Wisconsin Legislature: DHS 132.45(5)(d)

f. Level of care;

2. All physician’s orders including, when applicable, orders concerning:

a. Admission to the facility as required by s. DHS 132.52 (2) (a);

b. Medications and treatments as specified by s. DHS 132.60 (5);

c. Diets as required by s. DHS 132.63 (4);

d. Rehabilitative services as required by s. DHS 132.64 (2);

e. Limitations on activities;

f. Restraint orders as required by s. DHS 132.60 (6); and

g. Discharge or transfer as required by s. DHS 132.53;

3. Physician progress notes following each visit.

4. Annual physical examination, if required; and

5. Alternate visit schedule, and justification for such alternate visits.

1. A history and assessment of the resident’s nursing needs as required by s. DHS 132.52;

2. Initial care plan as required by s. DHS 132.52 (4), and the care plan required by s. DHS 132.60 (8);

3. Nursing notes are required as follows:

a. For residents requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least weekly; and

b. For residents not requiring skilled care, a narrative nursing note shall be required as often as needed to document the resident’s condition, but at least every other week;

4. In addition to subds. 1., 2., and 3., nursing documentation describing:

a. The general physical and mental condition of the resident, including any unusual symptoms or actions;

b. All incidents or accidents including time, place, details of incident or accident, action taken, and follow-up care;

c. The administration of all medications (see s. DHS 132.60 (5) (d)), the need for PRN medications and the resident’s response, refusal to take medication, omission of medications, errors in the administration of medications, and drug reactions;

d. Food and fluid intake, when the monitoring of intake is necessary;

e. Any unusual occurrences of appetite or refusal or reluctance to accept diets;

f. Summary of restorative nursing measures which are provided;

g. Summary of the use of physical and chemical restraints.

h. Other non-routine nursing care given;

i. The condition of a resident upon discharge; and

j. The time of death, the physician called, and the person to whom the body was released.

(d) Social service records. Notes regarding pertinent social data and action taken.

(e) Activities records. Documentation of activities programming, a summary of attendance, and quarterly progress notes.

(f) Rehabilitative services.

1. An evaluation of the rehabilitative needs of the resident; and

2. Progress notes detailing treatment given, evaluation, and progress.

(h) Dental services. Records of all dental services.

(i) Diagnostic services. Records of all diagnostic tests performed during the resident’s stay in the facility.

(j) Plan of care. Plan of care required by s. DHS 132.60 (8).

(k) Authorization or consent. A photocopy of any court order or other document authorizing another person to speak or act on behalf of the resident and any resident consent form required under this chapter, except that if the authorization or consent form exceeds one page in length an accurate summary may be substituted in the resident record and the complete authorization or consent form shall in this case be maintained as required under sub. (6) (i). The summary shall include:

1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;

2. The date on which the authorization or consent takes effect and the date on which it expires;

3. The express legal nature of the authorization or consent and any limitations on it; and

4. Any other factors reasonably necessary to clarify the scope and extent of the authorization or consent.

(L) Discharge or transfer information. Documents, prepared upon a resident’s discharge or transfer from the facility, summarizing, when appropriate:

1. Current medical findings and condition;

2. Final diagnoses;

3. Rehabilitation potential;

4. A summary of the course of treatment;

5. Nursing and dietary information;

6. Ambulation status;

7. Administrative and social information; and

8. Needed continued care and instructions.

(6) Other records. The facility shall retain:

(a) Dietary records. All menus and therapeutic diets;

(b) Staffing records. Records of staff work schedules and time worked;

(d) Resident census. At least a weekly census of all residents, indicating numbers of residents requiring each level of care;

(e) Professional consultations. Documentation of professional consultations by:

1. A dietitian, if required by s. DHS 132.63 (2) (b);

2. A registered nurse, if required by s. DHS 132.62 (2); and

3. Others, as may be used by the facility;

(f) Inservice and orientation programs. Subject matter, instructors and attendance records of all inservice and orientation programs;

(g) Transfer agreements. Transfer agreements, unless exempt under s. DHS 132.53 (4);

(h) Funds and property statement. The statement prepared upon a resident’s discharge or transfer from the facility that accounts for all funds and property held by the facility for the resident.

(i) Court orders and consent forms. Copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of the resident.

History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; am. (1) (3) (c) (5) (intro.), (b) 1. intro. and e., 2. a. and d., 3., (c) 1. and 2., (d) 1., (e), (f) 1. and (g), (6) (g), renum. (4) (a) to (e), (5) (e) and (6) (h) to be (4) (c) to (g), (5) (L) and (6) (i) and am. (5) (L), cr. (4) (a) and (b), (5) (e) and (6) (h), Register, January, 1987, No. 373, eff. 2-1-87; CR 04-053: r. and recr. (3) and (5) (d), am. (4) (g) 2. and (5) (e), r. (5) (g) Register October 2004 No. 586, eff. 11-1-04; CR 06-053: r. (4) (a), (b) and (d), (e) and (f) 1. and 3., am. (4) (f) 2. (g) 1., (5) (b) 3. and 5., (c) 4. g., and (6) (h), renum. (4) (f) 2., 4. and 5. to be (4) (f) 1., 2. and 3., Register August 2007 No. 620, eff. 9-1-07.

DHS 132.46 Quality assessment and assurance.

(1) Committee maintenance and composition. A facility shall maintain a quality assessment and assurance committee for the purpose of identifying and addressing quality of care issues. The committee shall be comprised of at least all of the following individuals:

(a) The director of nursing services.

(b) The medical director or a physician designated by the facility.

(2) Committee responsibilities. The quality assessment and assurance committee shall do all of the following:

(a) Meet at least quarterly to identify quality of care issues with respect to which quality assessment and assurance activities are necessary.

(b) Identify, develop and implement appropriate plans of action to correct identified quality deficiencies.

(3) Confidentiality. The department may not require disclosure of the records of the quality assessment and assurance committee except to determine compliance with the requirements of this section. This paragraph does not apply to any record otherwise specified in this chapter or s. 50.04 (3), 50.07 (1) (c) or 146.82 (2) (a) 5., Stats.

History: CR 04-053: cr. Register October 2004 No. 586, eff. 11-1-04.

Subchapter V — Admissions, Retentions and Removals

DHS 132.51 Limitations on admissions and programs.

(1) License limitations.

(a) Bed capacity. No facility may house more residents than the maximum bed capacity for which it is licensed. Persons participating in a day care program are not residents for purposes of this chapter.

(b) Care levels.

1. No person who requires care greater than that which the facility is licensed to provide may be admitted to or retained in the facility.

2. No resident whose condition changes to require care greater than that which the facility is licensed to provide shall be retained.

(2) Other limitations on admissions.

(a) Persons requiring unavailable services. Persons who require services which the facility does not provide or make available shall not be admitted or retained.

(b) Communicable diseases.

1. ‘Communicable disease management.’ The nursing home shall have the ability to appropriately manage persons with communicable disease the nursing home admits or retains based on currently recognized standards of practice.

2. ‘Reportable diseases.’ Facilities shall report suspected communicable diseases that are reportable under ch. DHS 145 to the local public health officer or to the department’s bureau of communicable disease.

Note: For a copy of ch. DHS 145 which includes a list of the communicable diseases which must be reported, write the Bureau of Public Health, P.O. Box 309, Madison, WI 53701 (phone 608-267-9003). There is no charge for a copy of ch. DHS 145. The referenced publications,“Guideline for Isolation Precautions in Hospitals and Guideline for Infection Control in Hospital Personnel” (HHS Publication No. (CSC) 83-8314) and “Universal Precautions for Prevention of . . . Bloodborne Pathogens in Health Care Settings”, may be purchased from the Superintendent of Documents, Washington D.C. 20402, and is available for review in the office of the Department’s Division of Quality Assurance and the Legislative Reference Bureau.