Wisconsin Legislature: DHS 134.65

5. A variety of foods, including protein foods, fruits, vegetables, dairy products, breads and cereals, shall be provided.

(b) Modified diets.

1. Modified diets shall be prescribed by the attending physician. The attending physician may delegate to a licensed or certified dietitian the task of prescribing a resident’s diet, including a modified diet, to the extent allowed by law. A modified diet shall be served consistent with that order. A dietitian shall participate in decisions about modified and special diets. A record of the order shall be kept on file.

2. The modified diet shall be reviewed by the physician and the dietitian on a regularly scheduled basis and adjusted as needed. Modifications may include changes in the type and texture of food.

(5) Meal service.

(a) Schedule. The facility shall serve at least 3 meals daily at regular times comparable to normal meal times in the community. No more than 14 hours may elapse between a substantial evening meal and breakfast the following day, and not less than 10 hours may elapse between breakfast and the evening meal of the same day.

(b) Table service. All meals shall be served in dining rooms unless otherwise required by a physician or by decision of the resident’s interdisciplinary team. The facility shall provide table service in dining rooms for all residents who can and want to eat at a table, including residents in wheelchairs.

(c) Developmental needs of residents. Dining areas shall be equipped with tables, chairs, eating utensils and dishes to meet the developmental needs of each resident.

(d) Self-help. There shall be adequate staff and supervision in dining rooms and resident rooms to direct self-help eating procedures and to ensure that each resident receives sufficient and appropriate foods to meet the resident’s needs.

(e) Re-service. Food served but uneaten shall be discarded unless it is served in the manufacturer’s package which remains unopened and is maintained at a safe temperature.

(f) Temperature. Food shall be served at proper temperatures but not more than 50ºF. (10ºC.) for cold foods and not less than 120ºF. (49ºC.) for hot foods.

(g) Snacks. If not prohibited by the resident’s diet or condition, snacks shall be routinely offered to each resident between the evening meal and bedtime. Between-meal snacks shall be planned in advance and shall be consistent with daily nutritional needs.

(6) Food supplies, preparation and cooking.

(a) Food supplies. Food shall be obtained from sources that comply with all laws relating to food and food labeling.

(b) Preparation and cooking. Food shall be cleaned, prepared and cooked using methods that conserve nutritive value, flavor and appearance and prevent food contamination. Food shall be cut, chopped or ground as required for individual residents.

(7) Sanitation.

(a) Equipment, utensils and environment.

1. All equipment, appliances and utensils used in preparation or serving food shall be maintained in a functional, sanitary and safe condition. New and replacement equipment shall meet criteria, if any, established by the national sanitation foundation.

2. The floors, walls and ceilings of all rooms in which food or drink is stored, prepared or served, or in which utensils are washed or stored, shall be kept clean and in good repair.

3. All furnishings, table linens, drapes and furniture in rooms in which food is stored, prepared or served, or in which utensils are washed or stored, shall be in good condition and maintained in a clean and sanitary condition.

Note: Copies of the National Sanitation Foundation’s “Listing of Food Service Equipment” are kept on file and may be consulted in the Department’s Division of Quality Assurance and the Legislative Reference Bureau.

(b) Storage and handling of food.

1. Food shall be stored, prepared, distributed and served under sanitary conditions that prevent contamination.

2. All potentially hazardous food that requires refrigeration to prevent spoilage shall, except when being prepared or served, be kept in a refrigerator which shall have a temperature maintained at or below 40° F. (4° C.).

Note: See ch. DHS 145 for the requirements for reporting incidents of suspected disease transmitted by food.

(c) Animals. Animals shall be kept out of areas of the facility where food is prepared, served or stored or where utensils are washed or stored.

(8) Dishwashing. Whether washed by hand or by mechanical means, all dishes, plates, cups, glasses, pots, pans and utensils shall be cleaned in accordance with accepted procedures, which shall include separate steps for pre-washing, washing, rinsing and sanitizing by means of hot water or chemicals or a combination approved by the department.

Note: For more detailed information on safe and proper methods of dishwashing, see s. DHS 190.10.

History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; CR 04-053: r. (6) (c) and (7) (a) 4. Register October 2004 No. 586, eff. 11-1-04; 2017 Wis. Act 101: am. (4) (b) 1. Register December 2017 No. 744, eff. 1-1-18.

DHS 134.65 Dental services.

(1) Formal arrangements. The facility shall have a formal written arrangement with dental service providers to provide the dental services required for each resident under this section. The services shall be provided by personnel licensed or certified under ch. 447, Stats.

(2) Dental care.

(a) Dental examination.

1. Not later than one month after a resident’s admission, unless the person was given a comparable examination within 6 months before admission, each resident shall be provided with comprehensive diagnostic dental services that include a complete extraoral and intraoral examination using all diagnostic aids necessary to properly evaluate the resident’s oral condition.

2. The results of the examination under subd. 1. shall be entered into the resident’s record.

(b) Treatment. The facility shall ensure that each resident is provided with dental treatment through a system that ensures that each resident is reexamined at least once a year and more often if needed.

(c) Emergency dental care. The facility shall provide for emergency dental care for residents on a 24-hour a day basis by licensed dentists.

(d) Dental education and training. The facility shall provide education and training in the maintenance of oral health, including a dental hygiene program that informs residents and all staff of nutrition and diet control measures, and residents and living unit staff of proper oral hygiene methods.

Note: For resident care staff in-service training requirements, see s. DHS 134.45 (2) (b); for record requirements, see s. DHS 134.47 (4) (i); for discharge and transfer record requirements, see s. DHS 134.53 (4) (d).

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

DHS 134.66 Medical services.

(1) Medical services - general. A facility shall have written agreements with health care providers to provide residents with 24-hour medical services, including emergency care.

(2) Physician services.

(a) Attending physician.

1. Each resident shall be under the supervision of a physician of the resident’s or guardian’s choice who shall evaluate and monitor the resident’s immediate and long-term needs and prescribe measures necessary for the health, safety and welfare of the resident.

2. The attending physician shall participate in the development of the individual program plan required under s. DHS 134.60 (1) (b) 1. for each newly admitted resident under his or her care as part of the interdisciplinary team process.

3. The attending physician shall ensure that arrangements are made for medical care of the resident during the attending physician’s absence.

(b) Physician’s visits.

1. Each resident shall be seen by his or her attending physician at least once a year and more often as needed.

2. The attending physician shall review the resident’s individual program plan required under s. DHS 134.60 (1) (b).

3. The attending physician shall write orders for medications, special studies and routine screening examinations as indicated by the resident’s condition or as observed at the time of a visit and shall also review existing orders and treatments for needed changes at the time of each visit.

4. A progress note shall be written, dated and signed by the attending physician at the time of each visit.

5. Physician visits are not required for respite care residents except as provided under s. DHS 134.70 (5).

(c) Participation in evaluation. A physician shall participate in the interdisciplinary review under s. DHS 134.60 (1) (c) 2. when a physician’s participation is indicated by the medical or psychological needs of the resident.

(d) Designated physician. The facility shall designate a physician by written agreement with the physician to advise the facility about general health conditions and practices and to render or arrange for emergency medical care for a resident when the resident’s attending physician is not available.

Note: See requirements in s. DHS 134.68 for providing or obtaining laboratory, radiologic and blood services.

(3) Monitoring resident health. The facility shall promptly detect resident health problems by means of adequate medical surveillance and regular medical examinations, including annual examinations of vision and hearing, routine immunizations and tuberculosis control measures, and shall refer residents for treatment of these problems.

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

DHS 134.67 Pharmaceutical services.

(1) Definitions. In this section:

(a) “Medication” has the meaning prescribed for “drug” in s. 450.06, Stats.

(b) “Prescription medication” has the meaning prescribed for “prescription drug” in s. 450.07, Stats.

(2) Services. Each facility shall provide for obtaining medications for the residents directly from licensed pharmacies.

(3) Supervision.

(a) The facility shall have a written agreement with a pharmacist and a registered nurse who, with the administrator, shall develop the pharmaceutical policies and procedures appropriate to the size and nature of the facility that will ensure the health, safety and welfare of the residents, including policies and procedures concerning:

1. Handling and storage of medications;

2. Administration of medications, including self-administration;

3. Review of medication errors;

4. Maintenance of an emergency medication kit under sub. (4); and

5. Automatic termination of medication orders which are not limited as to time and dosages.

(b) The pharmacist or, in a small facility, a registered nurse shall visit the facility at least quarterly to review drug regimens and medication practices and shall submit a written report of findings and recommendations to the facility administrator.

(c) The facility shall maintain a current pharmacy manual which includes policies and procedures and defines functions and responsibilities relating to pharmacy services. The manual shall be revised annually to keep it abreast of developments in services and management techniques.

(d) A pharmacist or, in a small facility, a registered nurse shall review the medication record of each resident at least quarterly for potential adverse reactions, allergies, interactions and contraindications, and shall advise the physician of any changes that should be made in it.

(4) Emergency medication kit.

(a) If a facility has an emergency medication kit, the emergency medication kit shall be under the control of a pharmacist.

(c) The emergency kit shall be sealed and stored in a locked area accessible only to licensed nurses, physicians, pharmacists and other persons who may be authorized in writing by the physician designated under s. DHS 134.66 (2) (d) to have access to the kit.

(5) Requirements for all medication systems.

(a) Obtaining new medications.

1. When a medication is needed which is not stocked, a registered nurse or designee shall telephone an order to the pharmacist who shall fill the order and release the medication in return for a copy of the physician’s written order.

2. When a new medication is needed which is stocked, a copy of the resident’s new medication order shall be sent to the pharmacist filling medication orders for the resident.

(b) Storing and labeling medications. Unless exempted under par. (d), all medications shall be handled in accordance with the following provisions:

1. Medications shall be stored in locked cabinets, closets or rooms, be conveniently located in well-lighted areas and be kept at a temperature of no more than 85ºF. (29ºC.);

2. Medications shall be stored in their original containers and may not be transferred between containers, except by a physician or pharmacist;

a. Separately locked and securely fastened boxes or drawers, or permanently affixed compartments within the locked medications area, shall be provided for storage of schedule II drugs, subject to 21 USC ch. 13 and ch. 961, Stats.;

b. For schedule II drugs, a proof-of-use record shall be maintained which lists, on separate proof-of-use sheets for each type and strength of schedule II drug, the date and time administered, resident’s name, physician’s name, dose, signature of the person administering the dose, and balance;

c. Proof-of-use records shall be audited daily by the registered nurse or designee, except that in facilities in which a registered nurse is not required, the administrator or designee shall perform the audit of proof-of-use records daily;

d. When the medication is received by the facility, the person completing the control record shall sign the record and indicate the amount received;