Chapter DHS 134

DHS 134.60(2)(d)2.b. b. For each residential living unit which has one or more residents with a classification of DD level II, the facility shall provide a direct care staff-to-resident ratio of 1 to 4 each day, with ratios of one direct care staff person on duty to 8 residents on the day shift, one direct care staff person on duty to 16 residents on the evening shift and one direct care staff person on duty to 16 residents on the night shift.

DHS 134.60(2)(d)2.c. c. For each residential living unit which has one or more residents with a classification of DD level III, the facility shall provide a direct care staff-to-resident ratio of 1 to 6.4 each day, with ratios of one direct care staff person on duty to 16 residents on the day shift, one direct care staff person on duty to 16 residents on the evening shift and one direct care staff person on duty to 32 residents on the night shift.

DHS 134.60(3) (3) Active treatment programming.

DHS 134.60(3)(a) (a) Except as provided in par. (b), each resident shall receive active treatment. Active treatment shall include:

DHS 134.60(3)(a)1. 1. The resident’s regular participation, in accordance with the IPP, in professionally developed and supervised activities, experiences and therapies. The resident’s participation shall be directed toward:

DHS 134.60(3)(a)1.a. a. The acquisition of developmental, behavioral and social skills necessary for the resident’s maximum possible individual independence; or

DHS 134.60(3)(a)1.b. b. For dependent residents where no further positive growth is demonstrable, the prevention of regression or loss of current optimal functional status; and

DHS 134.60(3)(a)2. 2. An individual post-institutionalization plan, as part of the IPP developed before discharge by a qualified intellectual disabilities professional and other appropriate professionals. This shall include provision for appropriate services, protective supervision and other follow-up services in the resident’s new environment.

DHS 134.60(3)(b) (b) Active treatment does not include the maintenance of generally independent residents who are able to function with little supervision or who require few, if any, of the significant active treatment services described in this subsection.

DHS 134.60(4) (4) Medications, treatments and therapies.

DHS 134.60(4)(a) (a) Orders.

DHS 134.60(4)(a)1. 1. Medications, treatments and habilitative or rehabilitative therapies shall be administered as ordered by a physician or dentist subject to the resident’s right to refuse them. If the resident has a court-appointed guardian, the guardian’s consent rather than the resident’s consent is required. No medication, treatment or changes in medication or treatment may be administered to a resident without a physician’s or dentist’s written order which shall be filed in the resident’s record.

DHS 134.60 Note Note: Section 51.61 (6), Stats., requires that written informed consent for treatment, including medications, be obtained from any person who was voluntarily admitted for treatment for developmental disabilities, mental illness, drug abuse or alcohol abuse. Section 42 CFR 442.404 (b) and (f) requires the written informed consent of every resident for treatment, including medications. This includes voluntary admissions as well as involuntary admissions under ch. 51 or 55, Stats.

DHS 134.60(4)(a)4. 4. Each resident’s medications shall be reviewed by a registered nurse at the time of the annual review of the IPP.

DHS 134.60(4)(b) (b) Stop orders.

DHS 134.60(4)(b)1. 1. Medications not specifically limited as to time or number of doses when ordered shall be automatically stopped in accordance with facility policies and procedures developed under s. DHS 134.67 (3) (a) 5.

DHS 134.60(4)(b)2. 2. The facility shall notify each resident’s attending physician or dentist of stop order policies and shall contact the physician or dentist promptly for renewal of orders that are subject to automatic termination.

DHS 134.60(4)(d) (d) Administration of medications.

DHS 134.60(4)(d)1. 1. Medications may be administered only by a nurse, a practitioner or a person who has completed training in a drug administration course approved by the department. Facility staff shall immediately record the administration of medications in the resident’s record.

DHS 134.60(4)(d)2. 2. Facilities shall develop policies and procedures designed to provide safe and accurate acquisition, receipt, dispensing and administration of medications and these policies and procedures shall be followed by personnel assigned to prepare and administer medications and to record their administration. Except when a single unit dose drug delivery system is used, the same person shall prepare and administer the resident’s medications.

DHS 134.60(4)(d)3. 3. If for any reason a medication is not administered as ordered in a unit dose drug delivery system, an unadministered dose slip with an explanation of the omission shall be placed in the resident’s medication container and a notation shall be made in the resident’s record.

DHS 134.60(4)(d)4. 4. Self-administration of medications by a resident shall be permitted if the interdisciplinary team determines that self-administration is appropriate and if the resident’s physician or dentist, as appropriate, authorizes it.

DHS 134.60(4)(d)5. 5. Medication errors and suspected or apparent drug reactions shall be reported to the physician or registered nurse in charge or on call as soon as discovered and an entry shall be made in the resident’s record. Appropriate action or interventions shall be taken.

DHS 134.60 Note Note: See s. DHS 134.67, pharmaceutical services, for additional requirements.

DHS 134.60(4)(e) (e) Habilitative or rehabilitative therapies. Any habilitative or rehabilitative therapy ordered by a physician or dentist shall be administered by a therapist or QIDP. Any treatments and changes in treatments shall be documented in the resident’s record.

DHS 134.60(5) (5) Physical restraints.

DHS 134.60(5)(a) (a) Definitions. In this subsection:

DHS 134.60(5)(a)1. 1. “Mechanical support” means any article, device or garment used only to achieve proper body position or balance of the resident or in specific medical or surgical treatment, including a geri chair, posey belt, jacket, bedside rail or protective head gear.

DHS 134.60(5)(a)2. 2. “Physical restraint” means any article, device or garment used primarily to modify resident behavior by interfering with the free movement of the resident or normal functioning of a portion of the body, and which the resident is unable to remove easily, or confinement in a locked room, but does not include mechanical supports. A totally enclosed crib or barred enclosure is a physical restraint.

DHS 134.60(5)(b) (b) Use of restraints.

DHS 134.60(5)(b)1. 1. Except as provided in subd. 2., a physical restraint may be applied only as an integral part of the resident’s behavior management program on the written order of a physician. The order shall indicate the resident’s name, the reason for the restraint and the period during which the restraint is to be applied. An order for a physical restraint not used as an integral part of a behavior management program may not be in effect longer than 12 hours.

DHS 134.60(5)(b)2. 2. In an emergency, a physical restraint may be temporarily applied without an order of a physician if necessary to protect the resident or another person from injury or to prevent physical harm to the resident or another person resulting from the destruction of property, provided that the physician is notified within one hour following application of the restraint and authorizes its continued use and that:

DHS 134.60(5)(b)2.a. a. For the initial emergency authorization, the physician specifies the type of restraint to be used, reasons for the restraint and time limit or change in behavior that will determine when the restraints are removed;

DHS 134.60(5)(b)2.b. b. A follow-up contact is made with the physician if an emergency restraint is continued for more than 12 hours; and

DHS 134.60(5)(b)2.c. c. Written authorization for the emergency use of restraints is obtained from the physician within 48 hours following the initial physician contact.

DHS 134.60(5)(b)3. 3. A physical restraint may only be used when less restrictive measures are ineffective and provided that a habilitation plan is developed and implemented to reduce the individual’s dependency on the physical restraints.

DHS 134.60(5)(b)4. 4. A physical restraint may not be used as punishment, for the convenience of the staff or as a substitute for an active treatment program or any particular treatment.

DHS 134.60(5)(b)5. 5. A physical restraint used as a time-out device, as defined in sub. (6), shall be applied only during a behavior management program and only in the presence of staff trained to implement the program.

DHS 134.60(5)(b)6. 6.

DHS 134.60(5)(b)6.a. a. Staff trained in the use of restraints shall check physically restrained residents at least every 30 minutes.

DHS 134.60(5)(b)6.b. b. Residents in physical restraints shall have their positions changed, personal needs met, and an opportunity for motion and exercise for a period of at least 10 minutes during every 2 hour period of physical restraint.

DHS 134.60(5)(b)7. 7. If the mobility of a resident is required to be restrained and can be appropriately restrained either by a locked unit or another physical restraint, a locked unit shall be used and s. DHS 134.33 shall apply.

DHS 134.60(5)(b)8. 8. Any use of restraints shall be noted, dated and signed in the resident’s record. A record shall be kept of the periodic checking on the resident in restraints required by subd. 6.

DHS 134.60(6) (6) Behavior management programs.

DHS 134.60(6)(a) (a) Definition. In this subsection and in sub. (5), “time-out” means a procedure to improve a resident’s behavior by removing positive reinforcement when the behavior is undesirable.

DHS 134.60(6)(b) (b) Plans. A written plan shall be developed for each resident participating in a behavior management program, including a resident placed in a physical restraint to modify behavior or for whom drugs are used to manage behavior. The plan shall be incorporated into the resident’s IPP and shall include:

DHS 134.60(6)(b)1. 1. The behavioral objectives of the program;

DHS 134.60(6)(b)2. 2. The methods to be used;

DHS 134.60(6)(b)3. 3. The schedule for the use of each method;

DHS 134.60(6)(b)4. 4. The persons responsible for the program;

DHS 134.60(6)(b)5. 5. The data to be collected to assess progress toward the desired objectives; and

DHS 134.60(6)(b)6. 6. The methods for documenting the resident’s progress and determining the effectiveness of the program.

DHS 134.60(6)(c) (c) Review and approval. The department shall review for approval every plan for a behavior management program before the program is started for the following:

DHS 134.60(6)(c)1. 1. Any unlocked time-out that exceeds one hour;

DHS 134.60(6)(c)2. 2. Any procedure considered unusual or intrusive, such as a procedure that would be considered painful or humiliating by most persons or a procedure involving the confinement of an ambulatory person by means of a physical restraint or specialized clothing; or

DHS 134.60(6)(c)3. 3. Any procedure that restricts or denies a resident right under subch. II.

DHS 134.60(6)(d) (d) Consent. A behavior management program may be conducted only with the written consent of the resident, the parents of a minor resident or the resident’s guardian.

DHS 134.60(6)(e) (e) Duration. Time-out involving removal from a situation may not be used for longer than one hour and then only during the behavior management program and only in the presence of staff trained to implement the program.

DHS 134.60(7) (7) Conduct and control.

DHS 134.60(7)(a) (a) The facility shall have written policies and procedures for resident conduct and control that are available in each living unit and to parents and guardians.

DHS 134.60(7)(b) (b) When appropriate, residents shall be allowed to participate in formulating policies and procedures for resident conduct and control.

DHS 134.60(7)(c) (c) Corporal punishment of a resident is not permitted.

DHS 134.60(7)(d) (d) No resident may discipline another resident unless this is done as part of an organized self-government program conducted in accordance with written policy and is an integral part of an overall treatment program supervised by a licensed psychologist or physician.

DHS 134.60 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; CR 04-053: r. (4) (a) 2. and 3. and (c), am. (4) (d) 2. and (5) (b) 1. Register October 2004 No. 586, eff. 11-1-04; correction in (4) (a) 1. made under s. 13.93 (2m) (b) 7., Stats., Register October 2007 No. 622; 2019 Wis. Act 1: am. (1) (a) 2., (2) (a) 1., 2., 3., 6. to 9., (3) (a) 2., (4) (e) Register May 2019 No. 761, eff. 6-1-19; CR 20-068: am. (2) (a) 1. Register December 2021 No. 792, eff. 1-1-22.

DHS 134.61 DHS 134.61 Nursing services.

DHS 134.61(1) (1) Required services. All facilities shall provide residents with nursing services in accordance with the needs of the residents. These services shall include:

DHS 134.61(1)(a) (a) The development, review, and updating of an IPP as part of the interdisciplinary team process;

DHS 134.61(1)(b) (b) The development, with a physician, of a medical care plan of treatment for a resident when the physician has determined that the resident requires such a plan;

DHS 134.61(1)(c) (c) In facilities with residents who have been determined by the physician not to require a medical care plan, arrangements for a nurse to conduct health surveillance of each resident on a quarterly basis;

DHS 134.61(1)(d) (d) Based on the nurse’s recorded findings, action by the nurse, including referral to a physician when necessary, to address the health problems of a resident; and

DHS 134.61(1)(e) (e) Implementation with other members of the interdisciplinary team of appropriate protective and preventive health measures, including training residents and staff as needed in appropriate personal health and hygiene measures.

DHS 134.61(2) (2) Nursing administration.

DHS 134.61(2)(a) (a) Health services supervision.

DHS 134.61(2)(a)1. 1. A facility shall have a health services supervisor to supervise the facility’s health services full-time on one shift a day, 7 days a week, for residents for whom a physician has ordered a medical care plan.

DHS 134.61(2)(a)2. 2. The health services supervisor required under subd. 1. shall be:

DHS 134.61(2)(a)2.a. a. A registered nurse; or

DHS 134.61(2)(a)2.b. b. A licensed practical nurse with consultation at regular intervals from a registered nurse under contract to the facility.

DHS 134.61(3) (3) Training.

DHS 134.61(3)(a) (a) A registered nurse shall participate as appropriate in the planning and implementation of training programs for facility personnel.

DHS 134.61(3)(b) (b) The facility shall train resident care personnel in:

DHS 134.61(3)(b)1. 1. Detecting signs of illness or dysfunction that warrant medical or nursing intervention;

DHS 134.61(3)(b)2. 2. Basic skills required to meet the health needs and problems of the residents; and

DHS 134.61(3)(b)3. 3. First aid for accidents and illnesses.

DHS 134.61 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 134.62 DHS 134.62 Professional program services.

DHS 134.62(1) (1) Provision of services. All facilities shall have or arrange for professional program services staff to implement the active treatment program defined in a resident’s individual program plan (IPP). Professional program staff shall work directly with the resident and with other staff who work with the resident in carrying out the goals and objectives stated in the resident’s IPP.

DHS 134.62(2) (2) Qualifications of professional program staff.

DHS 134.62(2)(a) (a) Psychology staff. Psychological services shall be provided by a psychologist licensed under ch. 455, Stats.

DHS 134.62(2)(b) (b) Physical therapy staff. Physical therapy services shall be given or supervised by a registered physical therapist licensed under ss. 448.05 and 448.07, Stats.