DHS 134.53 HistoryHistory: 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 134.54DHS 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 134.60DHS 134.60 Resident care.

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)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.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 NoteNote: 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)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.