Wis. Admin. Code DHS § DHS 88.09

Current through October 28, 2024
Section DHS 88.09 - Records
(1) RESIDENT RECORDS.
(a) The licensee shall maintain a record for each resident. Resident records shall be maintained in a secure location within the home to prevent unauthorized access.
(b) The records of residents shall be confidential. Access to records of a resident's HIV test results shall be controlled by s. 252.15, Stats. Access to other resident records shall be restricted to the following: the resident, the resident's guardian, authorized representatives of the department, other persons or agencies with the informed written consent of the resident or resident's guardian, if applicable, persons or agencies authorized by s. 51.30, Stats., ss. 146.81 to 146.83, Stats., or 42 CFR Part 2, and persons or agencies authorized by other applicable law.

Note: Section 51.30(4) (b) 5 and 15., Stats., permits sharing of limited information in certain circumstances between the department and a county department established under s. 46.215, 46.22, 46.23, 51.42 or 51.437, Stats.

Note: For information on 42 CFR Part 2 which relates to a resident who is in the home because of alcohol or other drug abuse, write or phone the appropriate regional office of the department's division of disability and elder services which will refer you to the appropriate county agency in your county. See Appendix A for the addresses and phone numbers of these offices.

Note: The records of residents with mental disabilities are subject to requirements of s. 51.30, Stats., and ch. DHS 92.

(c) Copies of a resident's record shall be made available on request to the resident, the resident's guardian or a designated representative of the resident as soon as reasonably practicable if authorized in writing by the resident, at a cost no greater than the cost of reproduction.
(d) A resident's record shall include all of the following:
1. The resident's name and date of birth.
2. The name, address, and phone number of the resident's legal guardian, if any.
3. The name, address and phone number of every person, including the resident's physician, to be notified in the event of an emergency.
4. The name, address and phone number of the placing agency, if any, and service coordinator, if any.
5. Medical insurance or medical assistance and medicare identification numbers and the name of the pharmacy that the resident uses. In this subdivision, "medical assistance" means the assistance program operated by the department under ss. 49.43 to 49.497, Stats., and "medicare" means the insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395.22 and 42 CFR, Pts. 405 to 421.
6. The service agreement required under s. DHS 88.06(2) (b) and (c).
7. The report of the medical examination required under s. DHS 88.06(2) (a).
8. The individual service plan required under s. DHS 88.06(3).
9. The statement indicating that resident rights and grievance procedures have been explained and copies have been provided to the parties as required under s. DHS 88.06(2) (c) 8.
10. Medication records under s. DHS 88.07(3) (d) and (e).
11. Records maintained by the licensee of the resident's finances, including written authorization from the resident or the resident's guardian to control the resident's funds.
(e) The licensee shall retain a resident's record for at least 7 years after the resident's discharge. The record shall be kept in a secure, dry place.
(2) SERVICE PROVIDER AND LICENSEE RECORDS.
(a)Service provider record. The licensee shall maintain and keep up to date a separate personnel record for each service provider. The licensee shall ensure that all service provider records are adequately safeguarded against destruction, loss or unauthorized use. A service provider record shall include all of the following:
1. Name and address.
2. Social security number.
3. Date of birth.
4. Beginning date of employment.
5. Job-related experience and training.
6. Educational qualifications.
7. Job description.
8. Documentation of successful completion of the training requirements under s. DHS 88.04(5).
9. The results of screening for communicable disease.
10. Description of any disciplinary action.
11. Date of discharge or resignation.
(b)Licensee record. The licensee shall maintain and keep up to date a separate record for the licensee which shall contain the information listed in par. (a) 1., 2., 3., 5., 6., 8. and 9.
(c)Location and retention period. Service provider and licensee records shall be available at the adult family home for review by the licensing agency. A service provider's record shall be available while the service provider is employed by the home and for at least 3 years after ending employment.

Wis. Admin. Code Department of Health Services DHS 88.09

Cr. Register, January, 1996, No. 482, eff. 2-1-96.