Chapter DHS 131

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:

DHS 131.39(6)(a)1. 1. The kitchen.

DHS 131.39(6)(a)2. 2. Any attached garage.

DHS 131.39(6)(b) (b) Smoke and heat detectors installed under this section shall be listed by a nationally recognized testing laboratory.

DHS 131.39(7) (7) Attached garages.

DHS 131.39(7)(a) (a) Common walls between a hospice facility and an attached garage shall be protected with not less than one layer of 5/8-inch Type X gypsum board with taped joints, or equivalent, on the garage side and with not less than one layer of 1/2-inch gypsum board with taped joints, or equivalent, on the hospice side. The walls shall provide a complete separation.

DHS 131.39(7)(b) (b) Floor-ceiling assemblies between garages and the hospice facility shall be protected with not less than one layer of 5/8-inch type X gypsum board on the garage side of the ceiling or room framing.

DHS 131.39(7)(c) (c) Openings between an attached garage and a hospice facility shall be protected by a self-closing 1-3/4 inch solid wood core door or an equivalent self-closing fire-resistive rated door.

DHS 131.39(7)(d) (d) The garage floor shall be pitched away from the hospice facility and at its highest point shall be at least 1-1/2 inches below the floor of the facility.

DHS 131.39(7)(e) (e) If a required exit leads into the garage, the garage shall have at least a 32 inch wide service door.

DHS 131.39(8) (8) Fire report. All incidents of fire in a hospice shall be reported to the department within 72 hours.

DHS 131.39 Note Note: Online fire reporting is available at: Health Care Facility Report F-62500 at: https://www.dhs.wisconsin.gov/publications/p01729.pdf.

DHS 131.39 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: r. and recr. (1), r. (4), am. (5) (c) 1., r. (5) (c) 2., am. (6) (a) (intro.), (b), cr. (8) Register July 2020 No. 775, eff. 8-1-20; renum. (5) (c) 1. to (5) (c) under s. 13.92 (4) (b) 1., Stats., and correction in (5) (c) made under s. 35.17, Stats., Register July 2020 No. 775.

DHS 131.40 DHS 131.40 Plans for new construction and alterations.

DHS 131.40(1) (1) Definition. In this section, “alteration” has the meaning provided in s. SPS 361.05 (1) International Building Code, Sec. 202.

DHS 131.40(2) (2) Signing and sealing. Construction documents submitted to the department for review shall be prepared, signed and sealed as required by ch. 443, Stats., and s. A-E 2.02.

DHS 131.40(3) (3) Contents and information.

DHS 131.40(3)(a) (a)

DHS 131.40(3)(a)1. 1. Construction documents submitted to the department for review shall be dimensioned and drawn to scale.

DHS 131.40(3)(a)2. 2. The scale used for the construction documents shall be indicated on the documents.

DHS 131.40(3)(b) (b)

DHS 131.40(3)(b)1. 1. Except as provided in subd. 2., at least 4 sets of construction documents shall be submitted to the department for review.

DHS 131.40(3)(b)2. 2.

DHS 131.40(3)(b)2.a. a. At least one set of construction specifications shall be submitted to the department for review.

DHS 131.40(3)(b)2.b. b. One complete set of plans may be submitted, provided it is accompanied with 3 copies of the cover sheet for the complete set, and provided all 4 cover sheets comply with sub. (2).

DHS 131.40(3)(c) (c) Fees shall be remitted at the time the plans are submitted. No plan examinations, approvals, or onsite reviews shall be made until fees are received.

DHS 131.40(4) (4) Application approval.

DHS 131.40(4)(a) (a) A plan review application form shall be included with the construction documents and information submitted to the department for examination and approval. The department shall review and make a determination on an application for plan review under this chapter within 30 business days.

DHS 131.40(4)(b) (b) An application for conditional approval will not be granted if, upon examination, the department determines that the construction documents or application for approval require additional information.

DHS 131.40(4)(c) (c) If, upon examination, the department determines that the construction documents and the application for approval comply substantially with this chapter, a conditional approval, in writing, shall be granted and the plans shall be stamped conditionally approved. All conditions stated in the conditional approval shall be complied with by the applicant before or during construction.

DHS 131.40(4)(d) (d) If, upon examination, the department determines that the construction documents or application for approval do not substantially comply with this chapter, the application for conditional approval shall be denied, in writing.

DHS 131.40(5) (5) Expiration of approval.

DHS 131.40(5)(a) (a) Building shell. Plan approval by the department for new buildings and building additions shall expire 2 years after the approval date indicated on the approved building plans if the building shell is not closed-in within those 2 years.

DHS 131.40(5)(b) (b) Occupancy. Plan approval by the department for new buildings and building additions shall expire 3 years after the approval date indicated on the approved building plans if the building is not ready for occupancy within those 3 years.

DHS 131.40(5)(c) (c) Alterations. Plan approval by the department for interior building alterations shall expire one year after the approval date indicated on the approved building plans if the alteration work is not completed within that year.

DHS 131.40(5)(d) (d) HVAC construction only. Plan approval by the department for heating, ventilating, or air conditioning construction that does not include any associated building construction shall expire one year after the approval date indicated on the approved plans if the building or building area affected by the plans is not ready for occupancy within that year.

DHS 131.40(5)(e) (e) Fire protection systems only. Plan approval by the department for a fire protection system that does not include any associated building construction shall expire 2 years after the approval date indicated on the approved plans if the building or building area affected by the plans is not ready for occupancy within those 2 years.

DHS 131.40(6) (6) Extension of plan approval. Upon request and payment of the fee specified in s. DHS 131.42 (3) (d), the expiration dates in sub. (5) (a) to (e) may be extended provided the request is submitted prior to expiration of the original approval.

DHS 131.40(7) (7) Changes to approved final plans. Any changes in the approved final plans affecting the application of the requirements of this subchapter shall be shown on the approved final plans and shall be submitted to the department for approval before construction is undertaken. The department shall notify the hospice in writing of any conflict with this subchapter found in its review of modified plans and specifications.

DHS 131.40(8) (8) Permission to start construction.

DHS 131.40(8)(a) (a) A building owner may request and the department may grant permission to start construction for the footings and foundations upon submission of construction documents under s. DHS 131.40 (3).

DHS 131.40(8)(b) (b) The department shall review and make a determination on an application for permission to start construction of the footings and foundations within 3 business days of receipt of the application and all forms, fees under s. DHS 131.42 (3) (b), construction documents and information required to complete the review.

DHS 131.40(8)(c) (c) A building owner who has been granted permission to start construction of the footings and foundations may proceed at the owner’s own risk without assurance that a conditional approval for the building will be granted.

DHS 131.40(9) (9) Onsite reviews. The department may conduct onsite reviews during the construction phase of the project including framing reviews, above ceiling reviews, and finish reviews.

DHS 131.40 History History: CR 19-092: cr. Register July 2020 No. 775, eff. 8-1-20.

DHS 131.41 DHS 131.41 Plan review.

DHS 131.41(1) (1) Before the start of any construction or alteration project for a hospice, the plans for the construction or alteration shall be submitted to the department, pursuant to s. DHS 131.40, for review and approval by the department.

DHS 131.41(2) (2) The department shall review hospice construction and alteration plans for compliance with all of the following: