Chapter DHS 134

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.

DHS 134.67(5)(c)2. 2. Records shall be kept of all medications returned for credit. Any medication under subd. 1. not returned for credit shall be destroyed in the facility and a record of the destruction shall be prepared which shall be signed and dated by 2 or more personnel who witnessed the destruction and who are licensed or registered in the health care field.

DHS 134.67(5)(d) (d) Resident control and use of medications.

DHS 134.67(5)(d)1. 1. Residents may have medications in their possession or stored at their bedsides if ordered by a physician or otherwise permitted under s. DHS 134.60 (4) (d) 4.

DHS 134.67(5)(d)2. 2. Medications in the possession of a resident which, if ingested or brought into contact with the nasal or eye mucosa would produce toxic or irritant effects, shall be stored and used by a resident only in accordance with the health, safety and welfare of all residents.

DHS 134.67(6) (6) Additional requirements for unit dose systems.

DHS 134.67(6)(a) (a) Scope. When a unit-dose drug delivery system is used, the requirements of this subsection shall apply in addition to those of sub. (5).

DHS 134.67(6)(b) (b) General procedures.

DHS 134.67(6)(b)1. 1. The individual medication in a unit dose system shall be labeled with the drug name, strength, expiration date and lot or control number.

DHS 134.67(6)(b)2. 2. A resident’s medication tray or drawer in a unit dose system shall be labeled with the resident’s name and room number.

DHS 134.67(6)(b)3. 3. Each medication shall be dispensed separately in single unit dose packaging exactly as ordered by the physician and in a manner that ensures the stability of the medication.

DHS 134.67(6)(b)4. 4. An individual resident’s supply of medications shall be placed in a separate, individually labeled container, transferred to the living unit and placed in a locked cabinet or cart. This supply may not exceed 4 days for any one resident.

DHS 134.67(6)(b)5. 5. If not delivered to the facility by the pharmacist, the pharmacist’s agent shall transport unit dose drugs in locked containers.

DHS 134.67(6)(b)6. 6. Individual medications shall remain in the identifiable unit dose package until directly administered to the resident. Transferring between containers is prohibited.

DHS 134.67(6)(b)7. 7. Unit dose carts or cassettes shall be kept in a locked area when not in use.

DHS 134.67 History History: Cr. Register, June, 1988, No. 390, eff. 7-1-88; CR 04-053: r. and recr. (2), r. (4) (b) and (5) (c) 3. Register October 2004 No. 586, eff. 11-1-04.

DHS 134.68 DHS 134.68 Laboratory, radiologic and blood services.

DHS 134.68(1) (1) Diagnostic services.

DHS 134.68(1)(a) (a) Facilities shall provide or promptly obtain laboratory, radiologic and other diagnostic services needed by residents.

DHS 134.68(1)(b) (b) Any laboratory and radiologic services provided by a facility shall meet the applicable requirements for hospitals found in ch. DHS 124.

DHS 134.68(1)(c) (c) If a facility does not provide the services required by this section, the facility shall make arrangements for obtaining the services from a physician’s office, hospital, nursing facility, portable x-ray supplier or independent laboratory.

DHS 134.68(1)(d) (d) No services under this subsection may be provided without an order of a physician or a physician extender.

DHS 134.68(1)(e) (e) A resident’s attending physician shall be notified promptly of the findings of all tests conducted on the resident.

DHS 134.68(1)(f) (f) The facility shall assist the resident, if necessary, in arranging for transportation to and from the provider of service.

DHS 134.68 Note Note: For record requirements, see s. DHS 134.47.