DHS 105.19(4)(c)5.5. Promptly inform the physician and other personnel participating in the patient’s care of changes in the patient’s condition and needs. DHS 105.19(5)(5) Patient rights. A nurse shall provide a written statement of the rights of the recipient for whom services are provided to the recipient or guardian or any interested party prior to the provision of services. The recipient or guardian shall acknowledge recipient of the statement in writing. The nurse shall promote and protect the exercise of these rights and keep written documentation of compliance with this subsection. Each recipient receiving care shall have the following rights: DHS 105.19(5)(a)(a) To be fully informed of all rules and regulations affecting the recipient; DHS 105.19(5)(b)(b) To be fully informed of all services to be provided by the nurse and of related charges, including any charges for services for which the recipient may be responsible; DHS 105.19(5)(c)(c) To be fully informed of one’s own health condition, unless medically contraindicated, and to be afforded the opportunity to participate in the planning of services, including referral to a health care institution or other agency; DHS 105.19(5)(d)(d) To refuse treatment to the extent permitted by law and to be informed of the medical consequences of that refusal; DHS 105.19(5)(e)(e) To confidential treatment of personal and medical records and to approve or refuse their release to any individual, except in the case of transfer to a health care facility; DHS 105.19(5)(f)(f) To be taught, and have the family or other persons living with the recipient taught, the treatment required, so that the recipient can, to the extent possible, help himself or herself, and the family or other party designated by the recipient can understand and help the recipient; DHS 105.19(5)(h)(h) To complain about care that was provided or not provided, and to seek resolution of the complaint without fear of recrimination. DHS 105.19(6)(6) Universal precautions. A nurse shall have the necessary orientation, education and training in epidemiology, modes of transmission and prevention of HIV and other blood-borne or body fluid-borne infections and shall follow universal blood and body-fluid precautions for each recipient for whom services are provided. The nurse shall employ protective measures recommended by the federal centers for disease control (CDC), including those pertaining to medical equipment and supplies, to minimize the risk of infection from HIV and other blood-borne pathogens. DHS 105.19 NoteNote: A copy of the CDC recommended universal precautions may be obtained from the Division of Quality Assurance, P.O. Box 2969, Madison, Wisconsin 53701.
DHS 105.19(7)(7) Medical record. The nurse shall maintain a medical record for each recipient. The record shall document the nature and scope of all services provided and shall be systematically organized and readily accessible to authorized department personnel. The medical record shall document the recipient’s condition, problems, progress and all services rendered, and shall include: DHS 105.19(7)(b)(b) Appropriate hospital information, including discharge information, diagnosis, current patient status and post-discharge plan of care; DHS 105.19(7)(d)(d) All medical orders, including the written plan of care and all interim physician’s orders; DHS 105.19(7)(e)(e) A consolidated list of medications, including start and stop dates, dosage, route of administration and frequency. This list shall be reviewed and updated for each nursing visit, if necessary; DHS 105.19(7)(f)(f) Progress notes posted as frequently as necessary to clearly and accurately document the recipient’s status and services provided. In this paragraph, “progress note” means a written notation, dated and signed by a member of the health team providing covered services, that summarizes facts about care furnished and the recipient’s response during a given period of time; DHS 105.19(7)(g)(g) Clinical notes written the day service is provided and incorporated into the clinical record within 7 days after the visit or recipient contact. In this paragraph, “clinical note” means a notation of a contact with a recipient that is written and dated by a member of the home health team providing covered services, and that describes signs and symptoms, treatment and drugs administered and the patient’s reaction, and any changes in physical or emotional condition; DHS 105.19(7)(h)(h) Written summaries of the recipient’s care provided by the nurse to the physician at least every 62 days; and DHS 105.19(7)(i)(i) Written authorizations from the recipient or the recipient’s guardian when it is necessary for the nurse to procure medical supplies or equipment needed by the recipient. DHS 105.19(7m)(7m) Electronic visit verification. The nurse is required to capture and retain EVV records. DHS 105.19(8)(a)(a) A recipient’s nurse shall designate an alternate nurse to provide services to the recipient in the event the nurse is temporarily unable to provide services. The recipient shall be informed of the identity of the alternate nurse before the alternate nurse provides services. DHS 105.19(8)(b)(b) The nurse shall document a plan for recipient-specific emergency procedures in the event a life-threatening situation or fire occurs or there are severe weather warnings. This plan shall be made available to the recipient and all caregivers prior to initiation of these procedures. DHS 105.19(8)(c)(c) The nurse shall take appropriate action and immediately notify the recipient’s physician, guardian, if any, and any other responsible person designated in writing by the patient or guardian of any significant accident, injury or adverse change in the recipient’s condition. DHS 105.19(9)(9) Discharge of the recipient. A recipient shall be discharged from services provided by the nurse upon the recipient’s request, upon the decision of the recipient’s physician, or if the nurse documents that continuing to provide services to the recipient presents a direct threat to the nurse’s health or safety and further documents the refusal of the attending physician to authorize discharge of the recipient with full knowledge and understanding of the threat to the nurse. The nurse shall recommend discharge to the physician and recipient if the recipient does not require services or requires services beyond the nurse’s capability. The nurse provider shall issue a notification of discharge to the recipient or guardian, if possible at least 2 calendar weeks prior to cessation of skilled nursing services, and shall, in all circumstances, provide assistance in arranging for the continuity of all medically necessary care prior to discharge.