Chapter DHS 132

DHS 132.53 Note Note: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, Wisconsin 53707.

DHS 132.53(6)(b)7. 7. The appeal procedures in this paragraph do not apply if the continued presence of the resident poses a danger to the health, safety or welfare of the resident or other residents.

DHS 132.53 Note Note: The bureau of quality assurance was renamed the division of quality assurance.

DHS 132.53 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; cr. (2) (b) 8. and 9., am. (2) (c), (3) (b) 2. and (c), Register, January, 1987, No. 373, eff. 2-1-87; renum. (2) (c) to be (2) (c) 1. and am., cr. (2) (c) 2., Register, February, 1989, No. 398, eff. 3-1-89; am. (2) (c) 2. b., Register, October, 1989, No. 406, eff. 11-1-89; r. and recr. (1) to (3), cr. (4) (d) and (6), Register, June, 1991, No. 426, eff. 7-1-91; CR 06-053: am. (2) (b) 1., r. (4) (c), Register August 2007 No. 620, eff. 9-1-07.

DHS 132.54 DHS 132.54 Transfer within the facility. Prior to any transfer of a resident between rooms or beds within a facility, the resident or guardian, if any, and any other person designated by the resident shall be given reasonable notice and an explanation of the reasons for transfer. Transfer of a resident between rooms or beds within a facility may be made only for medical reasons or for the resident’s welfare or the welfare of other residents or as permitted under s. DHS 132.31 (1) (p) 1.

DHS 132.54 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; am. Register, January, 1987, No. 373, eff. 2-1-87.

subch. VI of ch. DHS 132 Subchapter VI — Services

DHS 132.60 DHS 132.60 Resident care.

DHS 132.60(1) (1) Individual care. Unless it is in conflict with the plan of care, each resident shall receive care based upon individual needs.

DHS 132.60(1)(a) (a) Hygiene.

DHS 132.60(1)(a)1. 1. Each resident shall be kept comfortably clean and well-groomed.

DHS 132.60(1)(b) (b) Decubiti prevention. Nursing personnel shall employ appropriate nursing management techniques to promote the maintenance of skin integrity and to prevent development of decubiti (bedsores). These techniques may include periodic position change, massage therapy and regular monitoring of skin integrity.

DHS 132.60(1)(c) (c) Basic nursing care.

DHS 132.60(1)(c)2. 2. Nursing personnel shall provide care designed to maintain current functioning and to improve the resident’s ability to carry out activities of daily living, including assistance with maintaining good body alignment and proper positioning to prevent deformities.

DHS 132.60(1)(c)3. 3. Each resident shall be encouraged to be up and out of bed as much as possible, unless otherwise ordered by a physician.

DHS 132.60(1)(c)4. 4. Any significant changes in the condition of any resident shall be reported to the nurse in charge or on call, who shall take appropriate action including the notice provided for in sub. (3).

DHS 132.60(1)(c)5. 5. The nursing home shall provide appropriate assessment and treatment of pain for each resident suspected of or experiencing pain based on accepted standards of practice that includes all of the following:

DHS 132.60(1)(c)5.a. a. An initial assessment of pain intensity that shall include: the resident’s self-report of pain, unless the resident is unable to communicate; quality and characteristics of the pain, including the onset, duration and location of pain; what measures increase or decrease the pain; the resident’s pain relief goal; and the effect of the pain on the resident’s daily life and functioning.

DHS 132.60(1)(c)5.b. b. Regular and periodic reassessment of the pain after the initial assessment, including quarterly reviews, whenever the resident’s medical condition changes, and at any time pain is suspected, including prompt reassessment when a change in pain is self-reported, suspected or observed.

DHS 132.60(1)(c)5.c. c. The delivery and evaluation of pain treatment interventions to assist the resident to be as free of pain as possible.

DHS 132.60(1)(c)5.d. d. Consideration and implementation, as appropriate, of nonpharmacological interventions to control pain.

DHS 132.60(1)(d) (d) Rehabilitative measures. Residents shall be assisted in carrying out rehabilitative measures initiated by a rehabilitative therapist or ordered by a physician, including assistance with adjusting to any disabilities and using any prosthetic devices.

DHS 132.60 Note Note: See s. DHS 132.60 (5) (a) 1. for treatments and orders.

DHS 132.60(2) (2) Nourishment.

DHS 132.60(2)(a) (a) Diets. Residents shall be served diets as prescribed.

DHS 132.60(2)(b) (b) Adaptive devices. Adaptive self-help devices, including dentures if available, shall be provided to residents, and residents shall be trained in their use to contribute to independence in eating.

DHS 132.60(2)(d) (d) Food and fluid intake and diet acceptance. A resident’s food and fluid intake and acceptance of diet shall be observed, and significant deviations from normal eating patterns shall be reported to the nurse and either the resident’s physician or dietitian as appropriate.

DHS 132.60 Note Note: For other dietary requirements, see s. DHS 132.63.

DHS 132.60(3) (3) Notification of changes in condition or status of resident.

DHS 132.60(3)(a) (a) Changes in condition. A resident’s physician, guardian, if any, and any other responsible person designated in writing by the resident or guardian to be notified shall be notified promptly of any significant accident, injury, or adverse change in the resident’s condition.

DHS 132.60(3)(b) (b) Changes in status. A resident’s guardian and any other person designated in writing by the resident or guardian shall be notified promptly of any significant non-medical change in the resident’s status, including financial situation, any plan to discharge the resident, or any plan to transfer the resident within the facility or to another facility.

DHS 132.60 Note Note: For responses to changes in medical condition, see s. DHS 132.60 (1) (c) 4; for records, see s. DHS 132.45 (5) (c) 4.

DHS 132.60(5) (5) Treatment and orders.

DHS 132.60(5)(a) (a) Orders.

DHS 132.60(5)(a)1. 1. ‘Restriction.’ Medications, treatments and rehabilitative therapies shall be administered as ordered by an authorized prescriber subject to the resident’s right to refuse them. No medication, treatment or changes in medication or treatment may be administered to a resident or a daycare client without an authorized prescriber’s written order which shall be filed in the resident’s or daycare client’s clinical record.

DHS 132.60(5)(a)2. 2. ‘Oral orders.’ Oral orders shall be immediately written, signed and dated by the nurse, pharmacist or therapist on the prescriber’s order sheet, and shall be countersigned by the prescriber and filed in the resident’s clinical record within 10 days of the order.

DHS 132.60(5)(d) (d) Administration of medications.

DHS 132.60(5)(d)1. 1. ‘Personnel who may administer medications.’ In a nursing home, medication may be administered only by a nurse, a practitioner, as defined in s. 450.01 (17), Stats., or a person who has completed training in a drug administration course approved by the department.

DHS 132.60(5)(d)2. 2. ‘Responsibility for administration.’ Policies and procedures designed to provide safe and accurate acquisition, receipt, dispensing and administration of medications shall be developed by the facility and shall be followed by personnel assigned to prepare and administer medications and to record their administration. The same person shall prepare, administer, and immediately record in the resident’s clinical record the administration of medications, except when a single unit dose package distribution system is used.

DHS 132.60(5)(d)5. 5. ‘Errors and reactions.’ Medication errors and suspected or apparent drug reactions shall be reported to the nurse in charge or on call as soon as discovered and an entry made in the resident’s clinical record. The nurse shall take appropriate action.

DHS 132.60 Note Note: See s. DHS 132.65, pharmaceutical services, for additional requirements.

DHS 132.60(6) (6) Physical and chemical restraints.

DHS 132.60(6)(b) (b) Orders required. Physical or chemical restraints shall be applied or administered only on the written order of a physician which shall indicate the resident’s name, the reason for restraint, and the period during which the restraint is to be applied.

DHS 132.60(6)(e) (e) Type of restraints. Physical restraints shall be of a type which can be removed promptly in an emergency, and shall be the least restrictive type appropriate to the resident.

DHS 132.60(6)(f) (f) Periodic care. Nursing personnel shall check a physically restrained resident as necessary, but at least every 2 hours, to see that the resident’s personal needs are met and to change the resident’s position.

DHS 132.60(8) (8) Resident care planning.

DHS 132.60(8)(a) (a) Development and content of care plans. Except in the case of a person admitted for short-term care, within 4 weeks following admission a written care plan shall be developed, based on the resident’s history and assessments from all appropriate disciplines and the physician’s evaluation and orders, as required by s. DHS 132.52.

DHS 132.60 Note Note: For requirements upon admission, see s. DHS 132.52. For requirements for short-term care residents, see s. DHS 132.70 (2).

DHS 132.60(8)(b) (b) Evaluations and updates. The care of each resident shall be reviewed by each of the services involved in the resident’s care and the care plan evaluated and updated as needed.

DHS 132.60(8)(c) (c) Implementation. The care plans shall be substantially followed.

DHS 132.60 Note Note: The department encourages and promotes the principles of resident self-determination and person directed care.

DHS 132.60 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; r. and recr. (5) (d) 1., Register, February, 1983, No. 326, eff. 3-1-83; am. (1) (d), (2) (d), (3) (5) (a) 1. to 3., (6) (c) and (8) (a), r. and recr. (1) (b) and (6) (f), Register, January, 1987, No. 373, eff. 2-1-87; am. (6) (a) 1. Register, February, 1989, No. 398, eff. 3-1-89; cr. (8) (d), Register, November, 1990, No. 419, eff. 12-1-90; correction in (5) (d) made under s. 13.93 (2m) (b) 7., Stats., Register, August, 2000, No. 536; CR 04-053: cr. (1) (c) 5., am. (5) (a) 1. and 2., (5) (d) 2., and (6) (b), r. (5) (a) 3. and (c) Register October 2004 No. 586, eff. 11-1-04; CR 06-053: r. (1) (a) 2. and 3., (c) 1., and (e), (2) (c), (4), (5) (a) 4., (b), (d) 3., 4., 6. and (e), (6) (a), (c), (d), (g), (7), and (8) (a) 1., and 2., and (d), am. (5) (a) 1., (6) (b), and (8) (a) (intro.), Register August 2007 No. 620, eff. 9-1-07.

DHS 132.61 DHS 132.61 Medical services. Every skilled care facility shall retain, pursuant to a written agreement, a physician to serve as medical director on a part-time or full-time basis as is appropriate for the needs of the residents and the facility. Medical direction and coordination of medical care in the facility shall be provided by the medical director.

DHS 132.61 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; r. and recr. (2) (b), Register, January, 1987, No. 373, eff. 2-1-87; correction in (2) (b) made under s. 13.93 (2m) (b) 7., Stats., Register, December, 1996, No. 492; CR 06-053: r. (1) (c), (2), cons., renum. and am. (1) (a) and (b) to be DHS 132.61, Register August 2007 No. 620, eff. 9-1-07.

DHS 132.62 DHS 132.62 Nursing services.

DHS 132.62(1) (1) Definitions. “Nursing personnel” means nurses, nurse aides, nursing assistants, and orderlies.

DHS 132.62(2) (2) Nursing administration.

DHS 132.62(2)(a) (a) Director of nursing services in skilled care and intermediate care facilities.

DHS 132.62(2)(a)1. 1. ‘Staffing requirement.’ Every skilled care facility and every intermediate care facility shall employ a full-time director of nursing services who may also serve as a charge nurse in accordance with par. (b).

DHS 132.62(2)(a)2. 2. ‘Qualifications.’ The director of nursing services shall be a registered nurse.

DHS 132.62(2)(a)3. 3. ‘Duties.’ The director of nursing services shall be responsible for:

DHS 132.62(2)(a)3.a. a. Supervising the functions, activities and training of the nursing personnel;

DHS 132.62(2)(a)3.b. b. Developing and maintaining standard nursing practice, nursing policy and procedure manuals, and written job descriptions for each level of nursing personnel;

DHS 132.62(2)(a)3.c. c. Coordinating nursing services with other resident services;

DHS 132.62(2)(a)3.d. d. Designating the charge nurses provided for by this section;

DHS 132.62(2)(a)3.e. e. Being on call at all times, or designating another registered nurse to be on call, when no registered nurse is on duty in the facility; and

DHS 132.62(2)(a)3.f. f. Ensuring that the duties of nursing personnel shall be clearly defined and assigned to staff members consistent with the level of education, preparation, experience, and licensing of each.

DHS 132.62(2)(b) (b) Charge nurses in skilled care facilities and intermediate care facilities.

DHS 132.62(2)(b)1. 1. ‘Staffing requirement.’ A skilled nursing facility shall have at least one charge nurse on duty at all times, and:

DHS 132.62(2)(b)1.a. a. A facility with fewer than 60 residents in need of skilled nursing care shall have at least one registered nurse, who may be the director of nursing services, on duty as charge nurse during every daytime tour of duty;

DHS 132.62(2)(b)1.b. b. A facility with 60 to 74 residents in need of skilled nursing care shall, in addition to the director of nursing services, have at least one registered nurse on duty as charge nurse during every daytime tour of duty;

DHS 132.62(2)(b)1.c. c. A facility with 75 to 99 residents in need of skilled nursing care shall have, in addition to the director of nursing services, at least one registered nurse on duty as charge nurse during every daytime tour of duty. In addition, the facility shall have at least one registered nurse on duty as charge nurse every day on at least one other non-daytime tour of duty.

DHS 132.62(2)(b)1.d. d. A facility with 100 or more residents in need of skilled nursing care shall have, in addition to the director of nursing services, at least one registered nurse on duty as charge nurse at all times.

DHS 132.62(2)(b)1.e. e. An intermediate care facility shall have a charge nurse during every daytime tour of duty, who may be the director of nursing.

DHS 132.62(2)(b)3. 3. ‘Duties.’

DHS 132.62(2)(b)3.a. a. The charge nurse, if a registered nurse, shall supervise the nursing care of all assigned residents, and delegate the duty to provide for the direct care of specific residents, including administration of medications, to nursing personnel based upon individual resident needs, the facility’s physical arrangement, and the staff capability.

DHS 132.62(2)(b)3.b. b. The charge nurse, if a licensed practical nurse, shall manage and direct the nursing and other activities of other licensed practical nurses and less skilled assistants and shall arrange for the provision of direct care to specific residents, including administration of medications, by nursing personnel based upon individual resident needs, the facility’s physical arrangement, and the staff capability. A licensed practical nurse who serves as a charge nurse shall be under the supervision and direction of a registered nurse who is either in the facility or on call.

DHS 132.62(3) (3) Nurse staffing. In addition to the requirements of sub. (2), there shall be adequate nursing service personnel assigned to care for the specific needs of each resident on each tour of duty. Those personnel shall be briefed on the condition and appropriate care of each resident.

DHS 132.62 History History: Cr. Register, July, 1982, No. 319, eff. 8-1-82; am. (2) (b) 2. and (c), r. (2) (d), Register, January, 1987, No 373, eff. 2-1-87; am. (3) (a), Register, February, 1989, No. 398, eff. 3-1-89; CR 04-053: am. (2) (a) 1. and r. and recr. (3) (a) Register October 2004 No. 586, eff. 11-1-04; CR 06-053: r. (1) (b), (2) (a) 2. b., (b) 2. and (c), (3) (a) and (c) to (h), renum. (1) (a) to be (1), cons., renum. and am. (2) (a) 2. (intro.) and a. to be (2) (a) 2., cons., renum. and am. (3) (intro.) and (b) to be (3), Register August 2007 No. 620, eff. 9-1-07.

DHS 132.63 DHS 132.63 Dietary service.

DHS 132.63(1) (1) Dietary service. The facility shall provide each resident a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.

DHS 132.63(2) (2) Staff.

DHS 132.63(2)(a) (a) Dietitian. The nursing home shall employ or retain on a consultant basis a dietitian to plan, direct and ensure implementation of dietary service functions.

DHS 132.63(2)(b) (b) Director of food services.

DHS 132.63(2)(b)1. 1. The nursing home shall designate a person to serve as the director of food services. A qualified director of food services is a person responsible for implementation of dietary service functions in the nursing home and who meets any of the following requirements:

DHS 132.63(2)(b)1.a. a. Is a dietitian.

DHS 132.63(2)(b)1.b. b. Has completed at least a course of study in food service management approved by the dietary managers association or an equivalent program.

DHS 132.63(2)(b)1.c. c. Holds an associate degree as a dietetic technician from a program approved by the American dietetics association.

DHS 132.63(2)(b)2. 2. If the director of food services is not a dietitian, the director of food services shall consult with a qualified dietitian on a frequent and regularly scheduled basis.