Chapter DHS 134

DHS 134.45 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 134.46 DHS 134.46 Abuse of residents.

DHS 134.46(1) (1) Considerate care and treatment. Employees and all other persons with whom residents come into contact shall treat the residents with courtesy, respect and full recognition of their dignity and individuality and shall give them considerate care and treatment at all times.

DHS 134.46(2) (2) Resident abuse. No person may abuse a resident.

DHS 134.46(3) (3) Abuse complaints. The facility shall ensure that every suspected instance of abuse of a resident by an employee or anyone else is reported, investigated, reviewed and documented in accordance with s. DHS 134.31 (7).

DHS 134.46 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 134.47 DHS 134.47 Records.

DHS 134.47(1) (1) Department access. The administrator of a facility or the administrator’s designee shall provide the department with any information the department needs to determine if the facility is in compliance with chs. 50, 51 and 55, Stats., and this chapter and shall provide reasonable opportunities for an authorized representative of the department to examine facility records to gather this information.

DHS 134.47(2) (2) Staffing for records management.

DHS 134.47(2)(a) (a) A facility shall have sufficient numbers of qualified records management staff and necessary support personnel available to accurately process, check, index, file and promptly retrieve records and to record data.

DHS 134.47(2)(b) (b) Duties specified in this section that relate to resident records shall be completed by staff in a timely manner.

DHS 134.47(3) (3) General requirements concerning resident records.

DHS 134.47(3)(a) (a) Organization. The facility shall maintain a systematically organized record system appropriate to the nature and size of the facility for the collection and release of information about residents.

DHS 134.47(3)(b) (b) Unit record. A resident record shall be maintained for each resident. The record shall be available and maintained on the unit on which the individual resides.

DHS 134.47(3)(c) (c) Index. A master alphabetical resident record index shall be maintained at a central location.

DHS 134.47(3)(d) (d) Confidentiality. The facility shall ensure that all information contained in resident records is kept confidential pursuant to s. 51.30, Stats., and ch. DHS 92, and shall protect the information against loss, destruction or unauthorized use. In this connection:

DHS 134.47(3)(d)1. 1. The facility shall have written policies to govern access to and duplication and release of information from resident records; and

DHS 134.47(3)(d)2. 2. The facility shall obtain the written consent of the resident or guardian before releasing information to unauthorized individuals.

DHS 134.47(3)(e) (e) Availability of records. Resident records of current residents shall be stored in the facility and shall be easily accessible at all times to persons authorized to provide care and treatment. Resident records of both current and past residents shall be readily available to persons designated by statute or authorized by the resident to obtain the release of the medical records.

DHS 134.47(3)(f) (f) Maintenance.

DHS 134.47(3)(f)1. 1. A resident record shall be adequate for planning and evaluation of the resident’s habilitation or rehabilitation program, or both, and shall furnish documentary evidence of the resident’s progress in the program.

DHS 134.47(3)(f)2. 2. The facility shall provide adequate space, equipment and supplies to review, index, file and retrieve resident records.

DHS 134.47(3)(g) (g) Retention and destruction.

DHS 134.47(3)(g)1. 1. The resident record shall be completed and stored within 60 days following a resident’s discharge or death.

DHS 134.47(3)(g)2. 2. For purposes of this chapter, a resident record, including a legible copy of any court order or other document authorizing another person to speak or act on behalf of the resident, shall be retained for a period of at least 5 years following a resident’s discharge or death.

DHS 134.47(3)(g)3. 3. A resident’s record may be destroyed after 5 years has elapsed following the resident’s discharge or death, provided that:

DHS 134.47(3)(g)3.a. a. The confidentiality of the information is maintained; and

DHS 134.47(3)(g)3.b. b. The facility permanently retains at least a record of the resident’s identity, final diagnosis, physician and dates of admission and discharge.

DHS 134.47(3)(g)4. 4. In the event that a facility closes, the facility shall arrange for the storage and safekeeping of resident records for the period and under the conditions required by this paragraph.

DHS 134.47(3)(g)5. 5. If the ownership of a facility changes, the resident records and indexes shall remain with the facility.

DHS 134.47 Note Note: Although this chapter obliges a facility to retain a resident’s record for only 5 years following the resident’s discharge or death, ch. DHS 92 requires a facility to retain the record of an individual with developmental disabilities for at least 7 years. See s. DHS 92.12 (1).

DHS 134.47(3)(h) (h) Preparation.

DHS 134.47(3)(h)1. 1. All entries in records shall be legible, permanently recorded, dated and authenticated with the name and title of the person making the entry. A rubber stamp reproduction or electronic representation of a person’s signature may be used instead of a handwritten signature if:

DHS 134.47(3)(h)1.a. a. The stamp or electronic representation is used only by the person who makes the entry; and

DHS 134.47(3)(h)1.b. b. The facility possesses a statement signed by the person, certifying that only that person shall possess and use the stamp or electronic representation.

DHS 134.47(3)(h)2. 2. Symbols and abbreviations may be used in resident records if approved by a written facility policy which defines the symbols and abbreviations and controls their use.

DHS 134.47(4) (4) Contents of a resident’s record. Except for a person admitted for short-term care, to whom s. DHS 134.70 (7) applies, a resident’s record shall contain all information relevant to admission and to the resident’s care and treatment, including the following:

DHS 134.47(4)(a) (a) Admission information. Information obtained on admission, including:

DHS 134.47(4)(a)1. 1. Name, date of admission, birth date and place, citizenship status, marital status and social security number;

DHS 134.47(4)(a)2. 2. Father’s name and birthplace and mother’s maiden name and birthplace;

DHS 134.47(4)(a)3. 3. Names and addresses of parents, legal guardian and next of kin;

DHS 134.47(4)(a)4. 4. Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;

DHS 134.47(4)(a)5. 5. Reason for admission or referral;

DHS 134.47(4)(a)6. 6. Type and legal status of admission;

DHS 134.47(4)(a)7. 7. Legal competency status;

DHS 134.47(4)(a)8. 8. Language spoken or understood;

DHS 134.47(4)(a)9. 9. Sources of support, including social security, veterans’ benefits and insurance;

DHS 134.47(4)(a)10. 10. Religious affiliation, if any;

DHS 134.47(4)(a)11. 11. Medical evaluation results, including current medical findings, a summary of prior treatment, the diagnosis at time of admission, the resident’s habilitative or rehabilitative potential and level of care and results of the physical examination required under s. DHS 134.52 (4); and

DHS 134.47(4)(a)12. 12. Any physician’s concurrence under s. DHS 134.52 (2) (c) concerning admission to the facility.

DHS 134.47(4)(b) (b) Preadmission evaluation reports. Any report or summary of an evaluation conducted by the interdisciplinary team or a team member under s. DHS 134.52 (3) prior to an individual’s admission to the facility and reports of any other relevant medical histories or evaluations conducted prior to the individual’s admission.

DHS 134.47(4)(c) (c) Authorizations or consents. 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 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. (5) (a) and (b). The summary shall include:

DHS 134.47(4)(c)1. 1. The name and address of the guardian or other person having authority to speak or act on behalf of the resident;

DHS 134.47(4)(c)2. 2. The date on which the authorization or consent takes effect and the date on which it expires;

DHS 134.47(4)(c)3. 3. The express legal nature of the authorization or consent and any limitations on it; and

DHS 134.47(4)(c)4. 4. Any other facts that are reasonably necessary to clarify the scope and extent of the authorization or consent.

DHS 134.47(4)(d) (d) Resident care planning documentation. Resident care planning documentation, including:

DHS 134.47(4)(d)1. 1. The comprehensive evaluation of the resident and written training and habilitation objectives;

DHS 134.47(4)(d)2. 2. The annual review of the resident’s program by the interdisciplinary team;

DHS 134.47(4)(d)3. 3. In measurable terms, documentation by the qualified intellectual disabilities professional of the resident’s performance in relationship to the objectives contained in the individual program plan;

DHS 134.47(4)(d)4. 4. Professional and special programs and service plans, evaluations and progress notes; and

DHS 134.47(4)(d)5. 5. Direct care staff notes reflecting the projected and actual outcome of the resident’s habilitation or rehabilitation program.

DHS 134.47(4)(e) (e) Medical service documentation. Documentation of medical services and treatments provided to the resident, including:

DHS 134.47(4)(e)1. 1. Physician orders for:

DHS 134.47(4)(e)1.a. a. Medications and treatments;

DHS 134.47(4)(e)1.b. b. Diets;

DHS 134.47(4)(e)1.c. c. Special or professional services; and

DHS 134.47(4)(e)1.d. d. Limitations on activities;

DHS 134.47(4)(e)2. 2. Restraint orders required under s. DHS 134.60 (5) (b);

DHS 134.47(4)(e)3. 3. Discharge or transfer records required under s. DHS 134.53 (4) (d);

DHS 134.47(4)(e)4. 4. Physician progress notes following each physician visit required under s. DHS 134.66 (2) (b) 4.; and

DHS 134.47(4)(e)5. 5. The report on the resident’s annual physical examination.

DHS 134.47(4)(f) (f) Nursing service documentation. Documentation of nursing needs and the nursing services provided, including:

DHS 134.47(4)(f)1. 1. The nursing care component of the individual program plan reviewed and revised annually as required by s. DHS 134.60 (1) (c) 2;

DHS 134.47(4)(f)2. 2. Nursing notes as needed to document the resident’s condition:

DHS 134.47(4)(f)3. 3. Other nursing documentation describing;

DHS 134.47(4)(f)3.a. a. The general physical and mental condition of the resident, including any unusual symptoms or behavior;

DHS 134.47(4)(f)3.b. b. All incidents or accidents, including time, place, details of the incident or accident, action taken and follow-up care;

DHS 134.47(4)(f)3.c. c. Functional training and habilitation;

DHS 134.47(4)(f)3.d. d. The administration of all medications as required under s. DHS 134.60 (4) (d), the need for as-needed administration of medications and the effect that the medication has on the resident’s condition, the resident’s refusal to take medication, omission of medications, errors in the administration of medications and drug reactions;

DHS 134.47(4)(f)3.e. e. Height and weight;

DHS 134.47(4)(f)3.f. f. Food and fluid intake, when the monitoring of intake is necessary;

DHS 134.47(4)(f)3.g. g. Any unusual occurrences of appetite or refusal or reluctance to accept diets;

DHS 134.47(4)(f)3.h. h. Rehabilitative nursing measures provided;

DHS 134.47(4)(f)3.i. i. The use of restraints, documentation for which is required under s. DHS 134.60 (5) (b) 8.;

DHS 134.47(4)(f)3.j. j. Immunizations and other non-routine nursing care given;

DHS 134.47(4)(f)3.k. k. Any family visits and contacts;

DHS 134.47(4)(f)3.L. L. The condition of a resident upon discharge; and

DHS 134.47(4)(f)3.m. m. The time of death, the physician called and the person to whom the body was released.