Wisconsin Legislature: DHS 88.07(2)(d)

(a) The licensee shall ensure that a written assessment and individual service plan are completed and developed for each resident within 30 days after placement.

(b) The individual service plan and written assessment shall be developed by the placing agency, if any, the service coordinator, if any, the licensee, the resident and the resident’s guardian, if any, and designated representative, if any, with the resident participating in a manner appropriate for the resident’s level of understanding and method of communication.

(c) The assessment shall identify the person’s needs and abilities in at least the areas of activities of daily living, medications, health, level of supervision required in the home and community, vocational, recreational, social and transportation.

(d) The individual service plan shall contain at least the following:

1. A description of the services the licensee will provide to meet assessed need.

2. Identification of the level of supervision required in the home and community.

3. Descriptions of services provided by outside agencies.

4. Identification of who will monitor the plan.

5. A statement of agreement with the plan, dated and signed by all persons involved in developing the plan.

(e) A copy of the individual service plan shall be provided to all persons involved in the development of it.

(f) The individual service plan shall be reviewed at least once every 6 months by the licensee, the resident or the resident’s guardian, the service coordinator, if any, the designated representative, if any, and, if applicable, the placing agency with the resident participating in a manner appropriate for the resident’s level of understanding and method of communication. This review is to determine continued appropriateness of the plan and to update the plan as necessary. A plan shall be updated, in writing, whenever the resident’s needs or preferences change substantially or when requested by the resident or the resident’s guardian.

History: Cr. Register, January, 1996, No. 482, eff. 2-1-96; cr. (1) (a) 4. and (4), Register, October, 2000, No. 538, eff. 11-1-00; reprinted to restore dropped copy in (1) Register December 2003 No. 576; corrections in (1) (a) 4. and (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 10-091: r. (1) (a) 4. Register December 2010 No. 660, eff. 1-1-11; CR 10-145: r. (4) Register May 2011 No. 665, eff. 6-1-11.

DHS 88.07 Resident care.

(1) General requirements.

(a) The licensee shall provide a safe, emotionally stable, homelike and humane environment for residents.

(b) The licensee shall encourage a resident’s autonomy, respect a resident’s need for physical and emotional privacy and take a resident’s preferences, choices and status as an adult into consideration while providing care, supervision and training.

(c) The licensee shall plan activities and services with the residents to accommodate individual resident needs and preferences and shall provide opportunities for each resident to participate in cultural, religious, political, social and intellectual activities within the home and community. A resident may not be compelled to participate in these activities.

(d) The licensee shall allow a resident to participate in all activities that the resident selects unless contrary to the resident’s individualized service plan or the home’s program statement.

(e) The licensee shall arrange for a service provider to be present in the home when the licensee is gone overnight or when the licensee’s absence prevents the resident from receiving the services, training or supervision specified in the resident’s individual service plan under s. DHS 88.06 (3).

(2) Services.

(a) The licensee shall provide or arrange for the provision of individualized services specified in a resident’s individual service plan that are the licensee’s responsibility.

(b) Services shall be directed to the goal of assisting, teaching and supporting the resident to promote his or her health, well-being, self-esteem, independence and quality of life. The services shall include but are not limited to:

1. Supervising or assisting a resident with or teaching a resident about activities of daily living.

2. Providing, arranging, transporting or accompanying a resident to leisure and recreational activities, employment and other activities identified in the resident’s individual service plan.

3. Providing, arranging, transporting or accompanying a resident to medical or other appointments as part of the resident’s individual service plan.

4. Keeping a current record of all medical visits, reports and recommendations for a resident.

5. Monitoring resident health by observing and documenting changes in each resident’s health and referring a resident to health care providers when necessary.

6. Notifying the placing agency, if any, and guardian, if any, of any significant changes in a resident’s medical condition, including any life-threatening, disabling or serious illness, any illness lasting more than 3 days, an injury sustained by the resident, medical treatment needed by the resident or the resident’s absence from the home for more than 24 hours.

(c) Services that are provided shall be services determined by the resident, licensee, service coordinator, if any, placing agency, if any, and guardian, if any, to be needed by the resident and within the capability of the licensee to provide.

(d) A licensee may arrange for or, if qualified, personally provide nursing care to residents. No more than 7 hours of nursing care per week may be provided to a resident.

(e) The licensee shall ensure that each resident has an annual health examination by a physician.

(3) Prescription medications.

(a) Every prescription medication shall be securely stored, shall remain in its original container as received from the pharmacy and be stored as specified by the pharmacist.

(b) A resident has the right to refuse prescription medication unless there is a court order requiring the resident to take the medication. When the resident under court order does not take the medication, the licensee shall notify the court and the responsible physician.

(c) If the licensee or service provider assists a resident with a prescription medication, the licensee or service provider shall help the resident securely store the medication, take the correct dosage at the correct time and communicate effectively with his or her physician.

(d) Before a licensee or service provider dispenses or administers a prescription medication to a resident, the licensee shall obtain a written order from the physician who prescribed the medication specifying who by name or position is permitted to administer the medication, under what circumstances and in what dosage the medication is to be administered. The licensee shall keep the written order in the resident’s file.

(e)

1. The licensee shall keep a record of all prescription medications controlled, dispensed or administered by the licensee which show the name of the resident, the name of the particular medication, the date and time the resident took the medication and errors and omissions. The medication controlled by licensee shall be kept in a locked place.

2. The record shall also contain information describing potential side effects and adverse reactions caused by each prescription medication.

(4) Nutrition.

(a) A licensee shall provide each resident with a quantity and variety of foods sufficient to meet the resident’s nutritional needs and preferences and to maintain the resident’s health.

(b) The licensee shall provide to each resident or ensure that each resident receives 3 nutritious meals each day and snacks that are typical in a family setting.

(d) Residents shall be routinely served their meals in common dining areas with other household members.

(e) Meals prepared by the licensee shall take into account special physical and religious dietary needs of the residents. A special diet shall be served to a resident if prescribed by the resident’s physician.

History: Cr. Register, January, 1996, No. 482, eff. 2-1-96.

DHS 88.08 Termination of placement. A licensee may terminate a resident’s placement only after giving the resident, the resident’s guardian, if any, the resident’s service coordinator, the placing agency, if any, and the designated representative, if any, 30 days written notice. The termination of a placement shall be consistent with the service agreement under s. DHS 88.06 (2) (c) 7. The 30 day notice is not required for an emergency termination necessary to prevent harm to the resident or other household members.

History: Cr. Register, January, 1996, No. 482, eff. 2-1-96.

DHS 88.09 Records.

(1) Resident records.

(a) The licensee shall maintain a record for each resident. Resident records shall be maintained in a secure location within the home to prevent unauthorized access.

(b) The records of residents shall be confidential. Access to records of a resident’s HIV test results shall be controlled by s. 252.15, Stats. Access to other resident records shall be restricted to the following: the resident, the resident’s guardian, authorized representatives of the department, other persons or agencies with the informed written consent of the resident or resident’s guardian, if applicable, persons or agencies authorized by s. 51.30, Stats., ss. 146.81 to 146.83, Stats., or 42 CFR Part 2, and persons or agencies authorized by other applicable law.

Note: Section 51.30 (4) (b) 5. and 15., Stats., permits sharing of limited information in certain circumstances between the department and a county department established under s. 46.215, 46.22, 46.23, 51.42 or 51.437, Stats.

Note: For information on 42 CFR Part 2 which relates to a resident who is in the home because of alcohol or other drug abuse, write or phone the appropriate regional office of the department’s division of disability and elder services which will refer you to the appropriate county agency in your county. See Appendix A for the addresses and phone numbers of these offices.

Note: The records of residents with mental disabilities are subject to requirements of s. 51.30, Stats., and ch. DHS 92.

(c) Copies of a resident’s record shall be made available on request to the resident, the resident’s guardian or a designated representative of the resident as soon as reasonably practicable if authorized in writing by the resident, at a cost no greater than the cost of reproduction.

(d) A resident’s record shall include all of the following:

1. The resident’s name and date of birth.

2. The name, address, and phone number of the resident’s legal guardian, if any.

3. The name, address and phone number of every person, including the resident’s physician, to be notified in the event of an emergency.

4. The name, address and phone number of the placing agency, if any, and service coordinator, if any.

5. Medical insurance or medical assistance and medicare identification numbers and the name of the pharmacy that the resident uses. In this subdivision, “medical assistance” means the assistance program operated by the department under ss. 49.43 to 49.497, Stats., and “medicare” means the insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395.22 and 42 CFR, Pts. 405 to 421.

6. The service agreement required under s. DHS 88.06 (2) (b) and (c).

7. The report of the medical examination required under s. DHS 88.06 (2) (a).

8. The individual service plan required under s. DHS 88.06 (3).

9. The statement indicating that resident rights and grievance procedures have been explained and copies have been provided to the parties as required under s. DHS 88.06 (2) (c) 8.

10. Medication records under s. DHS 88.07 (3) (d) and (e).

11. Records maintained by the licensee of the resident’s finances, including written authorization from the resident or the resident’s guardian to control the resident’s funds.

(e) The licensee shall retain a resident’s record for at least 7 years after the resident’s discharge. The record shall be kept in a secure, dry place.

(2) Service provider and licensee records.

(a) Service provider record. The licensee shall maintain and keep up to date a separate personnel record for each service provider. The licensee shall ensure that all service provider records are adequately safeguarded against destruction, loss or unauthorized use. A service provider record shall include all of the following:

1. Name and address.

2. Social security number.

3. Date of birth.

4. Beginning date of employment.

5. Job-related experience and training.

6. Educational qualifications.

7. Job description.

8. Documentation of successful completion of the training requirements under s. DHS 88.04 (5).

9. The results of screening for communicable disease.

10. Description of any disciplinary action.

11. Date of discharge or resignation.

(b) Licensee record. The licensee shall maintain and keep up to date a separate record for the licensee which shall contain the information listed in par. (a) 1., 2., 3., 5., 6., 8. and 9.

(c) Location and retention period. Service provider and licensee records shall be available at the adult family home for review by the licensing agency. A service provider’s record shall be available while the service provider is employed by the home and for at least 3 years after ending employment.

History: Cr. Register, January, 1996, No. 482, eff. 2-1-96.

DHS 88.10 Resident rights.

(1) Legal rights. A licensee shall comply with all applicable statutes and rules relating to resident rights, including s. 51.61, Stats., chs. 54, 55, and 304, Stats., and chs. DHS 92 and 94.

Note: These laws may clarify or condition a particular resident’s right, depending on the legal status of the resident or a service being received by the resident.

(2) Explanation of resident rights. The licensee shall explain and provide copies of the resident rights under sub. (3) and the grievance procedure under sub. (5) to the person being admitted, that person’s guardian, family members involved in the placement and any designated representative of the person before the service agreement is signed.