Chapter DHS 83

DHS 83.37(1)(g)2. 2. If a resident’s medication has been changed or discontinued, the CBRF may retain a resident’s medication for no more than 30 days unless an order by a physician or a request by a pharmacist is written every 30 days to retain the medication.

DHS 83.37(1)(g)3. 3. The CBRF shall develop and implement a policy for disposing unused, discontinued, outdated, or recalled medications in compliance with federal, state and local standards or laws. The CBRF shall arrange for the stored medications to be destroyed in compliance with standard practices. Medications that cannot be returned to the pharmacy shall be separated from other medication in current use in the facility and stored in a locked area, with access limited to the administrator or designee. The administrator or designee and one other employee shall witness, sign, and date the record of destruction. The record shall include the medication name, strength and amount.

DHS 83.37(1)(h) (h) Scheduled psychotropic medications. When a psychotropic medication is prescribed for a resident, the CBRF shall do all of the following:

DHS 83.37(1)(h)1. 1. Ensure the resident is reassessed by a pharmacist, practitioner or registered nurse, as needed, but at least quarterly for the desired responses and possible side effects of the medication. The results of the assessments shall be documented in the resident’s record as required under s. DHS 83.42 (1) (q).

DHS 83.37(1)(h)2. 2. Ensure all resident care staff understands the potential benefits and side effects of the medication.

DHS 83.37(1)(i) (i) As needed (PRN) psychotropic medication. When a psychotropic medication is prescribed on an as needed basis for a resident, the CBRF shall do all of the following:

DHS 83.37(1)(i)1. 1. The resident’s individual service plan shall include the rationale for use and a detailed description of the behaviors which indicate the need for administration of PRN psychotropic medication.

DHS 83.37(1)(i)2. 2. The administrator or qualified designee shall monitor at least monthly for the inappropriate use of PRN psychotropic medication, including but not limited to, use contrary to the individual service plan, presence of significant adverse side effects, use for discipline or staff convenience, or contrary to the intended use.

DHS 83.37(1)(i)3. 3. Documentation in the resident’s record shall include the rationale for use, description of behaviors requiring the PRN psychotropic medication, the effectiveness of the medication, the presence of any side effects, and monitoring for inappropriate use for each PRN psychotropic medication given.

DHS 83.37(1)(j) (j) Proof-of-use record. The CBRF shall maintain a proof-of-use record for schedule II drugs, subject to 21 USC 812 (c), and Wisconsin’s uniform controlled substances act, ch. 961, Stats., that contains the date and time administered, the resident’s name, the practitioner’s name, dose, signature of the person administering the dose, and the remaining balance of the drug. The administrator or designee shall audit, sign and date the proof-of-use records on a daily basis.

DHS 83.37(1)(k) (k) Medication error or adverse reaction.

DHS 83.37(1)(k)1. 1. The CBRF shall document in the resident’s record any error in the administration of prescription or over-the-counter medication, known adverse drug reaction or resident refusal to take medication.

DHS 83.37(1)(k)2. 2. The CBRF shall report all errors in the administration of medication and any adverse drug reactions to a licensed practitioner, supervising nurse or pharmacist immediately. Unless otherwise directed by the prescribing practitioner, the CBRF shall report to the prescribing practitioner, supervising nurse or pharmacist as soon as possible after the resident refuses a medication for 2 consecutive days.

DHS 83.37(1)(L) (L) Medication information. The CBRF shall make available written information to resident care staff on the purpose and side effects of medications taken by residents.

DHS 83.37(2) (2) Medication administration.

DHS 83.37(2)(a) (a) Self-administered by resident.

DHS 83.37(2)(a)1. 1. The resident shall self-administer prescribed and over-the-counter medications and dietary supplements, unless the resident has been found incompetent under ch. 54, Stats., or does not have the physical or mental capacity to self-administer as determined by the resident’s physician, or the resident requests in writing that CBRF employees manage and administer medication.

DHS 83.37(2)(a)2. 2. Except as specified under sub. (4), when a resident self-administers medications, prescribed and over-the-counter medications and dietary supplements shall remain under the control of the resident. The CBRF shall provide a secure place for the storage of medications in the resident’s room.

DHS 83.37(2)(a)3. 3. A resident with the mental and physical capacity to develop increased independence in medication administration shall receive self-administration instruction.

DHS 83.37(2)(b) (b) Medication administration supervised by a registered nurse, practitioner or pharmacist. When medication administration is supervised by a registered nurse, practitioner or pharmacist, the CBRF shall ensure all of the following:

DHS 83.37(2)(b)1. 1. The registered nurse, practitioner or pharmacist coordinates, directs and inspects the administration of medications and the medication administration system.

DHS 83.37(2)(b)2. 2. The registered nurse, practitioner or pharmacist participates in the resident’s assessment under s. DHS 83.35 (1) and development and review of the individual service plan under s. DHS 83.35 (3) regarding the resident’s medical condition and the goals of the medication regimen.

DHS 83.37(2)(c) (c) Medication administration not supervised by a registered nurse, practitioner or pharmacist. When medication administration is not supervised by a registered nurse, practitioner or pharmacist, the CBRF shall arrange for a pharmacist to package and label a resident’s prescription medications in unit dose. Medications available over-the-counter may be excluded from unit dose packaging requirements, unless the physician specifies unit dose.

DHS 83.37(2)(d) (d) Documentation of medication administration. As required under s. DHS 83.42 (1) (o), at the time of medication administration, the person administering the medication or treatment shall document in the resident record the name, dosage, date and time of medication taken or treatments performed and initial the medication administration record. Any side effects observed by the employee or symptoms reported by the resident shall be documented. The need for any PRN medication and the resident’s response shall be documented.

DHS 83.37(2)(e) (e) Other administration. Injectables, nebulizers, stomal and enteral medications, and medications, treatments or preparations delivered vaginally or rectally shall be administered by a registered nurse or by a licensed practical nurse within the scope of their license. Medication administration described under sub. (2) (e) may be delegated to non-licensed employees pursuant to s. N 6.03 (3).

DHS 83.37(3) (3) Medication storage.

DHS 83.37(3)(a) (a) Original containers. The CBRF shall keep medications in the original containers and not transfer medications to another container, unless the CBRF complies with all of the following:

DHS 83.37(3)(a)1. 1. Transfer of medications from the original container to another container shall be done by a practitioner, registered nurse, or pharmacist. Transfer of medication to another container may be delegated to other personnel by a practitioner, registered nurse or pharmacist.

DHS 83.37(3)(a)2. 2. If a medication is administered by CBRF employees and the medication is transferred from the original container by a registered nurse, or practitioner or other personnel who were delegated the task, the CBRF shall have a legible label on the new container that includes, at a minimum, the resident’s name, medication name, dose and instructions for use. The CBRF shall maintain the original pharmacy container until the transferred medication is gone.

DHS 83.37(3)(b) (b) Unit dose packaging. For use during unplanned or non-routine events or activities, employees who have completed medication administration training as required in s. DHS 83.20 (2) (d) may transfer unit doses of medications into packages for the resident.

DHS 83.37(3)(c) (c) Administered by facility. The CBRF shall keep medicine cabinets locked and the key available only to personnel identified by the CBRF.

DHS 83.37(3)(d) (d) Refrigeration. Medications stored in a common refrigerator shall be properly labeled and stored in a locked box.

DHS 83.37(3)(e) (e) Proximity to chemicals. The CBRF may not store prescription and over-the-counter medications or dietary supplements next to chemicals or other contaminants.

DHS 83.37(3)(f) (f) Internal and external application. The CBRF shall physically separate medications for internal consumption from medications for external application.

DHS 83.37(3)(g) (g) Controlled substances. The CBRF shall provide separately locked and securely fastened boxes or drawers or permanently fixed compartments within the locked medications area for storage of schedule II drugs subject to 21 USC 812 (c), and Wisconsin’s uniform controlled substances act, ch. 961, Stats.

DHS 83.37(4) (4) Exemptions. Any CBRF that exclusively serves residents in the custody of a government correctional agency or who is alcohol or drug dependent is exempt from the requirements in sub. (2) (a) 2. These facilities may store medications in a central, secure area and employees may observe and record the self administration of medication as described in the resident’s individual service plan.

DHS 83.37 History History: CR 07-095: cr. Register January 2009 No. 637, eff. 4-1-09; CR 10-091: am. (1) (h) 1. Register December 2010 No. 660, eff. 1-1-11.

DHS 83.38 DHS 83.38 Program services.

DHS 83.38(1) (1) Services. As appropriate, the CBRF shall teach residents the necessary skills to achieve and maintain the resident’s highest level of functioning. In addition to the assessed needs as determined under s. DHS 83.35 (1), the CBRF shall provide or arrange services adequate to meet the needs of the residents in all of the following areas:

DHS 83.38(1)(a) (a) Personal care. Personal care services shall be designed and provided to allow a resident to increase or maintain independence.

DHS 83.38(1)(b) (b) Supervision. The CBRF shall provide supervision appropriate to the resident’s needs.

DHS 83.38(1)(c) (c) Leisure time activities. The CBRF shall provide a daily activity program to meet the interests and capabilities of the residents. Employees shall encourage and promote resident participation in the activity program. The CBRF shall develop and post the activity schedule in an area available to residents.

DHS 83.38(1)(d) (d) Community activities. The CBRF shall provide information and assistance to facilitate participation in personal and community activities. The CBRF shall develop, update and make available to all residents, monthly schedules and notices of community activities, including costs.

DHS 83.38(1)(e) (e) Family and social contacts. The CBRF shall encourage and assist residents in maintaining family and social contacts.

DHS 83.38(1)(f) (f) Communication skills. The CBRF shall provide services to meet the resident’s communication needs.

DHS 83.38(1)(g) (g) Health monitoring.

DHS 83.38(1)(g)1. 1. The CBRF shall monitor the health of residents and make arrangements for physical health, oral health or mental health services unless otherwise arranged for by the resident. Each resident shall have an annual physical health examination completed by a physician or an advanced practice nurse as defined in s. N 8.02 (1), unless seen by a physician or an advanced practice nurse as defined in s. N 8.02 (1) more frequently.

DHS 83.38(1)(g)2. 2. When indicated, a CBRF shall observe residents’ food and fluid intake and acceptance of diet. The CBRF shall report significant deviations from normal food and fluid intake patterns to the resident’s physician or dietician.

DHS 83.38(1)(g)3. 3. The CBRF shall document communication with the resident’s physician and other health care providers, and shall record any changes in the resident’s health or mental health status in the resident’s record.

DHS 83.38(1)(h) (h) Medication administration. The CBRF shall provide medication administration appropriate to the resident’s needs.

DHS 83.38(1)(i) (i) Behavior management. The CBRF shall provide services to manage resident’s behaviors that may be harmful to themselves or others.

DHS 83.38(1)(j) (j) Information and referral. The CBRF shall provide information and referral to appropriate community services.

DHS 83.38(1)(k) (k) Transportation. The CBRF shall provide or arrange for transportation when needed for medical appointments, work, educational or training programs, religious services and for a reasonable number of community activities of interest. CBRFs that transport residents shall develop and implement written policies addressing the safe and secure transportation of residents.

DHS 83.38(2) (2) Terminally ill resident services.

DHS 83.38(2)(a) (a) A CBRF may provide more than 3 hours of nursing care per week to a resident who has a terminal illness and who requires the care under the following conditions:

DHS 83.38(2)(a)1. 1. The resident’s primary care provider is a licensed hospice or licensed home health agency.

DHS 83.38(2)(a)2. 2. The resident’s primary care provider is not a licensed hospice or licensed home health agency, and the CBRF obtains a waiver from the department.

DHS 83.38(2)(b) (b) When a resident who requires less than 3 hours of nursing care or the resident’s legal representative waives the services of a hospice program or home health agency, the CBRF shall develop and implement the written plan of care required under par. (c), which the resident’s primary physician shall review and approve.

DHS 83.38(2)(c) (c) The primary care provider and the CBRF shall develop a written, coordinated plan of care before the initiation of palliative or supportive care.

DHS 83.38 History History: CR 07-095: cr. Register January 2009 No. 637, eff. 4-1-09; CR 10-091: am. (1) (g) 1. Register December 2010 No. 660, eff. 1-1-11.

DHS 83.39 DHS 83.39 Infection control program.

DHS 83.39(1) (1) The licensee shall establish and follow an infection control program based on current standards of practice to prevent the development and transmission of communicable disease and infection.

DHS 83.39(2) (2) The infection control program shall include written policies and training for employees.

DHS 83.39(3) (3) Employees shall follow hand washing procedures according to centers for disease control and prevention standards.

DHS 83.39(4) (4) Other occupants shall comply with infection control requirements as stated in s. DHS 83.17 (2).

DHS 83.39(5) (5) The CBRF shall ensure that pets are vaccinated against diseases, including rabies, if appropriate.

DHS 83.39 History History: CR 07-095: cr. Register January 2009 No. 637, eff. 4-1-09.

DHS 83.40 DHS 83.40 Oxygen storage. Oxygen storage shall be in an area that is well ventilated and safe from environmental hazards, tampering, or the chance of accidental damage to the valve stem. If oxygen cylinders are in use, oxygen cylinders shall be secured in an upright position. If stored upright, cylinders must be secured. If stored horizontally, cylinders shall be on a level surface where they will remain stationary.

DHS 83.40 History History: CR 07-095: cr. Register January 2009 No. 637, eff. 4-1-09.

DHS 83.41 DHS 83.41 Food service.

DHS 83.41(1) (1) General requirements.

DHS 83.41(1)(a) (a) Food supply.

DHS 83.41(1)(a)1. 1. The CBRF shall maintain a food supply that is adequate to meet the needs of the residents.

DHS 83.41(1)(a)2. 2. Food shall be obtained from acceptable sources.

DHS 83.41(1)(b) (b) Equipment. The CBRF shall store equipment and utensils in a clean manner and shall maintain all utensils and equipment in good repair.

DHS 83.41(1)(c) (c) Dishwashing.

DHS 83.41(1)(c)1. 1. Whether washed by hand or mechanical means, all equipment and utensils shall be cleaned using separate steps for pre-washing, washing, rinsing and sanitizing. Residential dishwashers may be used in kitchens serving 20 or fewer residents. Kitchens serving 21 or more residents shall have a commercial type dishwasher for washing and sanitizing equipment and utensils in accordance with standard practices described in the Wisconsin food code.

DHS 83.41(1)(c)2. 2. A 3-compartment sink for washing, rinsing and sanitizing utensils, with drain boards at each end is required for all large facilities with a central kitchen. Washing, rinsing and sanitizing procedures shall be in accordance with standard practices described in the Wisconsin food code. In addition, a single compartment sink or overhead spray wash located adjacent to the soiled drain board is required for pre-washing.

DHS 83.41(2) (2) Nutrition.

DHS 83.41(2)(a) (a) Diets.

DHS 83.41(2)(a)1. 1. The CBRF shall provide each resident with palatable food that meets the recommended dietary allowance based on current dietary guidelines for Americans and any special dietary needs of each resident.

DHS 83.41(2)(a)2. 2. The CBRF shall provide a therapeutic diet as ordered by a resident’s physician.

DHS 83.41 Note Note: To obtain information on the Dietary Guidelines for Americans, see www.usda.gov/cnpp.

DHS 83.41(2)(b) (b) Meals.

DHS 83.41(2)(b)1. 1. The CBRF shall provide meals that are routinely served family or restaurant style, unless contraindicated in a resident’s individual service plan or for short-term medical needs.

DHS 83.41(2)(b)2. 2. The CBRF shall provide at least 3 meals a day, unless otherwise arranged according to the program statement or the resident’s individual service plan. A nutritious snack shall be offered in the evening or more often as consistent with the resident’s dietary needs.

DHS 83.41(2)(b)3. 3. If a resident is away from the CBRF during the time a meal is served, the CBRF shall offer food to the resident on the resident’s return.

DHS 83.41(2)(c) (c) Menus.

DHS 83.41(2)(c)1. 1. The CBRF shall make reasonable adjustments to the menu for individual resident’s food likes, habits, customs, conditions and appetites.