DHS 134.44(5)(a)(a) New employees.
Every employee shall be certified in writing by a physician, physician assistant or advanced practice nurse prescriber as having been screened for the presence of clinically apparent communicable disease that could be transmitted to residents during the normal performance of the employee's duties. This certification shall include screening for tuberculosis within 90 days prior to employment.
(b) Continuing employees.
Employees shall be rescreened for clinically apparent communicable disease as described in par. (a)
based on the likelihood of exposure to a communicable disease, including tuberculosis. Exposures to a communicable disease may be in the facility, in the community or as a result of travel or other exposure.
Persons who reside in the facility but are not residents or employees, such as relatives of the facility's owners, shall be certified in writing as required in pars. (a)
(6) Disease surveillance and control.
When an employee or prospective employee has a communicable disease, he or she may not perform employment duties in the facility that may result in the transmission of the communicable disease until the facility makes safe accommodations to prevent the transmission of the communicable disease.
DHS 134.44 Note
Note: The Americans with Disabilities Act and Rehabilitation Act of 1973 prohibits the termination of an employee or the non-hiring of a person solely because that person has an infectious disease, illness or condition.
Facilities may use volunteers provided that the volunteers receive the orientation and supervision necessary so that resident health, safety and welfare are safeguarded and that the facilities do not rely upon volunteers to provide direct care to residents.
DHS 134.44 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88; CR 04-053
: r. and recr. (5) and (6) Register October 2004 No. 586
, eff. 11-1-04.
Orientation for new employees.
Except in an emergency, before a new employee, including a temporary employee, performs any duties, he or she shall be oriented to the facility and its policies, including policies and procedures concerning fire prevention, accident prevention and response to emergencies. By the time each new employee has worked 30 days in the facility, he or she shall be oriented to resident rights under s. DHS 134.31
, to his or her position and duties and to facility procedures.
The facility shall provide continuing inservice training for all employees to update and improve their skills in providing resident care, and supervisory and management training for each employee who is in or is a candidate for a supervisory position.
(b) Resident care.
The facility shall require employees who provide direct care to residents to attend educational programs designed to develop and improve employee skills and knowledge relating to the needs of the facility's residents, including their developmental, behavioral and health care needs. These programs shall be conducted as often as is necessary to enable staff to acquire the skills and techniques necessary to implement the individual program plans for each resident under their care.
Educational programs shall be held periodically for dietary staff. These programs shall include instruction in proper handling of food, personal hygiene and grooming, nutrition and modified diet patterns, sanitation, infection control and prevention of food-borne disease and other communicable disease.
(3) Training in medications administration.
Before persons other than nurses and practitioners may administer medications under s. DHS 134.60 (4) (d) 1.
, they shall be trained in a course approved by the department.
DHS 134.45 History
Cr. Register, June, 1988, No. 390
, eff. 7-1-88.
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.
(2) Resident abuse.
No person may abuse a resident.
(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
Cr. Register, June, 1988, No. 390
, eff. 7-1-88.
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
, Stats., and this chapter and shall provide reasonable opportunities for an authorized representative of the department to examine facility records to gather this information.
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.
Duties specified in this section that relate to resident records shall be completed by staff in a timely manner.
(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.
(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.
A master alphabetical resident record index shall be maintained at a central location.
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:
The facility shall have written policies to govern access to and duplication and release of information from resident records; and
The facility shall obtain the written consent of the resident or guardian before releasing information to unauthorized individuals.
(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.
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.
The facility shall provide adequate space, equipment and supplies to review, index, file and retrieve resident records.
The resident record shall be completed and stored within 60 days following a resident's discharge or death.
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.
A resident's record may be destroyed after 5 years has elapsed following the resident's discharge or death, provided that:
The facility permanently retains at least a record of the resident's identity, final diagnosis, physician and dates of admission and discharge.
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.
If the ownership of a facility changes, the resident records and indexes shall remain with the facility.
DHS 134.47 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)
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:
The stamp or electronic representation is used only by the person who makes the entry; and
The facility possesses a statement signed by the person, certifying that only that person shall possess and use the stamp or electronic representation.
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.
(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:
(a) Admission information.
Information obtained on admission, including:
Name, date of admission, birth date and place, citizenship status, marital status and social security number;
Father's name and birthplace and mother's maiden name and birthplace;
Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;
Sources of support, including social security, veterans' benefits and insurance;
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)
(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.
(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)
. The summary shall include:
The name and address of the guardian or other person having authority to speak or act on behalf of the resident;
The date on which the authorization or consent takes effect and the date on which it expires;
The express legal nature of the authorization or consent and any limitations on it; and
Any other facts that are reasonably necessary to clarify the scope and extent of the authorization or consent.
(d) Resident care planning documentation.
Resident care planning documentation, including:
The comprehensive evaluation of the resident and written training and habilitation objectives;
The annual review of the resident's program by the interdisciplinary team;
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;
Professional and special programs and service plans, evaluations and progress notes; and
Direct care staff notes reflecting the projected and actual outcome of the resident's habilitation or rehabilitation program.
(e) Medical service documentation.
Documentation of medical services and treatments provided to the resident, including:
(f) Nursing service documentation.
Documentation of nursing needs and the nursing services provided, including: