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History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.29Administration.
(1)Administrator. The administrator shall be responsible for day-to-day operation of the hospice.
(2)Duties of the administrator. The administrator shall do all of the following:
(a) Implement and regularly evaluate policies for the management and operation of the hospice and evaluation of the overall program performance of the hospice, and implement and regularly evaluate procedures consistent with those policies.
(b) Establish an organizational structure appropriate for directing the work of the hospice’s employees in accordance with the program’s policies and procedures.
(c) Maintain a continuous liaison between the governing body and the hospice employees.
(d) Ensure that employees are oriented to the program and their responsibilities, that they are continuously trained and that their performance is evaluated.
(e) Designate in writing, with the knowledge of the governing body, a qualified person to act in his or her absence.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.30Professional management responsibility.
(1)Responsibility. The hospice is responsible for providing services to the patient or family, or both, based on assessed need and as established by the plan of care.
(2)Contract services. The hospice may contract with other providers for the provision of services to a patient or the patient’s family, or both, in which case the hospice shall retain responsibility for the quality, availability, safety, effectiveness, documentation and overall coordination of the care provided to the patient or the patient’s family, or both, as directed by the hospice plan of care. The hospice shall:
(a) Ensure that there is continuity of care for the patient or the patient’s family, or both, in the relevant care setting.
(b) Be responsible for all services delivered to the patient or the patient’s family, or both, through the contract. The written contract shall include all of the following:
1. Identification of the services to be provided.
2. Stipulation that services are to be provided only with the authorization of the hospice and as directed by the hospice plan of care for the patient.
3. The manner in which the contracted services are coordinated and supervised by the hospice.
4. The delineation of the roles of the hospice and service provider in the admission process, assessment, interdisciplinary group meetings and ongoing provision of palliative and supportive care.
5. A method of evaluation of the effectiveness of those contracted services through the quality assurance program under s. DHS 131.22.
6. The qualifications of the personnel providing the services.
(c) Evaluate the services provided under a contractual arrangement on an annual basis.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.31Employees.
(1)Caregiver background checks. Each hospice shall comply with the caregiver background check and misconduct reporting requirements in s. 50.065, Stats., and ch. DHS 12, and the caregiver misconduct reporting and investigation requirements in ch. DHS 13.
(2)General requirements. Prior to beginning patient care, every employee or contracted staff shall be oriented to the hospice program and the job to which he or she is assigned.
(3)Orientation program. A hospice’s orientation program shall include all of the following:
(a) An overview of the hospice’s goal in providing palliative care.
(b) Policies and services of the program.
(c) Information concerning specific job duties.
(d) The role of the plan of care in determining the services to be provided.
(e) Ethics, confidentiality of patient information, patient rights and grievance procedures.
(4)Duties. Hospice employees or contracted staff may be assigned only those duties for which they are capable, as evidenced by documented training or possession of a license or certificate.
(5)Continuous training. A program of continuing training directed at maintenance of appropriate skill levels shall be provided for all hospice employees providing services to patients and their families.
(6)Evaluation. A hospice shall evaluate every employee annually for quality of performance and adherence to the hospice’s policies. Evaluations shall be followed up with appropriate action.
(7)Personnel practices.
(a) Hospice personnel practices shall be supported by appropriate written personnel policies.
(b) Personnel records shall include evidence of qualifications, licensure, performance evaluations and continuing training, and shall be kept up-to-date.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.32Medical director.
(1)The hospice shall have a medical director who shall be a medical doctor or a doctor of osteopathy.
(2)The medical director shall do all of the following:
(a) Direct the medical components of the program.
(b) Ensure that the terminal status of each individual admitted to the program has been established.
(c) Ensure that medications are used within accepted standards of practice.
(d) Ensure that a system is established and maintained to document the disposal of controlled drugs.
(e) Ensure that the medical needs of the patients are being met.
(f) Provide liaison as necessary between the core team and the attending physician.
(g) Ensure that a system is established for the disposal of controlled drugs.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.33Clinical record.
(1)General. A hospice shall establish a single and complete clinical record for every patient. Clinical record information shall remain confidential except as required by law or a third-party payment contract.
(2)Documentation and accessibility. The clinical record shall be completely accurate and up-to-date, readily accessible to all individuals providing services to the patient or the patient’s family, or both, and shall be systematically organized to facilitate prompt retrieval of information.
(3)Content. A patient’s clinical record shall contain all of the following:
(a) The initial, integrated and updated plans of care prepared under s. DHS 131.21.
(b) The initial, comprehensive and updated comprehensive assessments.
(c) Complete documentation of all services provided to the patient or the patient’s family or both, including:
1. Assessments.
2. Interventions.
3. Instructions given to the patient or family, or both.
4. Coordination of activities.
(d) Signed copies of the notice of patient rights under s. DHS 131.19 (1) (a) and service authorization statement under s. DHS 131.17 (4) (b).
(e) A current medications list.
(f) Responses to medications, symptom management, treatments, and services.
(g) Outcome measure data elements, as described in s. DHS 131.20 (5).
(h) Physician certification and recertification of terminal illness.
(i) A statement of whether or not the patient, if an adult, has prepared an advance directive; and a copy of the advance directive, if prepared.
(j) Physician orders.
(k) Patient and family identification information.
(L) Referral information, medical history and pertinent hospital discharge summaries.
(m) Transfer and discharge summaries.
(4)Authentication.
(a) Entries. All entries shall be legible, permanently recorded, dated and authenticated by the person making the entry, and shall include that person’s name and title.
(b) Written record. A written record shall be made for every service provided on the date the service is provided. This written record shall be incorporated into the clinical record no later than 7 calendar days after the date of service.
(c) Medical symbols. Medical symbols and abbreviations may be used in the clinical records if approved by a written program policy which defines the symbols and abbreviations and controls their use.
(d) Protection of information. Written record policies shall ensure that all record information is safeguarded against loss, destruction and unauthorized usage.
(e) Retention and destruction.
1. An original clinical record and legible copy or copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of the patient shall be retained for a period of at least 5 years following a patient’s discharge or death when there is no requirement in state law. All other records required by this chapter shall be retained for a period of at least 2 years.
2. A hospice shall arrange for the storage and safekeeping of records for the periods and under the conditions required by this paragraph in the event the hospice closes.
3. If the ownership of a hospice changes, the clinical records and indexes shall remain with the hospice.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
DHS 131.34Personnel qualifications.
(1)Personnel qualifications. All professionals who furnish services directly, under an individual contract, or under arrangements with a hospice, shall be legally authorized, licensed, certified or registered in accordance with applicable federal, state and local laws, and shall act only within the scope of his or her state license, or state certification, or registration. Personnel qualifications shall be kept current at all times.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.
Subchapter V — Physical Environment
DHS 131.35Definitions. In this subchapter:
(1)“Existing construction” or “existing facility” means a building which is in place or is being constructed with plans approved by the department prior to August 1, 2020.
(2)“Freestanding hospice facility” means a residential facility serving 3 or more patients which is not located in a licensed hospital or nursing home.
(3)“Life Safety Code” means the National Fire Protection Association’s Standard 101.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.