing physical plant approval and the DSHS ALF license prior to Medicaid enrollment. While Washington does not require a Certificate of Need (CON) for Assisted Living Facilities, applicants must first pass a rigorous architectural review by the Department of Health (DOH) Construction Review Services (CRS) and pass a DSHS pre-licensure inspection. Only after the facility is fully licensed and operational can the provider apply for a Core Provider Agreement through the Health Care Authority (HCA) ProviderOne portal and subsequently execute a Medicaid residential care contract with DSHS ALTSA.

1. Service Definition and Scope

Washington defines an Assisted Living Facility as a congregate residential setting providing housing and care to seven or more adults. Services include personal care, medication assistance, intermittent nursing services, and arranged activities designed to support the resident's independence and safety.

Medicaid does not pay for the room and board portion of an ALF stay. Instead, Medicaid Home and Community-Based Services (HCBS) waivers and state plan programs cover the cost of the direct care and supervision provided to eligible residents based on their assessed acuity level.

• Statutory Authority: Chapter 18.20 RCW governs the licensing of Assisted Living Facilities in Washington.
• Regulatory Authority: Chapter 388-78A WAC contains the comprehensive operational, staffing, and physical plant rules for ALFs.
• Medicaid Coverage: Services are primarily funded through the Community First Choice (CFC) state plan option and the Community Options Program Entry System (COPES) waiver.
• Service Components: Facilities must provide personal care, medication administration or assistance, intermittent nursing, and daily activities.
• Room and Board: Paid privately by the resident using their own income, such as Supplemental Security Income (SSI), at a rate set by the state.
• Specialized Dementia Care: Facilities offering memory care must obtain a Specialized Dementia Care Program (SDCP) certification, which becomes mandatory for all dementia care by July 1, 2026, under Senate Bill 5337.

2. Regulatory and Oversight Agencies

The licensing and ongoing regulatory oversight of ALFs in Washington is managed by the Department of Social and Health Services (DSHS). Specifically, the Aging and Long-Term Support Administration (ALTSA) handles both the facility licensure and the Medicaid residential care contracting.

The Washington State Health Care Authority (HCA) serves as the state Medicaid agency. HCA manages the ProviderOne Medicaid Management Information System (MMIS), where all providers must enroll to receive a Core Provider Agreement before billing for services.

• Licensing Agency: DSHS Aging and Long-Term Support Administration (ALTSA) Residential Care Services (https://www.dshs.wa.gov/altsa/residential-care-services)
• Medicaid Authority: Washington State Health Care Authority (HCA) (https://www.hca.wa.gov)
• Medicaid Portal: HCA ProviderOne (https://www.hca.wa.gov/billers-providers-partners/providerone)
• Background Checks: DSHS Background Check Central Unit (BCCU) (https://www.dshs.wa.gov/ffa/background-check-central-unit)
• Building Approval: Department of Health (DOH) Construction Review Services (CRS) (https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/construction-review-services)

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington State does not utilize a Certificate of Need (CON) process, closed network, or managed care exclusivity moratorium for Assisted Living Facilities. The CON requirement in Washington (RCW 70.38) applies to nursing homes and hospitals, but ALFs are explicitly exempt.

However, strict sequential prerequisites act as the primary gatekeepers. A provider cannot submit a Medicaid enrollment application to HCA or request an ALTSA contract until the physical building has been approved by DOH Construction Review Services and DSHS has issued an active ALF license. There is no provisional Medicaid enrollment for facilities still under construction or pending licensure.

• Certificate of Need: Not required for Assisted Living Facilities in Washington State; they are exempt under RCW 70.38.111.
• Physical Plant Approval: Applicants must submit architectural plans and pass inspections by DOH Construction Review Services (CRS) before DSHS will process a license application.
• Licensure Prerequisite: An active DSHS ALF license is a hard prerequisite; HCA ProviderOne will automatically deny Medicaid enrollment applications from unlicensed facilities.
• Medicaid Contracting: After HCA ProviderOne enrollment, the facility must secure a specific ALTSA residential care contract to serve COPES or CFC clients.
• Network Affiliation: No closed network or managed care exclusivity applies to basic ALF Medicaid contracting; it is an open enrollment process for fully licensed facilities.

4. Licensure and Certification Requirements

Obtaining an ALF license from DSHS requires a comprehensive application detailing the facility's ownership, operational policies, and physical plant. The process includes a substantial licensing fee and an initial on-site inspection by DSHS Residential Care Services.

Facilities must also ensure their administrative leadership meets state qualifications. Administrators must pass rigorous background checks and complete state-recognized training before the facility can open.

• Application Form: Providers must submit DSHS Form 10-345 (Assisted Living Facility License Application).
• Licensing Fee: The state charges an annual licensing fee of $116 per bed, which must be submitted with the initial application.
• Building Code: The facility must meet the specific physical plant requirements outlined in WAC 388-78A and local municipal building codes.
• Inspections: DSHS Residential Care Services conducts a mandatory initial pre-licensure inspection to verify compliance with all WAC standards.
• Administrator Qualifications: The facility administrator must be at least 21 years old, pass a BCCU background check, and complete a DSHS-recognized Administrator Training program.
• Dementia Certification: Facilities intending to operate a memory care unit must apply for Specialized Dementia Care Program (SDCP) certification.

5. Medicaid Provider Enrollment

Medicaid enrollment for Washington ALFs is a two-step process. First, the licensed facility must enroll as a Billing Provider in the HCA ProviderOne system and sign a Core Provider Agreement (CPA).

Once the CPA is active in ProviderOne, the facility must contact DSHS ALTSA to execute a specific residential care contract. This contract establishes the facility's eligibility to receive authorizations from DSHS case managers for Medicaid clients.

• System: All enrollment applications are processed through the HCA ProviderOne portal.
• Provider Type: Facilities must enroll as a Billing Provider (Facility/Agency) using their active DSHS license.
• Core Provider Agreement (CPA): The provider must electronically sign the HCA CPA during the ProviderOne enrollment process.
• ALTSA Contract: After ProviderOne approval, the facility must execute a Medicaid contract with DSHS ALTSA for COPES and CFC services.
• NPI Requirement: The facility must obtain and register a Type 2 National Provider Identifier (NPI) specific to the ALF location.
• Timeline: HCA ProviderOne enrollment typically takes 30 to 60 days, provided the DSHS license is already active and all documentation is complete.

6. Staffing, Training and Background Checks

Washington has stringent training and certification requirements for direct care workers in ALFs. Uncertified staff must complete basic training rapidly and obtain state certification to continue providing care.

Background checks are strictly enforced. No employee may have unsupervised access to residents until they have cleared a fingerprint-based background check through the state's centralized system.

• Background Checks: Mandatory fingerprint-based checks through the DSHS Background Check Central Unit (BCCU) are required for all staff with unsupervised resident access.
• Caregiver Certification: Direct care staff must be certified by the Department of Health as a Home Care Aide (HCA) or Nursing Assistant Certified (NAC) within 200 days of hire.
• Initial Training: Uncertified caregivers must complete 75 hours of DSHS-approved basic training before taking the HCA certification exam.
• Continuing Education: Administrators and direct care staff must complete 12 hours of DSHS-approved continuing education annually.
• First Aid/CPR: All direct care staff must maintain active, hands-on CPR and First Aid certifications.
• Nursing Staff: Any intermittent nursing services provided by the facility must be delivered by a Washington-licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN).

7. Documentation, Policies and Records

ALFs must maintain comprehensive operational and resident records to comply with WAC 388-78A and Medicaid standards. This includes detailed admission agreements, individualized care plans, and strict incident reporting protocols.

Facilities are also required to maintain specific insurance coverages to protect residents and the business, which are verified during DSHS surveys.

• Residency Agreement: Facilities must execute a signed agreement with each resident outlining services, fees, and Medicaid acceptance policies (WAC 388-78A-2140).
• Resident Assessment: A comprehensive assessment of the resident's needs must be completed within 14 days of move-in.
• Negotiated Service Agreement (NSA): An individualized care plan must be developed based on the assessment and updated annually or upon a significant change in condition.
• Insurance: Facilities must maintain commercial general liability and professional liability/errors and omissions insurance (WAC 388-78A-2734).
• Incident Reporting: Providers must immediately report suspected abuse, neglect, or significant injuries to the DSHS Complaint Resolution Unit (CRU).
• Disaster Plan: The facility must maintain and regularly drill a comprehensive emergency and disaster preparedness plan.

8. Billing, Rates and Claims

Medicaid billing for ALFs in Washington is conducted electronically through the HCA ProviderOne system. Facilities bill for the daily care services authorized by the resident's DSHS case manager.

Reimbursement rates are tiered based on the resident's acuity, which is determined by the state's Comprehensive Assessment Reporting Evaluation (CARE) tool. The facility is responsible for collecting the room and board amount directly from the resident.

• Billing System: Claims are submitted via the HCA ProviderOne portal using 837I institutional claim formats or direct data entry.
• Room and Board: Residents pay a state-established room and board rate directly to the facility from their personal income.
• Medicaid Rates: Daily reimbursement rates are set by DSHS and vary based on the resident's CARE classification level.
• Client Participation: Residents may owe a monthly participation amount toward their care costs, which the facility must collect and deduct from Medicaid claims.
• Timely Filing: Medicaid claims must be submitted within 365 days of the date of service to be eligible for payment.
• Prior Authorization: Services cannot be billed until they are explicitly authorized in ProviderOne by the resident's DSHS case manager.

9. Approval Sequence and Timeline

The end-to-end process of opening a new ALF and enrolling in Medicaid in Washington can take 12 to 18 months, heavily dependent on construction and building approvals. Licensure must be fully secured before Medicaid enrollment can begin.

Providers should not attempt to enroll in ProviderOne until they have their physical license in hand, as premature applications will be rejected and require the provider to start over.

• Step 1: Submit architectural plans to DOH Construction Review Services (CRS) and obtain physical plant approval (3 to 6 months).
• Step 2: Submit the DSHS ALF License Application and fee to ALTSA Residential Care Services (60 to 90 days for review).
• Step 3: Pass the DSHS Initial Licensing Inspection and receive the active ALF license (30 to 60 days).
• Step 4: Submit the Billing Provider enrollment application and Core Provider Agreement via HCA ProviderOne (30 to 60 days).
• Step 5: Execute the Medicaid residential care contract with DSHS ALTSA (30 to 45 days).
• Step 6: Receive client authorizations from DSHS case managers and commence Medicaid billing.

10. Common Denials and Survey Findings

DSHS conducts unannounced full inspections of ALFs approximately every 15 to 18 months. Deficiencies can result in civil fines, stop-placement orders, or license revocation.

On the enrollment side, HCA frequently denies ProviderOne applications due to mismatched data or applying before the DSHS license is fully active.

• Enrollment Denial: Submitting a ProviderOne application before the DSHS ALF license is active and verifiable.
• Enrollment Denial: Mismatched Tax ID or NPI information between the IRS, NPPES, and the ProviderOne application.
• Survey Deficiency: Failure to update the Negotiated Service Agreement (NSA) promptly when a resident experiences a significant change in condition.
• Survey Deficiency: Allowing new hires to have unsupervised access to residents before receiving a cleared BCCU background check.
• Survey Deficiency: Medication administration errors or missing signatures in the Medication Administration Record (MAR).
• Survey Deficiency: Failure to maintain physical plant standards, such as expired fire extinguishers or blocked egress routes.

11. Key Contacts and Resources

Providers must interact with multiple state agencies to maintain compliance. DSHS ALTSA is the primary contact for licensing and contracting, while HCA handles billing and ProviderOne technical support.

Utilizing the official state portals for background checks and building reviews is mandatory for all prospective and active ALF operators.

• DSHS ALTSA Residential Care Services: https://www.dshs.wa.gov/altsa/residential-care-services
• HCA ProviderOne Enrollment: https://www.hca.wa.gov/billers-providers-partners/become-apple-health-provider/enroll-provider
• DSHS Background Check Central Unit (BCCU): https://www.dshs.wa.gov/ffa/background-check-central-unit
• DOH Construction Review Services (CRS): https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/construction-review-services
• Washington State Legislature (WAC 388-78A): https://app.leg.wa.gov/wac/default.aspx?cite=388-78A

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