Chapter DHS 134

DHS 134.52(2)(a) (a) An interdisciplinary team has conducted or updated a comprehensive preadmission evaluation of the individual as specified in sub. (3) and has determined that residential care is the best available plan for the individual;

DHS 134.52(2)(b) (b) Except in an emergency, for an individual who is under age 65, there is a written recommendation of the county department established under s. 46.23, 51.42 or 51.437, Stats., in the individual’s county of residence, that residential care in the facility is the best available placement for the individual;

DHS 134.52(2)(c) (c) If the individual’s medical condition and diagnosis require on-going monitoring and physician supervision, the facility has obtained the concurrence of a physician in the admission decision and information about the person’s current medical condition and diagnosis, and any orders from a physician for immediate care have been received by the facility before or on the day of admission;

DHS 134.52(2)(d) (d) The facility has received written certification from a physician, physician assistant or advanced practice nurse prescriber that the individual has been screened for communicable diseases detrimental to other residents or a physician, physician assistant or advanced practice nurse prescriber has ordered procedures to treat and limit the spread of any communicable diseases the person may be found to have; and

DHS 134.52(2)(e) (e) Court-ordered protective placement has been obtained in accordance with s. 55.06, Stats., for a person who has been found by a court to be incompetent.

DHS 134.52(3) (3) Preadmission evaluation.

DHS 134.52(3)(a) (a) Within 90 days before the date of admission, an interdisciplinary team shall conduct or update a comprehensive evaluation of the individual. The evaluation shall include consideration of the individual’s:

DHS 134.52(3)(a)1. 1. Physical development and health;

DHS 134.52(3)(a)2. 2. Sensorimotor development;

DHS 134.52(3)(a)3. 3. Affective development;

DHS 134.52(3)(a)4. 4. Speech and language development and auditory functioning;

DHS 134.52(3)(a)5. 5. Cognitive development;

DHS 134.52(3)(a)6. 6. Vocational skills; and

DHS 134.52(3)(a)7. 7. Adaptive behaviors or independent living skills necessary for the individual to be able to function in the community.

DHS 134.52(3)(b) (b) The interdisciplinary team shall:

DHS 134.52(3)(b)1. 1. Identify the presenting problems and disabilities and, where possible, their causes;

DHS 134.52(3)(b)2. 2. Identify the individual’s developmental strengths;

DHS 134.52(3)(b)3. 3. Identify the individual’s developmental and behavioral modification needs;

DHS 134.52(3)(b)4. 4. Define the individual’s need for services without regard to availability of those services;

DHS 134.52(3)(b)5. 5. Review all available and applicable programs of care, treatment and training for the individual; and

DHS 134.52(3)(b)6. 6. Record the evaluation findings.

DHS 134.52(4) (4) Physical examination by physician.

DHS 134.52(4)(a) (a) Examination. Each resident shall have a physical examination by a physician or physician extender within 48 hours following admission unless an examination was performed within 15 days before admission.

DHS 134.52(4)(b) (b) Evaluation. Within 48 hours after admission the physician or physician extender shall complete the resident’s medical and physical examination record.

DHS 134.52(5) (5) Family care information and referral. If the secretary of the department has certified that a resource center, as defined in s. DHS 10.13 (42), is available for the facility under s. DHS 10.71, the facility shall provide information to prospective residents and refer residents and prospective residents to the aging and disability resource center as required under s. 50.04 (2g) to (2i), Stats., and s. DHS 10.73.

DHS 134.52 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; cr. (5), Register, October, 2000, No. 538, eff. 11-1-00; CR 04-053: r. and recr. (2) (d) Register October 2004 No. 586, eff. 11-1-04; corrections in (5) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637; CR 23-046: am. (2) (c) Register April 2024 No. 820, eff. 5-1-24.

DHS 134.53 DHS 134.53 Removal from the facility.

DHS 134.53(1) (1) Scope. The provisions of this section shall apply to all transfers, discharges and leaves of residents from facilities except that the removal of residents when a facility closes is governed by s. 50.03 (14), Stats.

DHS 134.53(2) (2) Reasons for removal. No resident may be temporarily or permanently transferred or discharged from a facility, except:

DHS 134.53(2)(a) (a) Voluntary removal. Upon the request or with the informed consent of the resident or guardian;

DHS 134.53(2)(b) (b) Involuntary removal.

DHS 134.53(2)(b)1. 1. For nonpayment of charges, following reasonable opportunity to pay any deficiency;

DHS 134.53(2)(b)2. 2. If the resident requires care that the facility is not licensed to provide;

DHS 134.53(2)(b)3. 3. If the resident requires care that the facility does not provide and is not required to provide under this chapter;

DHS 134.53(2)(b)4. 4. For medical reasons as ordered by a physician;

DHS 134.53(2)(b)5. 5. In case of a medical emergency or disaster;

DHS 134.53(2)(b)6. 6. For the resident’s welfare or the welfare of other residents;

DHS 134.53(2)(b)7. 7. If the resident does not need FDD care;

DHS 134.53(2)(b)8. 8. If the short-term care period for which the resident was admitted has expired; or

DHS 134.53(2)(b)9. 9. As otherwise permitted by law.

DHS 134.53(3) (3) Alternate placement. Except for removals under sub. (2) (b) 5., no resident may be involuntarily removed unless an alternative placement is arranged for the admission of the resident pursuant to sub. (4) (c).

DHS 134.53(4) (4) Permanent involuntary removal.

DHS 134.53(4)(a) (a) Consultation. Before a decision is made to transfer or discharge a resident under sub. (2) (b), facility staff shall meet with the resident’s parent or guardian, if any, and any other person the resident decides should be present, to discuss the need for and alternatives to the transfer or discharge.

DHS 134.53(4)(b) (b) Notice. The facility shall provide the resident, the resident’s family or guardian or other responsible person, the appropriate county department designated under s. 46.23, 51.42 or 51.437, Stats., and, if appropriate, the resident’s physician, with at least 30 days notice before making a permanent removal under sub. (2) (b), except under sub. (2) (b) 5. or if the continued presence of the resident endangers his or her health, safety or welfare or that of other residents.

DHS 134.53(4)(c) (c) Removal procedures.

DHS 134.53(4)(c)1. 1. Unless circumstances posing a danger to the health, safety or welfare of a resident require otherwise, at least 7 days before the planning conference required by subd. 2., the resident, guardian, if any, the appropriate county department designated under s. 46.23, 51.42 or 51.437, Stats., and any person designated by the resident, including the resident’s physician, shall be given a notice containing the time and place of the conference, a statement informing the resident that any persons of the resident’s choice may attend the conference and the procedure for submitting a complaint to the department about the prospective removal.

DHS 134.53(4)(c)2. 2. Unless the resident is receiving respite care or unless precluded by circumstances posing a danger to the health, safety or welfare of a resident, prior to any permanent involuntary removal under sub. (2) (b), a planning conference shall be held at least 14 days before removal with the resident, the resident’s guardian, if any, any appropriate county agency and any persons designated by the resident, including the resident’s physician or the facility QDIP, to review the need for relocation, assess the effect of relocation on the resident, discuss alternative placements and develop a relocation plan which includes at least those activities listed in subd. 3.

DHS 134.53 Note Note: The discharge planning conference requirement for a resident receiving recuperative care is found in s. DHS 134.70 (6).

DHS 134.53(4)(c)3. 3. Removal activities shall include:

DHS 134.53(4)(c)3.a. a. Counseling the resident about the impending removal;

DHS 134.53(4)(c)3.b. b. Making arrangements for the resident to make at least one visit to the potential alternative placement facility and to meet with that facility’s admissions staff, unless this is medically contraindicated or the resident chooses not to make the visit;

DHS 134.53(4)(c)3.c. c. Providing assistance in moving the resident and the resident’s belongings and funds to the new facility or quarters; and

DHS 134.53(4)(c)3.d. d. Making sure that the resident receives needed medications and treatments during relocation.

DHS 134.53(4)(d) (d) Transfer and discharge records. Upon removal of a resident, the documents required by s. DHS 134.47 (4) (k) shall be prepared and provided to the facility admitting the resident, along with any other information about the resident needed by the admitting facility. When a resident is permanently released, the facility shall prepare and place in the resident’s record a summary of habilitative, rehabilitative, medical, emotional, social and cognitive findings and progress and plans for care.

DHS 134.53(5) (5) Voluntary discharge. When a discharge is voluntary and expected to be permanent, the facility shall, prior to the removal:

DHS 134.53(5)(a) (a) Counsel the resident, the parent of a minor resident or the guardian who requests the discharge concerning the advantages and disadvantages of the discharge;

DHS 134.53(5)(b) (b) Under the guidance and recommendations of the facility’s interdisciplinary team, make necessary arrangements for appropriate services, including post-discharge planning, protective supervision and follow-up services, during relocation and in the new environment;

DHS 134.53(5)(c) (c) Advise the resident who is to be discharged at his or her own request of additional assistance available under sub. (4) (c) 3., and provide that assistance upon request; and

DHS 134.53(5)(d) (d) Notify the appropriate county department designated under s. 46.23, 51.42 or 51.437, Stats.

DHS 134.53(6) (6) Bedhold. If a resident on leave or temporarily discharged expressed the intention on leaving or being discharged of returning to the facility under the terms of the facility’s admission statement for bedhold, the resident may not be denied readmission unless at the time readmission is requested, a condition of sub. (2) (b) exists. The facility shall hold a resident’s bed until the resident returns unless the resident waives his or her right to have the bed held or 15 days has passed following the beginning of leave or temporary discharge.

DHS 134.53 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; 2019 Wis. Act 1: am. (4) (c) 2. Register May 2019 No. 761, eff. 6-1-19.

DHS 134.54 DHS 134.54 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 or guardian shall be given reasonable notice and an explanation of the reasons for the 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 134.31 (3) (q) 1.

DHS 134.54 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

subch. V of ch. DHS 134 Subchapter V — Services

DHS 134.60 DHS 134.60 Resident care.

DHS 134.60(1) (1) Resident care planning.

DHS 134.60(1)(a) (a) Interdisciplinary team.

DHS 134.60(1)(a)1. 1. An interdisciplinary team shall develop a resident’s individual program plan.

DHS 134.60(1)(a)2. 2. Membership on the interdisciplinary team for resident care planning may vary based on the professions, disciplines and service areas that are relevant to the resident’s needs, but shall include a qualified intellectual disabilities professional and a nurse, and a physician as required under s. DHS 134.66 (2) (a) 2. and (c).

DHS 134.60(1)(a)3. 3. The resident and the resident’s family or guardian shall be encouraged to participate as members of the team, unless the resident objects to participation by family members.

DHS 134.60(1)(b) (b) Development and content of the individual program plan.

DHS 134.60(1)(b)1. 1. Except in the case of a person admitted for short-term care, within 30 days following the date of admission, the interdisciplinary team, with the participation of the staff providing resident care, shall review the preadmission evaluation and physician’s plan of care and shall develop an IPP based on the new resident’s and an assessment of the resident’s needs by all relevant disciplines, including any physician’s evaluations or orders.

DHS 134.60(1)(b)2. 2. The IPP shall include:

DHS 134.60(1)(b)2.a. a. A list of realistic and measurable goals in priority order, with time limits for attainment;

DHS 134.60(1)(b)2.b. b. Behavioral objectives for each goal which must be attained before the goal is considered attained;

DHS 134.60(1)(b)2.c. c. A written statement of the methods or strategies for delivering care, for use by the staff providing resident care and by the professional and special services staff and other individuals involved in the resident’s care, and of the methods and strategies for assisting the resident to attain new skills, with documentation of which professional disciplines or which personnel providing resident care are responsible for the needed care or services;

DHS 134.60(1)(b)2.d. d. Evaluation procedures for determining whether the methods or strategies are accomplishing the care objectives; and

DHS 134.60(1)(b)2.e. e. A written interpretation of the preadmission evaluation in terms of any specific supportive actions, if appropriate, to be undertaken by the resident’s family or legal guardian and by appropriate community resources.

DHS 134.60 Note Note: For the requirement of a preadmission evaluation, see s. DHS 134.52. For development of a plan of care for short-term care residents, see s. DHS 134.70 (2).

DHS 134.60(1)(c) (c) Reassessment of individual program plan.

DHS 134.60(1)(c)1. 1. ‘Special and professional services review.’

DHS 134.60(1)(c)1.a. a. The care provided by staff from each of the disciplines involved in the resident ’s treatment shall be reviewed by the professional responsible for monitoring delivery of the specific service.

DHS 134.60(1)(c)1.b. b. Reassessment results and other necessary information obtained through the specialists’ assessments shall be disseminated to other resident care staff as part of the IPP process.

DHS 134.60(1)(c)1.c. c. Documentation of the reassessment results, treatment objectives, plans and procedures, and continuing treatment progress reports shall be recorded in the resident’s record.

DHS 134.60(1)(c)2. 2. ‘Interdisciplinary review.’ The interdisciplinary team, staff providing resident care and other relevant personnel shall review the IPP and status of the resident at least annually and make program recommendations as indicated by the resident’s developmental progress. The review shall consider at least the following:

DHS 134.60(1)(c)2.a. a. The appropriateness of the individual program plan and the individual’s progress toward meeting plan objectives;

DHS 134.60(1)(c)2.b. b. The advisability of continued residence, and recommendations for alternative programs and services; and

DHS 134.60(1)(c)2.c. c. The advisability of guardianship and a plan for assisting the resident in the exercise of his or her rights.

DHS 134.60(1)(d) (d) Implementation. Progress notes shall reflect the treatment and services provided to meet the goals stated in the IPP.