Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 134. FACILITIES SERVING PEOPLE WITH DEVELOPMENTAL DISABILITIES
SUBCHAPTER V -- SERVICES
Date:
08/31/2009
Document:
DHS 134.60 Resident care.
(1) RESIDENT CARE PLANNING. (a) Interdisciplinary team. 1. An interdisciplinary team shall develop' a resident's individual program plan.
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 mental retardation professional and a nurse, and a physician as required under s. DHS 134.66 (2) (a) 2. and (c).
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.
(b) Development and content of the individual program plan. 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.
2. The IPP shall include:
a. A list of realistic and measurable goals in priority order, with time limits for attainment;
b. Behavioral objectives for each goal which must be attained before the goal is considered attained;
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;
d. Evaluation procedures for determining whether the methods or strategies are accomplishing the care objectives; and
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.
Note: 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).
(c) Reassessment of individual program plan. 1. 'Special and professional services review.' 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.
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.
c. Documentation of the reassessment results, treatment objectives, plans and procedures, and continuing treatment progress reports shall be recorded in the resident's record.
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 snake program recommendations as indicated by the resident's developmental progress. The review shall consider at least the following:
a. The appropriateness of the individual program plan and the individual's progress toward meeting plan objectives;
b. The advisability of continued residence, and recommendations for alternative programs and services; and
c. The advisability of guardianship and a plan for assisting the resident in the exercise of his or her rights.
(d) Implementation. Progress notes shall reflect the treatment and services provided to meet the goals stated in the IPP.
(e) Notification of changes in condition, treatment or status of resident. Any significant change in the condition of a resident shall be reported to the individual in charge or on call who shall take appropriate action, including notification of designated parties, as follows:
1. A resident's parents, guardian, if any, physician and any other person designated in writing by the resident or guardian to be notified shall be notified promptly of any significant accident or injury affecting the resident or any adverse change in the resident's condition.
2. A resident's parents, guardian, if any, and any other person designated in writing by the resident or guardian to be notified shall be notified promptly of any significant non-medical change in the resident's status, including financial situation, any plan to discharge the resident or any plan to transfer the resident within the facility or to another facility.
(f) Emergencies. 1. In the event of a medical emergency, the facility shall provide or arrange for appropriate emergency services.
2. The facility shall have written procedures available to residents and staff for procuring a physician or an emergency service, such as a rescue squad, to furnish necessary medical care in an emergency and for providing care pending the arrival of a physician.
3. The names and telephone numbers of physicians, nurses and medical service personnel available for emergency calls shall be posted on or next to each telephone in the facility.
(g) Resident safety. The facility is responsible for the safety and security of residents. This includes responsibility for the assignment of specific staff to individual residents. Assigned staff shall be briefed beforehand on the condition and appropriate care of residents to whom they are assigned.
(2) RESIDENT CARE STAFFING. (a) Definitions. For each resident with a developmental disability, required minimum hours of direct care shall be calculated based on the following definitions:
1. "DD level I" means the classification of a person who functions as profoundly or severely retarded; is under the age of 18; is severely physically handicapped; is aggressive, assaultive or a security risk; or manifests psychotic-like behavior and may engage in maladaptive behavior persistently or frequently or in behavior that is life-threatening. This person's habilitation program emphasizes basic ADL skills and requires intensive staff effort.
2. "DD level II" means the classification of a person who functions as moderately retarded and who may occasionally engage in maladaptive behavior. This person's health status may be stable or unstable. This person is involved in a habilitation program to increase abilities in ADL skills and social skills.
3. "DD level III" means the classification of a person who functions as mildly retarded and who may rarely engage in maladaptive behavior. This person's health status is usually stable. This person is involved in a habilitation program to increase domestic and vocational skills.
4. "Direct care staff on duty" means persons assigned to the resident living unit whose primary responsibilities are resident care and implementation of resident habilitation programs.
5. "Maladaptive behavior" means a person's act or activity which differs from the response generally expected in the situation and which prevents the person from performing routine tasks.
6. "Mildly retarded" means a diagnosis of an intelligence quotient (IQ) of 50 to 55 at the lower end of a range to 70 at the upper end.
7. "Moderately retarded" means a diagnosis of an intelligence quotient (IQ) of 35 to 40 at the lower end of a range to 50 to 55 at the upper end.
8. "Profoundly retarded" means a diagnosis of an intelligence quotient (IQ) below 20 to 25.
9. "Severely retarded" means a diagnosis of an intelligence quotient (IQ) of 20 to 25 at the lower end of a range to 35 to 40 at the upper end.
(b) Total staffing. 1. Each resident living unit shall have adequate numbers of qualified staff to care for the specific needs of the residents and to conduct the resident living program required by this subchapter.
2. a. A living unit with more than 16 beds or a living unit that houses one or more residents for whom a physician has ordered a medical care plan or one or more residents who are aggressive, assaultive or security risks, shall have direct care staff on duty and awake within the facility when residents are present. The direct care staff on duty shall be responsible for taking prompt, appropriate action in case of injury, illness, fire or other emergency and for involving appropriate outside professionals as required by the emergency.
b. A living unit with 16 or fewer beds which does not have any resident for whom the physician has ordered a medical care plan or any resident who is aggressive, assaultive or a security risk shall have at least one direct care staff member on duty when residents are present who is immediately accessible to the residents 24 hours a day to take reports of injuries and symptoms of illness, to involve appropriate outside professionals and to take prompt, appropriate action as required by any emergency.
(c) Records and weekly schedules. Weekly time schedules for staff shall be planned, posted and dated at least one week in advance, shall indicate the names and classifications of personnel providing resident care and relief personnel assigned on each living unit for each shift, and shall be updated as changes occur.
(d) Minimum direct care staff hours. 1. In this paragraph, "resident care staff time" means only the time of direct care staff on duty.
2. a. For each residential living unit which has one or more residents with a classification of DD level I, the facility shall provide a direct care staff-to-resident ratio of 1 to 3.2 each day, with ratios of one direct care staff person on duty to 8 residents on the day shift, one direct care staff person on duty to 8 residents on the evening shift and one direct care staff person on duty to 16 residents on the night shift.
b. For each residential living unit which has one or more residents with a classification of DD level II, the facility shall provide a direct care staff-to-resident ratio of 1 to 4 each day, with ratios of one direct care staff person on duty to 8 residents on the day shift, one direct care staff person on duty to 16 residents on the evening shift and one direct care staff person on duty to 16 residents on the night shift.
c. For each residential living unit which has one or more residents with a classification of DD level III, the facility shall provide a direct care staff-to-resident ratio of 1 to 6.4 each day, with ratios of one direct care staff person on duty to 16 residents on the day shift, one direct care staff person on duty to 16 residents on the evening shift and one direct care staff person on duty to 32 residents on the night shift.
(3) ACTIVE TREATMENT PROGRAMMING. (a) Except as provided in par. (b), each resident shall receive active treatment. Active treatment shall include:
1. The resident's regular participation, in accordance with the IPP, in professionally developed and supervised activities, experiences and therapies. The resident's participation shall be directed toward:
a. The acquisition of developmental, behavioral and social skills necessary for the resident's maximum possible individual independence; or
b. For dependent residents where no further positive growth is demonstrable, the prevention of regression or loss of current optimal functional status; and
2. An individual post-institutionalization plan, as part of the IPP developed before discharge by a qualified mental retardation professional and other appropriate professionals. This shall include provision for appropriate services, protective supervision and other follow-up services in the resident's new environment.
(b) Active treatment does not include the maintenance of generally independent residents who are able to function with little supervision or who require few, if any, of the significant active treatment services described in this subsection.
(4) MEDICATIONS, TREATMENTS AND THERAPIES. (a) Orders. 1. Medications, treatments and habilitative or rehabilitative therapies shall be administered as ordered by a physician or dentist subject to the resident's right to refuse them. If the resident has a court-appointed guardian, the guardian's consent rather than the resident's consent is required. No medication, treatment or changes in medication or treatment may be administered to a resident without a physician's or dentist's written order which shall be filed in the resident's record.
Note: Section 51.61 (6), Stats., requires that written informed consent for treatment, including medications, be obtained from any person who was voluntarily admitted for treatment for developmental disabilities, mental illness, drug abuse or alcohol abuse. Section 42 CFR 442.404 (b) and (f) requires the written informed consent of every resident for treatment, including medications. This includes voluntary admissions as well as involuntary admissions under ch. 51 or 55, Stats.
4. Each resident's medications shall be reviewed by a registered nurse at the time of the annual review of the IPP.
(b) Stop orders. 1. Medications not specifically limited as to time or number of doses when ordered shall be automatically stopped in accordance with facility policies and procedures developed under s. DHS 134.67 (3) (a) 5.
2. The facility shall notify each resident's attending physician or dentist of stop order policies and shall contact the physician or dentist promptly for renewal of orders that are subject to automatic termination.
(d) Administration of medications. 1. Medications may be administered only by a nurse, a practitioner or a person who has completed training in a drug administration course approved by the department. Facility staff shall immediately record the administration of medications in the resident's record.
2. Facilities shall develop policies and procedures designed to provide safe and accurate acquisition, receipt, dispensing and administration of medications and these policies and procedures shall be followed by personnel assigned to prepare and administer medications and to record their administration. Except when a single unit dose drug delivery system is used, the same person shall prepare and administer the resident's medications.
3. If for any reason a medication is not administered as ordered in a unit dose drug delivery system, an unadministered dose slip with an explanation of the omission shall be placed in the resident's medication container and a notation shall be made in the resident's record.
4. Self-administration of medications by a resident shall be permitted if the interdisciplinary team determines that self-administration is appropriate and if the resident's physician or dentist, as appropriate, authorizes it.
5. Medication errors and suspected or apparent drug reactions shall be reported to the physician or registered nurse in charge or on call as soon as discovered and an entry shall be made in the resident's record. Appropriate action or interventions shall be taken.
Note: See s. DHS 134.67, pharmaceutical services, for additional requirements.
(e) Habilitative or rehabilitative therapies. Any habilitative or rehabilitative therapy ordered by a physician or dentist shall be administered by a therapist or QMRP. Any treatments and changes in treatments shall be documented in the resident's record.
(5) PHYSICAL RESTRAINTS. (a) Definitions. In this subsection:
1. "Mechanical support" means any article, device or garment used only to achieve proper body position or balance of the resident or in specific medical or surgical treatment, including a geri chair, posey belt, jacket, bedside rail or protective head gear.
2. "Physical restraint" means any article, device or garment used primarily to modify resident behavior by interfering with the free movement of the resident or normal functioning of a portion of the body, and which the resident is unable to remove easily, or confinement in a locked room, but does not include mechanical supports. A totally enclosed crib or barred enclosure is a physical restraint.
(b) Use of restraints. 1. Except as provided in subd. 2., a physical restraint may be applied only as an integral part of the resident's behavior management program on the written order of a physician. The order shall indicate the resident's name, the reason for the restraint and the period during which the restraint is to be applied. An order for a physical restraint not used as an integral part of a behavior management program may not be in effect longer than 12 hours.
2. In an emergency, a physical restraint may be temporarily applied without an order of a physician if necessary to protect the resident or another person from injury or to prevent physical harm to the resident or another person resulting from the destruction of property, provided that the physician is notified within one hour following application of the restraint and authorizes its continued use and that:
a. For the initial emergency authorization, the physician specifies the type of restraint to be used, reasons for the restraint and time limit or change in behavior that will determine when the restraints are removed;
b. A follow-up contact is made with the physician if an emergency restraint is continued for more than 12 hours; and
c. Written authorization for the emergency use of restraints is obtained from the physician within 48 hours following the initial physician contact.
3. A physical restraint may only be used when less restrictive measures are ineffective and provided that a habilitation plan is developed and implemented to reduce the individual's dependency on the physical restraints.
4. A physical restraint may not be used as punishment, for the Convenience of the staff or as a substitute for an active treatment program or any particular treatment.
5. A physical restraint used as a time-out device, as defined in sub. (6), shall be applied only during a behavior management program and only in the presence of staff trained to implement the program.
6. a. Staff trained in the use of restraints shall check physically restrained residents at least every 30 minutes.
b. Residents in physical restraints shall have their positions changed, personal needs met, and an opportunity for motion and exercise for a period of at least 10 minutes during every 2 hour period of physical restraint.
7. If the mobility of a resident is required to be restrained and can be appropriately restrained either by a locked unit or another physical restraint, a locked unit shall be used and s. DHS 134.33 shall apply.
8. Any use of restraints shall be noted, dated and signed in the resident's record. A record shall be kept of the periodic checking on the resident in restraints required by subd. 6.
(6) BEHAVIOR MANAGEMENT PROGRAMS. (a) Definition. In this subsection and in sub. (5), "time-out" means a procedure to improve a resident's behavior by removing positive reinforcement when the behavior is undesirable.
(b) Plans. A written plan shall be developed for each resident participating in a behavior management program, including a resident placed in a physical restraint to modify behavior or for whom drugs are used to manage behavior. The plan shall be incorporated into the resident's IPP and shall include:
1. The behavioral objectives of the program;
2. The methods to be used;
3. The schedule for the use of each method;
4. The persons responsible for the program;
5. The data to be collected to assess progress toward the desired objectives; and
6. The methods for documenting the resident's progress and determining the effectiveness of the program.
(c) Review and approval. The department shall review for approval every plan for a behavior management program before the program is started for the following:
1. Any unlocked time-out that exceeds one hour;
2. Any procedure considered unusual or intrusive, such as a procedure that would be considered painful or humiliating by most persons or a procedure involving the confinement of an ambulatory person by means of a physical restraint or specialized clothing; or
3. Any procedure that restricts or denies a resident right under subch. II.
(d) Consent. A behavior management program may be conducted only with the written consent of the resident, the parents of a minor resident or the resident's guardian.
(e) Duration. Time-out involving removal from a situation may not be used for longer than one hour and then only during the behavior management program and only in the presence of staff trained to implement the program.
(7) CONDUCT AND CONTROL. (a) The facility shall have written policies and procedures for resident conduct and control that are available in each living unit and to parents and guardians.
(b) When appropriate, residents shall be allowed to participate in formulating policies and procedures for resident conduct and control.
(c) Corporal punishment of a resident is not permitted.
(d) No resident may discipline another resident unless this is done as part of an organized self-government program conducted in accordance with written policy and is an integral part of an overall treatment program supervised by a licensed psychologist or physician.
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