Wis. Admin. Code Department of Health Services § DHS 132.70 - Special requirements when persons are admitted for short-term care
(1) SCOPE. A
facility may admit persons for short-term care. A facility that admits persons
for short-term care may use the procedures included in this section rather than
the procedures included in ss.
DHS
132.52 and 132.60(8). Short-term care is for either
respite or recuperative purposes. The requirements in this section apply to all
facilities that admit persons for short-term care when they admit, evaluate or
provide care for these persons. Except as specified in this section, all
requirements of this chapter, including s.
DHS
132.51, apply to all facilities that admit persons for
short-term care.
(2) PROCEDURES FOR
ADMISSION. Respite care. For a person admitted to a facility
for respite care, the following admission and resident care planning procedures
may be carried out in place of the requirements under ss.
DHS
132.52 and 132.60(8):
(a) A registered nurse or physician shall
complete a comprehensive resident assessment of the person prior to or on the
day of admission. This comprehensive assessment shall include evaluation of the
person's medical, nursing, dietary, rehabilitative, pharmaceutical, dental,
social and activity needs. The consulting or staff pharmacist shall participate
in the comprehensive assessment. As part of the comprehensive assessment, when
the registered nurse or physician has identified a need for a special service,
staff from the discipline that provides the service shall, on referral from the
registered nurse or physician, complete a history and assessment of the
person's prior health and care in that discipline. The comprehensive resident
assessment shall include:
1. A summary of the
major needs of the person and of the care to be provided;
2. The attending physician's plans for
discharge.
(b) The
registered nurse, with verbal agreement of the attending physician, shall
develop a written plan of care for the person being admitted prior to or at the
time of admission. The plan of care shall be based on the comprehensive
resident assessment under par. (a), the physician's orders, and any special
assessments under par. (a).
(c)
The facility shall send a copy of the comprehensive resident assessment, the
physician's orders and the plan of care under par. (b) to the person's
attending physician. The attending physician shall sign the assessment and the
plan of care within 48 hours after the person is admitted.
(3) ADMISSION INFORMATION.
(a) This subsection takes the place of s.
DHS 132.31(1) (d)
1 for persons admitted for respite care or
recuperative care.
(b) No person
may be admitted to a facility for respite care or recuperative care without
signing or the person's guardian or designated representative signing an
acknowledgement of having received a statement before or on the day of
admission that indicates the expected length of stay, with a note that the
responsibility for care of the resident reverts to the resident or other
responsible party following expiration of the designated length of
stay.
(4) MEDICATIONS.
(c) Respite care residents and recuperative
care residents may bring medications into the facility as permitted by written
policy of the facility.
(7) RECORDS.
(a)
Contents. The medical
record for each respite care resident and each recuperative care resident shall
include, in place of the items required under s.
DHS
132.45(5):
1. The resident care plan prepared under sub.
(2) (b).
2. Admission nursing notes
identifying pertinent problems to be addressed and areas of care to be
maintained;
3. For recuperative
care residents, nursing notes addressing pertinent problems identified in the
resident care plan and, for respite care residents, nursing notes prepared by a
registered nurse or licensed practical nurse to document the resident's
condition and the care provided;
4.
Physicians' orders;
5. A record of
medications;
6. Any progress notes
by physicians or health care specialists that document resident care and
progress;
7. For respite care
residents, a record of change in condition during the stay at the facility;
and
8. For recuperative care
residents, the physician's discharge summary with identification of resident
progress, and, for respite care residents, the registered nurse's discharge
summary with notes of resident progress during the stay.
(b)
Location and
accessibility. The medical record for each short-term care resident
shall be kept with the medical records of other residents and shall be readily
accessible to authorized representatives of the department.
Notes
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