(i) The county of residence for each client.
(j) The estimated number of diversions from Winnebago Mental Health Institute.
(k) The number of repeat clients and readmissions.
(L) Any follow-up services utilized, as applicable.
(m) The number of transfers to other facilities, including Winnebago Mental Health Institute, hospitals, or other facilities.
(n)A description of any injuries, assaults, or other safety-related incidents.
(o)The number of times law enforcement was contacted due to intervention needed at the facility.
(p) A description of the number and type of employees providing staffing during the various times of day, including by telehealth.
(q) A breakdown of funding, including the amounts and sources of funding.
DHS 31.16 Client rights and grievance procedure. All CUCOF operations, policies, and services shall comply with s. 51.61, Stats. and ch. DHS 94, relating to patient rights and resolution of patient grievances. CUCOFs admitting minors should comply with 51.13(3) stats. Subchapter III - Facilities
DHS 31.17 Applicability
(1) This subchapter applies to publicly or privately operated and certified CUCOFs.
(2) A CUCOF that is approved as a hospital under ch. DHS 50 is not required to meet the requirements under this subchapter.
DHS 31.18 General facility requirements.
(1) A CUCOF shall operate 24 hours per day, 7 days per week.
(2) The facility of a CUCOF shall be constructed and maintained so that it is functional for assessment and treatment and for the delivery of health services appropriate to the needs of the community and with due regard for protecting the health and safety of the clients.
(3) No CUCOF shall have more clients at any given time than the maximum capacity indicated on the department-approved certification.
(4) A CUCOF shall be physically separated from other entities, programs, and services.
(5) A CUCOF shall comply with the Group I-2 occupancy state building code requirements in chs. SPS 361 and 366, and any applicable local ordinances or municipal building regulations. (6) A CUCOF shall maintain all rooms in the facility in a state of good repair and in a clean, safe, and sanitary condition.
(7) A CUCOF must be in compliance with the Americans with Disabilities Act, 42 USC 12101 et seq. (8) A CUCOF shall provide separate entrances or intakes for walk-in clients, law enforcement, and if applicable minor clients.
(9) A CUCOF shall provide a nurse station that facilitates direct staff visual observation of unit corridors and client care areas.
(10) A CUCOF shall have a clean workroom, soiled holding, and environmental services room.
DHS 31.19 Physical environment
(1) Space requirements.
(a) Client examination room. A CUCOF shall have a client examination room that shall include the following:
1. A wall that physically separates the client examination room from client rooms, living areas, staff areas, or facility common areas.
2. A functioning sink that is equipped with appropriate equipment and supplies for infection prevention.
(b) Medication storage areas. A CUCOF shall comply with physical security requirements in 21 CFR 1301.72. The medication storage area shall be clean and shall be separated by a wall from any restroom, cleaning products, or food-preparation storage areas. (c) Observation unit. A CUCOF that has an observation unit for clients receiving services for less than 24 hours shall do all of the following:
1.. Ensure that each bed in the observation unit is dedicated to one client at a time.
2. Provide a minimum floor area that allows for 3 feet between beds.
(d) Individual or dual occupancy client rooms.
1. A CUCOF shall have a minimum of 3 client rooms and 4 beds.
2. A CUCOF shall have a minimum of one single occupancy client room.
3. Designated client rooms shall not serve a multi-functional purpose.
4. Visual privacy shall be provided for each client in dual occupancy rooms.
5. The minimum floor area per bed shall be 80 square feet in multiple client rooms and 100 square feet in single client rooms. The distance between client beds in multi-client rooms shall be at least 3 feet.
6. Clients’ clothing and personal items may be stored in a separate designated area.
7. Corridors and spaces connected to a corridor that are not separable by a door shall not be used for client rooms, observation units, or hazardous areas.
(e) Toilet rooms.
1. ‘Client rooms.’
a. One toilet room shall serve no more than 6 dedicated client beds.
b. A handwashing sink shall be provided either in each client’s room or in the toilet room.
c. A shower shall be provided either in each client’s room or adjoining the toilet room.
2. ‘Observation unit.’
a. An observation unit shall have at least one toilet room with a sink per 10 beds.
b. An observation unit shall have at least one shower stall available to clients.
c. An observation unit shall have at least one soiled linen holding room.
3. ‘Access to toilet rooms.’ Every toilet door shall be designed to allow opening from the outside during an emergency when locked.
(f) Client call system. A reliable call mechanism shall be provided in locations where clients may be left unattended, including client rooms, toilet and bathing areas and designated high risk treatment areas from which persons may need to summon assistance.
(g) Visitor space and phone calls. A CUCOF shall allow space for visitors and telephone calls.
(h) Family space for minors. A CUCOF certified to serve minors shall have designated space available for families to assemble.
(2) Laundry services.
(a) Handling laundry. A CUCOF shall have a designated laundry area to sort, process and store clean and soiled laundry in a manner that prevents the spread of infection.
(b) Storage and transport. A CUCOF shall have separate clean and dirty laundry storage areas or containers. A CUCOF shall not transport, wash, or rinse soiled laundry in areas used for food preparation, serving or storage.
(c) Clothes dryers. A CUCOF shall enclose any clothes dryer having a rated capacity of more than 37,000 British Thermal Units an hour in a one-hour fire resistive rated enclosure. If the clothes dryer requires a vent, a CUCOF shall use dryer vent tubing that is of rigid material with a fire rating that exceeds the temperature rating of the dryer. The dryer vent tubing shall be clean and maintained according to the manufacturer’s recommendations.
(3) Building maintenance and site.
(a) Maintenance. The condition of the physical plant for the CUCOF and its exterior areas shall be maintained in good repair, free of hazards, and in such a manner that assures the safety and well-being of clients, staff, and visitors.
(b) Pest control. A CUCOF shall implement safe, effective procedures for control and extermination of insects, rodents, and vermin.
(c) Garbage and refuse. A CUCOF shall promptly dispose of garbage and refuse. Garbage and refuse in inside areas shall be kept in leak-proof, non-absorbent closed containers. Garbage and refuse in outside areas shall be stored in closed containers.
(d) Storage of toxic substances. A CUCOF shall ensure that any cleaning compounds, polishes, insecticides, and toxic substances are labeled and stored in a secure area.
(4) Building support systems.
(a) Heating.
1. A CUCOF shall maintain a heating system in a safe and properly functioning condition that can maintain temperatures between 70-75 degrees Fahrenheit in areas occupied by clients.
2.. A CUCOF shall ensure that a heating contractor or local utility company completes regular maintenance and provides documentation of the maintenance performed.
3. A CUCOF may not use a fuel-fired heater, wood burning stove, fireplace, portable space heater, or any other open flame combustible fuel-burning device.
(b) Public water supply. A CUCOF shall use a public water supply when available. If a public water supply is not available, a CUCOF shall have a well that is approved by the state department of natural resources. A CUCOF shall have the well water tested at least annually by the state laboratory of hygiene or other laboratory approved under ch. NR 149. A CUCOF shall maintain documentation of annual testing results. (c) Electrical.
1. ‘Installation and maintenance.’
a. A CUCOF shall be supplied with electrical service, wiring, outlets, and fixtures, which shall be properly installed and maintained in good and safe working condition.
b. Electrical outlets shall be located to limit the use of extension cords. Extension cords shall not be used in lieu of permanent wiring and shall not be used in any space where a client may be.
c. All temporary wiring and exposed wiring, whether in use or abandoned, shall be removed.
2. ‘Service size.’ The electrical service shall be of the proper size to handle the connected load.
3. ‘Protection.’
a. Tamper-resistant fuses or circuit breakers not to exceed the ampere capacity of the smallest wire size in the circuit shall protect the branch circuits.
b. Ground fault interrupt protection shall be required for all outlets within 6 feet of a plumbing fixture, all outlets on the exterior of a CUCOF.
c. Electrical receptacles shall be of a tamper-resistant type when located within client toilet rooms and bathing facilities, client bedrooms, and other client care spaces.
4. ‘Minimum number of fixtures.’ Every client room, bathroom, kitchen or kitchenette, dining room, laundry room and furnace room shall contain at least one approved or listed ceiling or wall-type electric light fixture equipped with sufficient lamps or tubes to provide at least 5-foot candles at floor level at the center of room. Where more than one fixture is used or required, the additional fixture or fixtures shall be equally spaced as far as is practical. A switched outlet may be substituted for a ceiling or wall fixture in client rooms and dining rooms.
5. ‘Minimum number of outlets.’
a. In common rooms, dining rooms and client rooms, there shall be one electric duplex outlet per 75 square feet of floor area, with a minimum of 2 per room.
b. In kitchens, there shall be one electric duplex outlet per 8 lineal feet or fraction thereof of countertop and preparation area, including island-type areas. If a kitchen is also used for dining purposes, there shall be at least one electric duplex outlet per 75 square feet of floor area. Separate outlets shall be provided for refrigerators.
