Chapter DHS 134

DHS 134.64(5)(d) (d) Self-help. There shall be adequate staff and supervision in dining rooms and resident rooms to direct self-help eating procedures and to ensure that each resident receives sufficient and appropriate foods to meet the resident’s needs.

DHS 134.64(5)(e) (e) Re-service. Food served but uneaten shall be discarded unless it is served in the manufacturer’s package which remains unopened and is maintained at a safe temperature.

DHS 134.64(5)(f) (f) Temperature. Food shall be served at proper temperatures but not more than 50ºF. (10ºC.) for cold foods and not less than 120ºF. (49ºC.) for hot foods.

DHS 134.64(5)(g) (g) Snacks. If not prohibited by the resident’s diet or condition, snacks shall be routinely offered to each resident between the evening meal and bedtime. Between-meal snacks shall be planned in advance and shall be consistent with daily nutritional needs.

DHS 134.64(6) (6) Food supplies, preparation and cooking.

DHS 134.64(6)(a) (a) Food supplies. Food shall be obtained from sources that comply with all laws relating to food and food labeling.

DHS 134.64(6)(b) (b) Preparation and cooking. Food shall be cleaned, prepared and cooked using methods that conserve nutritive value, flavor and appearance and prevent food contamination. Food shall be cut, chopped or ground as required for individual residents.

DHS 134.64(7) (7) Sanitation.

DHS 134.64(7)(a) (a) Equipment, utensils and environment.

DHS 134.64(7)(a)1. 1. All equipment, appliances and utensils used in preparation or serving food shall be maintained in a functional, sanitary and safe condition. New and replacement equipment shall meet criteria, if any, established by the national sanitation foundation.

DHS 134.64(7)(a)2. 2. The floors, walls and ceilings of all rooms in which food or drink is stored, prepared or served, or in which utensils are washed or stored, shall be kept clean and in good repair.

DHS 134.64(7)(a)3. 3. All furnishings, table linens, drapes and furniture in rooms in which food is stored, prepared or served, or in which utensils are washed or stored, shall be in good condition and maintained in a clean and sanitary condition.

DHS 134.64 Note Note: Copies of the National Sanitation Foundation’s “Listing of Food Service Equipment” are kept on file and may be consulted in the Department’s Division of Quality Assurance and the Legislative Reference Bureau.

DHS 134.64(7)(b) (b) Storage and handling of food.

DHS 134.64(7)(b)1. 1. Food shall be stored, prepared, distributed and served under sanitary conditions that prevent contamination.

DHS 134.64(7)(b)2. 2. All potentially hazardous food that requires refrigeration to prevent spoilage shall, except when being prepared or served, be kept in a refrigerator which shall have a temperature maintained at or below 40° F. (4° C.).

DHS 134.64 Note Note: See ch. DHS 145 for the requirements for reporting incidents of suspected disease transmitted by food.

DHS 134.64(7)(c) (c) Animals. Animals shall be kept out of areas of the facility where food is prepared, served or stored or where utensils are washed or stored.

DHS 134.64(8) (8) Dishwashing. Whether washed by hand or by mechanical means, all dishes, plates, cups, glasses, pots, pans and utensils shall be cleaned in accordance with accepted procedures, which shall include separate steps for pre-washing, washing, rinsing and sanitizing by means of hot water or chemicals or a combination approved by the department.

DHS 134.64 Note Note: For more detailed information on safe and proper methods of dishwashing, see s. DHS 190.10.

DHS 134.64 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; CR 04-053: r. (6) (c) and (7) (a) 4. Register October 2004 No. 586, eff. 11-1-04; 2017 Wis. Act 101: am. (4) (b) 1. Register December 2017 No. 744, eff. 1-1-18.

DHS 134.65 DHS 134.65 Dental services.

DHS 134.65(1) (1) Formal arrangements. The facility shall have a formal written arrangement with dental service providers to provide the dental services required for each resident under this section. The services shall be provided by personnel licensed or certified under ch. 447, Stats.

DHS 134.65(2) (2) Dental care.

DHS 134.65(2)(a) (a) Dental examination.

DHS 134.65(2)(a)1. 1. Not later than one month after a resident’s admission, unless the person was given a comparable examination within 6 months before admission, each resident shall be provided with comprehensive diagnostic dental services that include a complete extraoral and intraoral examination using all diagnostic aids necessary to properly evaluate the resident’s oral condition.

DHS 134.65(2)(a)2. 2. The results of the examination under subd. 1. shall be entered into the resident’s record.

DHS 134.65(2)(b) (b) Treatment. The facility shall ensure that each resident is provided with dental treatment through a system that ensures that each resident is reexamined at least once a year and more often if needed.

DHS 134.65(2)(c) (c) Emergency dental care. The facility shall provide for emergency dental care for residents on a 24-hour a day basis by licensed dentists.

DHS 134.65(2)(d) (d) Dental education and training. The facility shall provide education and training in the maintenance of oral health, including a dental hygiene program that informs residents and all staff of nutrition and diet control measures, and residents and living unit staff of proper oral hygiene methods.

DHS 134.65 Note Note: For resident care staff in-service training requirements, see s. DHS 134.45 (2) (b); for record requirements, see s. DHS 134.47 (4) (i); for discharge and transfer record requirements, see s. DHS 134.53 (4) (d).

DHS 134.65 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 134.66 DHS 134.66 Medical services.

DHS 134.66(1) (1) Medical services - general. A facility shall have written agreements with health care providers to provide residents with 24-hour medical services, including emergency care.

DHS 134.66(2) (2) Physician services.

DHS 134.66(2)(a) (a) Attending physician.

DHS 134.66(2)(a)1. 1. Each resident shall be under the supervision of a physician of the resident’s or guardian’s choice who shall evaluate and monitor the resident’s immediate and long-term needs and prescribe measures necessary for the health, safety and welfare of the resident.

DHS 134.66(2)(a)2. 2. The attending physician shall participate in the development of the individual program plan required under s. DHS 134.60 (1) (b) 1. for each newly admitted resident under his or her care as part of the interdisciplinary team process.

DHS 134.66(2)(a)3. 3. The attending physician shall ensure that arrangements are made for medical care of the resident during the attending physician’s absence.

DHS 134.66(2)(b) (b) Physician’s visits.

DHS 134.66(2)(b)1. 1. Each resident shall be seen by his or her attending physician at least once a year and more often as needed.

DHS 134.66(2)(b)2. 2. The attending physician shall review the resident’s individual program plan required under s. DHS 134.60 (1) (b).

DHS 134.66(2)(b)3. 3. The attending physician shall write orders for medications, special studies and routine screening examinations as indicated by the resident’s condition or as observed at the time of a visit and shall also review existing orders and treatments for needed changes at the time of each visit.

DHS 134.66(2)(b)4. 4. A progress note shall be written, dated and signed by the attending physician at the time of each visit.

DHS 134.66(2)(b)5. 5. Physician visits are not required for respite care residents except as provided under s. DHS 134.70 (5).

DHS 134.66(2)(c) (c) Participation in evaluation. A physician shall participate in the interdisciplinary review under s. DHS 134.60 (1) (c) 2. when a physician’s participation is indicated by the medical or psychological needs of the resident.

DHS 134.66(2)(d) (d) Designated physician. The facility shall designate a physician by written agreement with the physician to advise the facility about general health conditions and practices and to render or arrange for emergency medical care for a resident when the resident’s attending physician is not available.

DHS 134.66 Note Note: See requirements in s. DHS 134.68 for providing or obtaining laboratory, radiologic and blood services.

DHS 134.66(3) (3) Monitoring resident health. The facility shall promptly detect resident health problems by means of adequate medical surveillance and regular medical examinations, including annual examinations of vision and hearing, routine immunizations and tuberculosis control measures, and shall refer residents for treatment of these problems.

DHS 134.66 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88.

DHS 134.67 DHS 134.67 Pharmaceutical services.

DHS 134.67(1) (1) Definitions. In this section:

DHS 134.67(1)(a) (a) “Medication” has the meaning prescribed for “drug” in s. 450.06, Stats.

DHS 134.67(1)(b) (b) “Prescription medication” has the meaning prescribed for “prescription drug” in s. 450.07, Stats.

DHS 134.67(1)(c) (c) “Schedule II drug” means any drug listed in s. 961.16, Stats.

DHS 134.67(2) (2) Services. Each facility shall provide for obtaining medications for the residents directly from licensed pharmacies.

DHS 134.67(3) (3) Supervision.

DHS 134.67(3)(a) (a) The facility shall have a written agreement with a pharmacist and a registered nurse who, with the administrator, shall develop the pharmaceutical policies and procedures appropriate to the size and nature of the facility that will ensure the health, safety and welfare of the residents, including policies and procedures concerning:

DHS 134.67(3)(a)1. 1. Handling and storage of medications;

DHS 134.67(3)(a)2. 2. Administration of medications, including self-administration;

DHS 134.67(3)(a)3. 3. Review of medication errors;

DHS 134.67(3)(a)4. 4. Maintenance of an emergency medication kit under sub. (4); and

DHS 134.67(3)(a)5. 5. Automatic termination of medication orders which are not limited as to time and dosages.

DHS 134.67(3)(b) (b) The pharmacist or, in a small facility, a registered nurse shall visit the facility at least quarterly to review drug regimens and medication practices and shall submit a written report of findings and recommendations to the facility administrator.

DHS 134.67(3)(c) (c) The facility shall maintain a current pharmacy manual which includes policies and procedures and defines functions and responsibilities relating to pharmacy services. The manual shall be revised annually to keep it abreast of developments in services and management techniques.

DHS 134.67(3)(d) (d) A pharmacist or, in a small facility, a registered nurse shall review the medication record of each resident at least quarterly for potential adverse reactions, allergies, interactions and contraindications, and shall advise the physician of any changes that should be made in it.

DHS 134.67(4) (4) Emergency medication kit.

DHS 134.67(4)(a) (a) If a facility has an emergency medication kit, the emergency medication kit shall be under the control of a pharmacist.

DHS 134.67(4)(c) (c) The emergency kit shall be sealed and stored in a locked area accessible only to licensed nurses, physicians, pharmacists and other persons who may be authorized in writing by the physician designated under s. DHS 134.66 (2) (d) to have access to the kit.

DHS 134.67(5) (5) Requirements for all medication systems.

DHS 134.67(5)(a) (a) Obtaining new medications.

DHS 134.67(5)(a)1. 1. When a medication is needed which is not stocked, a registered nurse or designee shall telephone an order to the pharmacist who shall fill the order and release the medication in return for a copy of the physician’s written order.

DHS 134.67(5)(a)2. 2. When a new medication is needed which is stocked, a copy of the resident’s new medication order shall be sent to the pharmacist filling medication orders for the resident.

DHS 134.67(5)(b) (b) Storing and labeling medications. Unless exempted under par. (d), all medications shall be handled in accordance with the following provisions:

DHS 134.67(5)(b)1. 1. Medications shall be stored in locked cabinets, closets or rooms, be conveniently located in well-lighted areas and be kept at a temperature of no more than 85ºF. (29ºC.);

DHS 134.67(5)(b)2. 2. Medications shall be stored in their original containers and may not be transferred between containers, except by a physician or pharmacist;

DHS 134.67(5)(b)3. 3.

DHS 134.67(5)(b)3.a. a. Separately locked and securely fastened boxes or drawers, or permanently affixed compartments within the locked medications area, shall be provided for storage of schedule II drugs, subject to 21 USC ch. 13 and ch. 961, Stats.;

DHS 134.67(5)(b)3.b. b. For schedule II drugs, a proof-of-use record shall be maintained which lists, on separate proof-of-use sheets for each type and strength of schedule II drug, the date and time administered, resident’s name, physician’s name, dose, signature of the person administering the dose, and balance;

DHS 134.67(5)(b)3.c. c. Proof-of-use records shall be audited daily by the registered nurse or designee, except that in facilities in which a registered nurse is not required, the administrator or designee shall perform the audit of proof-of-use records daily;

DHS 134.67(5)(b)3.d. d. When the medication is received by the facility, the person completing the control record shall sign the record and indicate the amount received;

DHS 134.67(5)(b)4. 4. Medications packaged for an individual resident shall be kept physically separated from other residents’ medications;

DHS 134.67(5)(b)5. 5. Medications requiring refrigeration shall be kept in a separate covered container in a locked refrigeration unit, unless the refrigeration unit is available in a locked drug room;

DHS 134.67(5)(b)6. 6. Medications that are known to be poisonous if taken internally or that are labeled “for external use only” shall be kept physically separated from other medications within a locked area, except that time-released transdermal drug delivery systems, including nitroglycerin ointments, may be kept with internal medications;

DHS 134.67(5)(b)7. 7. Medications shall be accessible only to the registered nurse or designee, except that in facilities where no registered nurse is required, medications shall be accessible only to the administrator or designee. The key shall be in the possession of the person who is on duty and assigned to administer the medications;

DHS 134.67(5)(b)8. 8. Prescription medications shall be labeled as required by s. 450.07 (4), Stats., and with the expiration date. Nonprescription medications shall be labeled with the name of the medication, directions for use, expiration date and the name of the resident taking the medication; and

DHS 134.67(5)(b)9. 9. The facility may not give a medication to a resident after the expiration date of the medication.

DHS 134.67(5)(c) (c) Destruction of medications.

DHS 134.67(5)(c)1. 1. Unless otherwise ordered by a physician, a resident’s medication not returned to the pharmacy for credit shall be destroyed within 72 hours after receipt of a physician’s order discontinuing its use, the resident’s discharge, the resident’s death or passage of its expiration date. No resident’s medication may be held in the facility for more than 30 days unless an order is written by a physician every 30 days to hold the medication.