In this chapter:
“Critical access hospital" means a hospital that is designated by the department as meeting the requirements of 42 USC 1395i-4
(c) (2) (B) and is federally certified as meeting the requirements of 42 USC 1395i-4
“Dentist" means a person licensed to practice dentistry under ch. 447
“Department" means the Wisconsin department of health services.
“Health physicist" means a person holding a masters degree or doctorate in an appropriate discipline of radiologic physics or who has equivalent education and experience.
“Hospital" means any building, structure, institution or place that does all of the following:
Offers inpatient, overnight care on a 24-hour-a-day basis, or on an as-needed basis in the case of a critical access hospital.
Devotes itself primarily to the maintenance and operation of facilities for the diagnosis and treatment of, and medical or surgical care for, 3 or more nonrelated individuals, designated “patients" in this chapter, suffering from illness, disease, injury or disability, whether physical or mental, or who are pregnant.
Regularly makes available at least clinical laboratory services, diagnostic x-ray services and treatment facilities for surgery, obstetrical care or other definitive medical treatment, except as otherwise provided for critical access hospitals in this chapter.
“Hospital" may include, but is not limited to, related facilities such as outpatient facilities, nurses', interns' and residents' quarters, training facilities and central service facilities operated in connection with the hospital.
“Licensed practical nurse" means a person licensed as a trained practical nurse under ch. 441
Medical staff” means the hospital's organized component of physicians, podiatrists, dentists, and other practitioners eligible to be on the medical staff pursuant to the medical staff bylaws who are granted specific clinical privileges for the purposes of providing adequate medical, podiatric, dental care or other health care services for the patients of the hospital.
“Medicare" means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395
ccc and 42 CFR ch. IV, subch.
“Physician" means a person licensed to practice medicine or osteopathy under ch. 448
“Physician assistant" means a person certified under ch. 448
, Stats., to perform patient services under the supervision and direction of a licensed physician.
“Podiatrist" means a person licensed to practice podiatry or podiatric medicine and surgery under ch. 448
Practitioners” means physicians, dentists, podiatrists or other professions permitted by Wisconsin law to distribute, dispense and administer medications in the course of professional practice, admit patients to a hospital, or provide any other health care service that is within that profession's scope of practice and for which the governing body grants clinical privileges.
“Registered nurse" means a person who is licensed as a registered nurse under ch. 441
“Tissue" means a substance consisting of cells and intercellular material that is removed from a patient's body during a surgical procedure.
DHS 124.02 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; correction in (3) made under s. 13.93 (2m) (b) 6., Stats., Register, August, 1996, No. 488
; emerg. cr. (1m), am. (6), (12 and (19), r. and recr. (21), eff. 9-12-98; cr. (1m) and (10m), am. (6), (12) and (19) and r. and recr. (21), Register, January, 1999, No. 517
, eff. 2-1-99; correction in (3) made under s. 13.92 (4) (b) 6., Stats., Register January 2009 No. 637
; CR 19-135: r. (1), (4), (7), (8), r. and recr. (10), (14), r. (15) to (18), (20), (21) Register June 2020 No. 774, eff. 7-1-20; correction in (14) made under s. 35.17, Stats., Register June 2020.
No hospital may operate in Wisconsin unless it is approved by the department.
To be approved by the department, a hospital shall comply with this chapter and with all other applicable state laws and local ordinances, including all state laws and local ordinances relating to fire protection and safety, reporting of communicable disease, cancer reporting and post-mortem examination, and professional staff of the hospital shall be licensed or registered, as appropriate, in accordance with applicable laws.
An application for approval shall be submitted to the department on a form prescribed by the department.
DHS 124.03 Note
Note: For a copy of the hospital approval application form, write Division of Quality Assurance, P.O. Box 2969, Madison, Wisconsin 53701-2969.
The department shall review and make a determination on a complete application for approval within 90 working days after receiving the application.
Approval by the department applies only to the owner of a hospital who may not transfer or assign the approval to anyone else. When there is a change in the ownership of the hospital, the new owner shall submit a new application to the department.
If at any time the department determines that there has been a failure to comply with a requirement of this chapter, it may withhold, suspend or revoke the certificate of approval consistent with s. 50.35
Every 12 months, on a schedule determined by the department, a hospital shall submit to the department an annual report in the form and containing the information that the department requires, including payment of the fee required under s. 50.135 (2) (a)
, Stats. If a complete annual report is not timely filed, the department shall issue a warning to the holder of the certificate of approval. If a hospital that has not filed a timely report fails to submit a complete report to the department within 60 days after the date established under the schedule determined by the department, the department may revoke the approval of the hospital.
DHS 124.03 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; cr. (7), Register, August, 2000, No. 536
, eff. 9-1-00.
“Variance" means an alternative requirement in place of a requirement of this chapter.
“Waiver" means an exception from a requirement of this chapter.
(2) Requirements for waivers and variances.
A hospital may submit a request in writing to the department to grant a waiver or variance. The department may grant the waiver or variance if the department determines that the waiver or variance is necessary to protect the public health, safety, or welfare or to support the efficient and economic operation of the hospital. A waiver or variance supports the efficient and economic operation of the hospital in circumstances such as the following:
Strict enforcement of a requirement would result in unreasonable hardship on the hospital or on a patient.
An alternative to a rule, which may involve a new concept, method, procedure or technique, new equipment, new personnel qualifications or the conduct of a pilot project, is in the interests of better care or management.
All applications for the grant of a waiver or variance shall be made in writing to the department, specifying the following:
If the request is for a variance, the specific alternative action which the facility proposes;
The department may require additional information from the hospital prior to acting on the request.
The department shall grant or deny each request for waiver or variance in writing. Notice of a denial shall contain the reasons for denial.
The terms of a requested variance may be modified upon agreement between the department and the hospital.
The department may impose whatever conditions on the granting of a waiver or variance it considers necessary.
A hospital may contest the department's action on the hospital's application for a waiver or variance by requesting a hearing as provided by ch. 227
The hospital shall sustain the burden of proving that the denial of a waiver or variance is unreasonable.
The department may revoke a waiver or variance, subject to the hearing requirement in par. (c)
The department determines that the waiver or variance is adversely affecting the health, safety or welfare of the patients;
The hospital has failed to comply with the variance as granted or with a condition of the waiver or variance;
The person who has received the certificate of approval notifies the department in writing that the hospital wishes to relinquish the waiver or variance and be subject to the rule previously waived or varied; or
DHS 124.04 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; CR 19-135: r. and recr. (2) Register June 2020 No. 774, eff. 7-1-20; correction in numbering in (2) made under s. 13.92 (4) (b) 1., Stats., Register June 2020 No. 774.
Statements of deficiency and plans of correction. DHS 124.05(1)(1)
Based upon an inspection and investigation by the department under s. 50.36 (4)
, Stats., the department may issue a statement of deficiency notifying the hospital of noncompliance with a requirement of ch. 50
, Stats., or department rules.
The hospital shall submit a plan of correction to the department within 10 calendar days, including holidays and weekends, after receiving a statement of deficiency. The plan of correction shall include a reasonable fixed time period within which deficiencies are to be corrected.
After the plan of correction is submitted, the department shall determine whether the corrections proposed by the hospital would result in substantial compliance with the requirements of ch. 50
, Stats., and department rules, and notify the hospital of the department's determination. If the department determines the corrections proposed by the hospital would not result in substantial compliance, the department's notice shall describe the deficiency of the plan of correction.
DHS 124.05 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; cr. (3) (i), Register, November, 1993, No. 455
, eff. 12-1-93; correction in (3) (f) 2. made under s. 13.93 (2m) (b) 7., Stats., August, 2000, No. 536; correction in (3) (f) 2. made under s. 13.93 (2m) (b) 7., Stats., Register July 2001 No. 547
; CR 03-033
: am. (3) (h) Register December 2003 No. 576
, eff. 1-1-04; corrections in (3) (a) 2. and (f) 2. made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
; CR 09-089
: r. and recr. (3) (i), cr. (3) (j) Register March 2010 No. 651
, eff. 4-1-10; CR 19-135: r. and recr. Register June 2020 No. 774, eff. 7-1-20.
Patient rights and responsibilities in critical access hospitals. DHS 124.06(1)(1)
Every critical access hospital shall have written policies on patient rights and responsibilities, established by the governing body, which shall provide all of the following:
The patient may not be denied appropriate care because of the patient's race, creed, color, national origin, ancestry, religion, sex, sexual orientation, marital status, age, newborn status, handicap or source of payment.
The patient shall be treated with consideration, respect and recognition of the patient's individuality and personal needs, including the need for privacy in treatment.
The patient's medical record, including all computerized medical information, shall be kept confidential as required by law.
The patient, or a person authorized to act on behalf of the patient in making health care related decisions, shall have access to the patient's medical record as permitted by law.
The patient shall be entitled to know who has overall responsibility for the patient's care.
The patient, or any person authorized to act on behalf of the patient in making health care related decisions, shall receive information about the patient's illness, course of treatment and prognosis for recovery.
The patient shall have the opportunity to participate to the fullest extent possible in planning for the patient's care and treatment.
The patient or his or her designated representative shall be given, at the time of admission, a copy of the critical access hospital's policies on patient rights and responsibilities.
Except in emergencies, the consent of the patient or a person authorized to act on behalf of the patient in making health care related decisions shall be obtained before treatment is administered.
The patient may refuse treatment to the extent permitted by law and shall be informed of the medical consequences of the refusal.
The informed consent of the patient or a person authorized to act on behalf of the patient in making health care related decisions shall be obtained before the patient participates in any form of research.
Except in emergencies, the patient may not be transferred to another facility without being given a full explanation for the transfer, without provision being made for continuing care and without acceptance by the receiving institution.
The patient shall be permitted to examine, and to receive an explanation of, any bill that the patient receives from the critical access hospital, and the patient shall receive, upon request, information relating to financial assistance available through the critical access hospital.
The patient shall be informed of the patient's responsibility to comply with the rules of the critical access hospital, cooperate in the patient's own treatment, provide a complete and accurate medical history, be respectful of other patients, staff and property, and provide required information concerning payment of charges.
The patient shall be informed in writing about the critical access hospital's policies and procedures for initiation, review and resolution of patient complaints, including the address where complaints may be filed with the department.
The patient may designate persons who are permitted to visit the patient during the patient's stay at the critical access hospital.
A patient who receives treatment at a critical access hospital for mental illness, a developmental disability, alcohol abuse or drug abuse shall have, in addition, the rights listed under s. 51.61
, Stats., and ch. DHS 94
Critical access hospital staff assigned to direct patient care shall be informed of and demonstrate their understanding of the policies on patient rights and responsibilities through orientation and appropriate in-service training activities.