Areas of assessment.
The assessment, at a minimum, shall include all of the following areas applicable to the resident:
Physical health, including identification of chronic, short-term and recurring illnesses, oral health, physical disabilities, mobility status and the need for any restorative or rehabilitative care.
Medications the resident takes and the resident's ability to control and self-administer medications.
Nursing procedures the resident needs and the number of hours per week of nursing care the resident needs.
Mental and emotional health, including the resident's self-concept, motivation and attitudes, symptoms of mental illness and participation in treatment and programming.
Behavior patterns that are or may be harmful to the resident or other persons, including destruction of property.
Capacity for self-care, including the need for any personal care services, adaptive equipment or training.
Capacity for self-direction, including the ability to make decisions, to act independently and to make wants or needs known.
Social participation, including interpersonal relationships, communication skills, leisure time activities, family and community contacts and vocational needs.
The CBRF shall prepare a written report of the results of the assessment and shall retain the assessment in the resident's record.
(2) Temporary service plan.
Upon admission, the CBRF shall prepare and implement a written temporary service plan to meet the immediate needs of the resident, including persons admitted for respite care, until the individual service plan under sub. (3)
is developed and implemented.
Within 30 days after admission and based on the assessment under sub. (1)
, the CBRF shall develop a comprehensive individual service plan for each resident. The individual service plan shall include all of the following:
Establish measurable goals with specific time limits for attainment.
Specify methods for delivering needed care and who is responsible for delivering the care.
The CBRF shall involve the resident and the resident's legal representative, as appropriate, in developing the individual service plan and the resident or the resident's legal representative shall sign the plan acknowledging their involvement in, understanding of and agreement with the plan. If a resident has a medical prognosis of terminal illness, a hospice program or home health care agency, as identified in s. DHS 83.38 (2)
shall, in cooperation with the CBRF, coordinate the development of the individual service plan and its approval under s. DHS 83.38 (2) (b)
. The resident's case manager, if any, and any health care providers, shall be invited to participate in the development of the service plan.
The CBRF shall implement and follow the individual service plan as written.
Individual service plan review.
Annually or when there is a change in a resident's needs, abilities or physical or mental condition, the individual service plan shall be reviewed and revised based on the assessment under sub. (1)
. All reviews of the individual service plan shall include input from the resident or legal representative, case manager, resident care staff, and other service providers as appropriate. The resident or resident's legal representative shall sign the individual service plan, acknowledging their involvement in, understanding of and agreement with the individual service plan.
Documentation of review.
The CBRF shall document any changes made as a result of the comprehensive individual service plan review.
All employees who provide resident care and services shall have continual access to the resident's assessment and individual service plan.
(4) Satisfaction evaluation.
At least annually, the CBRF shall provide the resident and the resident's legal representative the opportunity to complete an evaluation of the resident's level of satisfaction with the CBRF's services. The evaluation shall be completed on either a department form or a form developed by the CBRF and approved by the department.
DHS 83.35 Note
The CBRF Resident Satisfaction Evaluation form, F62372, can be found at http://dhs.wisconsin.gov/forms/DQAnum.asp
or by contacting the Division of Quality Assurance Regional Office listed in Appendix A.
(5) Evaluation of resident evacuation limitations. DHS 83.35(5)(a)(a) Initial evaluation.
The CBRF shall evaluate each resident within 3 days of the resident's admission to determine whether the resident is able to evacuate the CBRF within 2 minutes in an unsprinklered CBRF and 4 minutes in a sprinklered CBRF without any help or verbal or physical prompting, and what type of limitations that resident may have that prevent the resident from evacuating the CBRF within the applicable period of time. A form provided by the department shall be used for the evaluation. The resident's evaluation shall be retained in the resident's record.
DHS 83.35 Note
The Resident Evacuation Assessment form, F62373, can be found at http://dhs.wisconsin.gov/forms/DQAnum.asp
or by contacting the Division of Quality Assurance Regional Office listed in Appendix A.
The CBRF shall evaluate each resident's mental or physical capability to respond to a fire alarm at least annually or when there is a change in the resident's mental or physical capability to respond to a fire alarm.
Notice to employees.
The CBRF shall notify each employee who works on the premises of the CBRF of each resident who needs more than 2 minutes to evacuate the CBRF and the type of assistance the resident needs to be evacuated.
The CBRF shall provide employees in sufficient numbers on a 24-hour basis to meet the needs of the residents.
An administrator or other designated qualified resident care staff in charge is on the premises of the CBRF daily to ensure the CBRF is providing safe and adequate care, treatment and services.
At least one qualified resident care staff is present in the CBRF when one or more residents are present in the CBRF.
At least one qualified resident care staff
is on duty and awake if at least one resident in the CBRF is in need of supervision, intervention or services on a 24-hour basis to prevent, control or improve the resident's constant or intermittent mental or physical condition that may occur or may become critical at any time including residents who are at risk of elopement, who have dementia, who are self-abusive, who become agitated or emotionally upset or who have changing or unstable health conditions that require close monitoring.
At least one qualified resident care staff
is on duty and awake if the evacuation capability of at least one resident is 4 minutes or more.
When all of the residents are away from the CBRF, at least one qualified resident care staff
shall be on call to provide coverage if a resident needs to return to the CBRF before the regularly scheduled return time. The CBRF shall provide each resident or the off-site location a means of contacting the resident care staff who is on call.
(2) Staffing schedule.
The CBRF shall maintain a current written schedule for staffing the CBRF. The schedule shall include each employee's full name, job assignment and time worked.
DHS 83.36 History
History: CR 07-095
: cr. Register January 2009 No. 637
, eff. 4-1-09.
There shall be a written practitioner's order in the resident's record for any prescription medication, over-the-counter medication or dietary supplements administered to a resident.
Prescription medications shall come from a licensed pharmacy or a physician and shall have a label permanently attached to the outside of the container. Over-the-counter medications maintained in the manufacturer's container shall be labeled with the resident's name. Over-the-counter medications not maintained in the manufacturer's container shall be labeled by a pharmacist.
The CBRF shall develop and implement a policy that identifies the medication packaging system used by the CBRF. Any pharmacy selected by the resident whose medications are administered by CBRF employees shall meet the medication packaging system chosen by the CBRF. This does not apply to residents who self administer medications.
As required in s. DHS 83.42 (1) (m)
, when a resident is taking prescription or over-the-counter medications or dietary supplements, the resident's record shall include a current list of the type and dosage of medications or supplements, directions for use, and any change in the resident's condition.
If residents' medications are administered by a CBRF employee, the CBRF shall arrange for a pharmacist or a physician to review each resident's medication regimen. This review shall occur within 30 days before or 30 days after the resident's admission, whenever there is a significant change in medication, and at least every 12 months.
At least annually, the CBRF shall have a physician, pharmacist, or registered nurse conduct an on-site review of the CBRF's medication administration and medication storage systems.
The CBRF shall obtain a written report of findings under subds. 1.
, and address any irregularities for appropriate action. When the review is done by someone other than the prescribing practitioner, the prescribing practitioner shall receive a copy of the report when there are irregularities identified with the resident's medication regimen, which may need physician involvement to address.
When an employee of the CBRF administers a resident's medication, the CBRF shall provide a list of the resident's current medications to all practitioners. If this information is not provided before a prescription is written, the CBRF shall update the resident's primary practitioner or pharmacist before the administration of any new medication.
When a resident self administers medications, the CBRF shall provide a list of the resident's current medications for the resident to provide to all practitioners.
When a resident is discharged, the resident's medications shall be sent with the resident.
If a resident's medication has been changed or discontinued, the CBRF may retain a resident's medication for no more than 30 days unless an order by a physician or a request by a pharmacist is written every 30 days to retain the medication.
The CBRF shall develop and implement a policy for disposing unused, discontinued, outdated, or recalled medications in compliance with federal, state and local standards or laws. The CBRF shall arrange for the stored medications to be destroyed in compliance with standard practices. Medications that cannot be returned to the pharmacy shall be separated from other medication in current use in the facility and stored in a locked area, with access limited to the administrator or designee. The administrator or designee and one other employee shall witness, sign, and date the record of destruction. The record shall include the medication name, strength and amount.
Scheduled psychotropic medications.
When a psychotropic medication is prescribed for a resident, the CBRF shall do all of the following:
Ensure the resident is reassessed by a pharmacist, practitioner or registered nurse, as needed, but at least quarterly for the desired responses and possible side effects of the medication. The results of the assessments shall be documented in the resident's record as required under s. DHS 83.42 (1) (q)
Ensure all resident care staff understands the potential benefits and side effects of the medication.
As needed (PRN) psychotropic medication.
When a psychotropic medication is prescribed on an as needed basis for a resident, the CBRF shall do all of the following:
The resident's individual service plan shall include the rationale for use and a detailed description of the behaviors which indicate the need for administration of PRN psychotropic medication.
The administrator or qualified designee shall monitor at least monthly for the inappropriate use of PRN psychotropic medication, including but not limited to, use contrary to the individual service plan, presence of significant adverse side effects, use for discipline or staff convenience, or contrary to the intended use.
Documentation in the resident's record shall include the rationale for use, description of behaviors requiring the PRN psychotropic medication, the effectiveness of the medication, the presence of any side effects, and monitoring for inappropriate use for each PRN psychotropic medication given.
The CBRF shall maintain a proof-of-use record for schedule II drugs, subject to 21 USC 812
(c), and Wisconsin's uniform controlled substances act, ch. 961, Stats.
, that contains the date and time administered, the resident's name, the practitioner's name, dose, signature of the person administering the dose, and the remaining balance of the drug. The administrator or designee shall audit, sign and date the proof-of-use records on a daily basis.
The CBRF shall document in the resident's record any error in the administration of prescription or over-the-counter medication, known adverse drug reaction or resident refusal to take medication.
The CBRF shall report all errors in the administration of medication and any adverse drug reactions to a licensed practitioner, supervising nurse or pharmacist immediately. Unless otherwise directed by the prescribing practitioner, the CBRF shall report to the prescribing practitioner, supervising nurse or pharmacist as soon as possible after the resident refuses a medication for 2 consecutive days.
The CBRF shall make available written information to resident care staff on the purpose and side effects of medications taken by residents.
The resident shall self-administer prescribed and over-the-counter medications and dietary supplements, unless the resident has been found incompetent under ch. 54, Stats.
, or does not have the physical or mental capacity to self-administer as determined by the resident's physician, or the resident requests in writing that CBRF employees manage and administer medication.
Except as specified under sub. (4)
, when a resident self-administers medications, prescribed and over-the-counter medications and dietary supplements shall remain under the control of the resident. The CBRF shall provide a secure place for the storage of medications in the resident's room.
A resident with the mental and physical capacity to develop increased independence in medication administration shall receive self-administration instruction.
Medication administration supervised by a registered nurse, practitioner or pharmacist.
When medication administration is supervised by a registered nurse, practitioner or pharmacist, the CBRF shall ensure all of the following:
The registered nurse, practitioner or pharmacist coordinates, directs and inspects the administration of medications and the medication administration system.
The registered nurse, practitioner or pharmacist participates in the resident's assessment under s. DHS 83.35 (1)
and development and review of the individual service plan under s. DHS 83.35 (3)
regarding the resident's medical condition and the goals of the medication regimen.
Medication administration not supervised by a registered nurse, practitioner or pharmacist.
When medication administration is not supervised by a registered nurse, practitioner or pharmacist, the CBRF shall arrange for a pharmacist to package and label a resident's prescription medications in unit dose. Medications available over-the-counter may be excluded from unit dose packaging requirements, unless the physician specifies unit dose.
Documentation of medication administration.
As required under s. DHS 83.42 (1) (o)
, at the time of medication administration, the person administering the medication or treatment shall document in the resident record the name, dosage, date and time of medication taken or treatments performed and initial the medication administration record. Any side effects observed by the employee or symptoms reported by the resident shall be documented. The need for any PRN medication and the resident's response shall be documented.
Injectables, nebulizers, stomal and enteral medications, and medications, treatments or preparations delivered vaginally or rectally shall be administered by a registered nurse or by a licensed practical nurse within the scope of their license. Medication administration described under sub. (2) (e)
may be delegated to non-licensed employees pursuant to s. N 6.03 (3)
The CBRF shall keep medications in the original containers and not transfer medications to another container, unless the CBRF complies with all of the following:
Transfer of medications from the original container to another container shall be done by a practitioner, registered nurse, or pharmacist. Transfer of medication to another container may be delegated to other personnel by a practitioner, registered nurse or pharmacist.
If a medication is administered by CBRF employees and the medication is transferred from the original container by a registered nurse, or practitioner or other personnel who were delegated the task, the CBRF shall have a legible label on the new container that includes, at a minimum, the resident's name, medication name, dose and instructions for use. The CBRF shall maintain the original pharmacy container until the transferred medication is gone.
Unit dose packaging.
For use during unplanned or non-routine events or activities, employees who have completed medication administration training as required in s. DHS 83.20 (2) (d)
may transfer unit doses of medications into packages for the resident.
Administered by facility.
The CBRF shall keep medicine cabinets locked and the key available only to personnel identified by the CBRF.