Chapter DHS 131

DHS 131.37(8)(a) (a) Every hospice facility shall be supplied with electrical service and shall have wiring, outlets and fixtures properly installed and maintained in good and safe working condition.

DHS 131.37(8)(b) (b) Extension cords shall not be used in lieu of permanent wiring.

DHS 131.37(8)(c) (c) Exposed wiring is prohibited.

DHS 131.37(8)(f) (f) There shall be a switch or equivalent device for turning on at least one light in each room or passageway. The switch or equivalent device shall be located so as to conveniently control the lighting in the area.

DHS 131.37(8)(g) (g) All electrical cords and appliances shall be maintained in a safe condition. Frayed wires and cracked or damaged switches, plugs and electric fixtures shall be repaired or replaced.

DHS 131.37(9) (9) Patient call system. A reliable call mechanism shall be provided in every location where patients may be left unattended, including patient rooms, toilet and bathing areas and designated high risk treatment areas from which individuals may need to summon assistance.

DHS 131.37(10) (10) Bedding and laundry. There shall be separate clean linen and dirty linen storage areas.

DHS 131.37(10)(b) (b) Each patient shall have available all of the following:

DHS 131.37(10)(b)1. 1. Sufficient blankets to keep warm.

DHS 131.37(10)(b)2. 2. A pillow.

DHS 131.37(10)(b)3. 3. Mattress and pillow covers as necessary to keep mattresses and pillows clean and dry.

DHS 131.37 Note Note: When plastic mattress covers are used, there shall be a mattress pad the same size as the mattress over the plastic mattress cover.

DHS 131.37(10)(c) (c) Clean sheets, pillowcases, towels and washcloths shall be available at least weekly and shall be changed as necessary to ensure that at all times they are clean and free from odors.

DHS 131.37(11) (11) Dayroom or lounge. At least one dayroom or lounge, centrally located, shall be provided for use of the patients.

DHS 131.37(12) (12) Size of dining room. Dining rooms shall be of sufficient size to seat all patients at no more than 2 shifts. Dining tables and chairs shall be provided. Television trays or portable card tables may not be used as the primary dining tables.

DHS 131.37(13) (13) Kitchen. The kitchen shall be located on the premises, or a satisfactory sanitary method of transportation of food shall be provided. If there is a kitchen on the premises, it shall meet food service needs and be arranged and equipped for proper refrigeration, heating, storage, preparation and serving of food. Adequate space shall be provided for proper refuse handling and washing of waste receptacles, and for storage of cleaning compounds.

DHS 131.37(14) (14) Multipurpose room. If a multipurpose room is used for dining, diversional and social activities of patients, there shall be sufficient space to accommodate all activities and minimize their interference with each other.

DHS 131.37(15) (15) Total area.

DHS 131.37(15)(a) (a) In existing facilities, the combined floor space of dining, recreation, and activity areas shall not be less than 15 square feet per bed. Solaria and lobby sitting space may be included, but shall not include required exit paths. A required exit path in these areas shall be at least 4 feet wide.

DHS 131.37(15)(b) (b) In new construction, the combined floor space of dining, recreation, and activity areas shall not be less than 25 square feet per bed. Solaria and lobby areas, exclusive of traffic areas, shall be categorized as living room space.

DHS 131.37(15)(c) (c) All required dining and living areas within the building shall be internally accessible to every patient of the hospice.

DHS 131.37(15)(d) (d) Each habitable room shall contain furnishings appropriate to the intended use of the room. Furnishings shall be safe for use by patients, and shall be comfortable, clean and maintained in good repair.

DHS 131.37(15)(e) (e) Adequate space and equipment shall be designated to meet the needs of the patients and family members for privacy and social activities.

DHS 131.37(16) (16) Heating.

DHS 131.37(16)(a) (a) The facility shall have a heating system capable of maintaining a temperature of 72º F. (20º C.) during periods of occupancy. Temperatures during sleeping hours may be reduced to 68º F. (18º C.). Higher or lower temperatures shall be available upon request.

DHS 131.37(16)(b) (b) The heating system shall be maintained in a safe and properly functioning condition.

DHS 131.37(16)(c) (c) The use of portable space heaters is prohibited.

DHS 131.37(17) (17) Bath and toilet facilities.

DHS 131.37(17)(a) (a) Each hospice shall have at least one separate bath and one separate toilet room or one combination bath and toilet room for the use of patients which is accessible from public, non-sleeping areas, except where private bath and toilet rooms are adjacent to each sleeping room.

DHS 131.37(17)(b) (b) Each floor in which patient sleeping, dining and living rooms are located shall have bath and toilet facilities or one combination bath and toilet room for use of patients which is accessible from public, non-sleeping areas, except where private bath and toilet rooms are adjacent to each bedroom.

DHS 131.37(17)(c) (c) All bath and toilet areas shall be well lighted.

DHS 131.37(17)(d) (d) Toilets, bathtubs and showers used by residents shall provide for individual privacy. If door locks are used for privacy they shall be operable from both sides in an emergency.

DHS 131.37(17)(e) (e) All toilet and bathing areas, facilities and fixtures shall be kept clean, in good repair and in good working order.

DHS 131.37(18) (18) Water supply.

DHS 131.37(18)(a) (a) Each sink, bathtub and shower shall be connected to hot and cold water, and adequate hot water shall be supplied to meet the needs of the patients.

DHS 131.37(18)(b) (b) Hot water from taps accessible to patients shall not exceed 115° F.

DHS 131.37(18)(c) (c) Where a public water supply is not available, the well or wells shall be approved by the Wisconsin department of natural resources. Water samples from an approved well shall be tested at least annually at the state laboratory of hygiene or another laboratory approved under 42 CFR 493 (CLIA).

DHS 131.37(18)(d) (d) The hospice shall make provision for obtaining emergency fuel and water supplies.

DHS 131.37(20) (20) Facility maintenance.

DHS 131.37(20)(a) (a) The building shall be maintained in good repair and free of hazards such as cracks in floors, walls or ceilings, warped or loose boards, warped, broken, loose or cracked floor covering such as tile or linoleum, loose handrails or railings, and loose or broken window panes.

DHS 131.37(20)(b) (b) All electrical, mechanical, water supply, fire protection and sewage disposal systems shall be maintained in a safe and functioning condition.

DHS 131.37(20)(c) (c) All plumbing fixtures shall be in good repair, properly functioning and satisfactorily provided with protection to prevent contamination from entering the water supply piping.

DHS 131.37(20)(d) (d) Rooms shall be kept clean, well ventilated and tidy.

DHS 131.37(20)(e) (e) All furniture and furnishings shall be kept clean and maintained in good repair.

DHS 131.37(20)(f) (f) Storage areas shall be maintained in a safe, dry and orderly condition. Attics and basements shall be free of accumulation of garbage, refuse, soiled laundry, discarded furniture, old newspapers, boxes, discarded equipment and similar items.

DHS 131.37(20)(g) (g) Abrasive strips or nonskid surfaces to reduce or prevent slipping shall be used where slippery surfaces present a hazard.

DHS 131.37(20)(h) (h) The grounds, yards, and sidewalks shall be maintained in a neat, orderly and safe condition.

DHS 131.37(21) (21) Floors and stairs. Floors and stairs shall be maintained in a nonhazardous condition.

DHS 131.37(22) (22) Exits. Sidewalks, doorways, stairways, fire escapes and driveways used for exiting shall be kept free of ice, snow and obstructions.

DHS 131.37(23) (23) Door locks. The employee in charge of the facility on each work shift shall have a key or other means of opening all locks or closing devices on all doors in the facility.

DHS 131.37(24) (24) Emergency plan.

DHS 131.37(24)(a) (a) Each hospice shall have a written plan posted in a conspicuous place which specifies procedures for the orderly evacuation of patients in case of an emergency. The plan shall include an evacuation diagram. The evacuation diagram shall in addition be posted in a conspicuous place in the facility.

DHS 131.37(24)(b) (b) The licensee, administrator and all staff who work in the hospice facility shall be trained in all aspects of the emergency plan.

DHS 131.37(24)(c) (c) The procedures for exiting or taking shelter in the event of a fire, tornado, flooding or other disaster to be followed for patient safety shall be clearly communicated by the staff to the patients within 72 hours after admission and practiced at least quarterly by staff.

DHS 131.37 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register September 2010 No. 657; corrections in (4) (a) and (b), (19) (a) to (c) made under s. 13.92 (4) (b) 7., Stats., Register January 2012 No. 673; CR 19-092: r. (2) to (4), am. (5) (a), r. and recr. (5) (a), am. (5) (b) 1., r. (5) (c) 1., am. (5) (d), (e) 3., r. (6), am. (7) (a), (c), r. and recr. (8) (b), (c), r. (8) (d), (e), am. (16) (c), (17) (a) 3., r. (17) (b), am. (18) (b), r. (19), (25) Register July 2020 No. 775, eff. 8-1-20; change in numbering in (17) made under s. 13.92 (4) (b) 1., Stats., Register July 2020.

DHS 131.38 DHS 131.38 Fire protection.

DHS 131.38(1) (1) Basic responsibility. The hospice shall provide fire protection adequate to ensure the safety of patients, staff and others on the hospice’s premises. Necessary safeguards such as extinguishers, sprinkling and detection devices, fire and smoke barriers and ventilation control barriers shall be installed to ensure rapid and effective fire and smoke control.

DHS 131.38(2) (2) Life safety code. Facilities shall meet the applicable provisions of the 2012 edition of the Life Safety Code (LSC).

DHS 131.38 Note Note: Copies of the 2012 Life Safety Code and related codes are on file in the Department’s Division of Quality Assurance and the Legislative Reference Bureau, and may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169.

DHS 131.38(3) (3) Fire safety evaluation system. An existing facility that does not meet all requirements of the applicable Life Safety Code may be considered in compliance with it if the facility achieves a passing score on the Fire Safety Evaluation System (FSES) developed by the U.S. department of commerce, national bureau of standards, to establish safety equivalencies under the Life Safety Code.

DHS 131.38 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 16-087: am. (2) Register September 2017 No. 741, eff. 10-1-17; CR 19-092: renum. (1) to (intro.) Register July 2020 No. 775, eff. 8-1-20; renum. (intro.) to (1) under s. 13.92 (4) (b) 1., Stats., and create (3) (title) under s. 13.92 (4) (b) 2., Stats., Register July 2020 No. 775.

DHS 131.39 DHS 131.39 Fire safety.

DHS 131.39(1) (1) Fire inspection. The licensee of the hospice shall do all of the following:

DHS 131.39(1)(a) (a) The hospice shall obtain an annual inspection of the facility by the local fire authority or certified fire inspector and shall retain fire inspection reports for 2 years.

DHS 131.39(1)(b) (b) The hospice shall provide to the emergency preparedness authority a copy of the facility written plan of orderly evacuation of patients in the event of fire.

DHS 131.39(2) (2) Smoking.

DHS 131.39(2)(a) (a) A written policy on smoking, consistent with the provisions in the Wisconsin Clean Indoor Air Act, s. 101.123, Stats., shall be developed by the licensee of the facility which shall designate areas outside the building where smoking is permitted, if any, and shall be clearly communicated by the staff to a patient within 24 hours after the patient’s admission.

DHS 131.39(3) (3) Fire extinguisher.

DHS 131.39(3)(a) (a) At least one fire extinguisher with a minimum 2A, 10-B-C rating shall be provided on each floor of the facility. A fire extinguisher shall be located at the head of each stairway. In addition, an extinguisher shall be located so that the maximum area per extinguisher does not exceed 3000 square feet and travel distance to an extinguisher does not exceed 75 feet. The extinguisher on the kitchen floor level shall be mounted in or near the kitchen.

DHS 131.39(3)(b) (b) All fire extinguishers shall be maintained in readily useable condition and inspected annually. One year after the initial purchase of a fire extinguisher and annually after that the extinguisher shall be provided with a tag which indicates the date of the most recent inspection.

DHS 131.39(3)(c) (c) An extinguisher shall be mounted on a wall or a post where it is clearly visible, unobstructed and mounted so that the top is not over 5 feet high. An extinguisher may not be tied down, locked in a cabinet or placed in a closet or on the floor except that it may be placed in a clearly marked, unlocked wall cabinet used exclusively for that purpose.

DHS 131.39(5) (5) Fire protection systems.

DHS 131.39(5)(a) (a) Location. No facility may install a smoke detection system that is not approved by the department.

DHS 131.39(5)(b) (b) Smoke detection systems. Each facility shall have, at a minimum, a low-voltage interconnected smoke detection system to protect the entire facility so that if any detector is activated it triggers an alarm audible throughout the building.

DHS 131.39(5)(c) (c) Installation, testing and maintenance. Smoke detectors shall be installed, tested and maintained in accordance with NFPA 72-2013 edition. Smoke alarm detectors powered by the hospice electrical system shall be tested according to the manufacturer’s recommendation but not less than once a month. The hospice shall maintain a written record of tests for the previous 2 years.

DHS 131.39 Note Note: Copies of the NFPA 72 National Fire Alarm and Signaling Code, 2013 edition are on file in the Department’s Division of Quality Assurance and the Legislative Reference Bureau and can be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169.

DHS 131.39(5)(d) (d) Location of detectors.

DHS 131.39(5)(d)1. 1. At least one smoke detector shall be located at each of the following locations:

DHS 131.39(5)(d)1.a. a. At the head of every open stairway.

DHS 131.39(5)(d)1.b. b. On the stair side of every enclosed stairway on each floor level.

DHS 131.39(5)(d)1.c. c. In every corridor, spaced not more than 30 feet apart and not further than 15 feet from any wall.

DHS 131.39(5)(d)1.d. d. In each common use room, including living rooms, dining rooms, family rooms, lounges and recreation rooms but not including kitchens, bathrooms or laundry rooms.

DHS 131.39(5)(d)1.e. e. In each sleeping room in which smoking is allowed.

DHS 131.39(5)(d)1.f. f. In each room of the staff living quarters, including the staff office but not including kitchens and bathrooms.

DHS 131.39(5)(d)1.g. g. In the basement or in each room in the basement except a furnace room or laundry room.

DHS 131.39(5)(d)1.h. h. In rooms which are differentiated by one or more ceiling drops which exceed 12 inches in height.

DHS 131.39(5)(d)2. 2. Detectors in rooms shall be mounted no more than 30 feet apart and no more than 15 feet from the closest wall unless the manufacturer specifies a greater or lesser distance for effective placement. Large rooms may require more than one smoke detector in order for the detection system to provide adequate protection.

DHS 131.39(6) (6) Heat detection.

DHS 131.39(6)(a) (a) Hospice facilities shall install at least one heat detector integrated with the smoke detection system at each of the following locations: