Physical environment
Currently, several physical environment standards are outdated, duplicative of other regulations or overly prescriptive. The department proposed to eliminate requirements related to bed arrangement in patient rooms, ceiling height, electrical outlets, number of toilets and sinks, and zoning requirements.
Plan review and fees for plan reviews
2015 Wisconsin Act 55 created s. 50.92 (3m), Stats., which assigned this responsibility to the department and directed the department to promulgate rules establishing a fee schedule for plan reviews. DHS 131 is revised to establish a fee schedule for plan reviews and to update, correct, or remove any outdated rule provisions or cross-references. 2b. Analysis of policy alternatives
There are no reasonable policy alternatives. 2015 Wisconsin Act 55 created s. 50.92 (3m), Stats., which assigned this responsibility to the Department of Health Services (“department”) and directed the department to promulgate rules establishing a fee schedule for plan reviews. The department therefore intends to revise ch. DHS 131 to establish a fee schedule for plan reviews and to update, correct, or remove any outdated rule provisions or cross-references.
The department could choose to propose voluntary guidelines for hospices, rather than establishing standards by rule. However, this alternative is not reasonable because voluntary compliance with such guidelines would prevent the department from ensuring consistency in the standard of care provided to vulnerable clients. Summary of, and comparison with, existing or proposed federal regulations
Title 42 CFR 418 contains the Federal Medicare Hospice Conditions of Participation. These regulations establish conditions and standards for the operation of hospices that primarily provide palliative and supportive care to an individual with terminal illness where he or she lives and if necessary arranges for or provides short-term inpatient care and treatment or respite care. State regulations are comparable and the intent of these regulations is to foster safe and adequate care and treatment of patients by hospice agencies. There are no federal regulations for governing plan review. Comparison with rules in adjacent states
Illinois:
Illinois licensure law for hospices is found in Title 77, Chapter I, subchapter b, Part 280 Hospice Programs. Illinois State Code requires that all hospices be licensed and offer the required services of nursing, medical social work, spiritual counseling, bereavement and volunteer services. These services must be available on a 24-hour basis to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions. A hospice patient’s plan of care must be established and maintained for each individual admitted to a hospice program and the services provided to an individual must be in accordance with the person’s plan of care. Bereavement services may be coordinated with the family’s clergy, if any, as well as with the other community resources judged by the hospice care team to be useful to the family unless the family declines. The hospice must ensure that each patient has an attending physician. The hospice program must have each patient or his or her representative complete and sign a form indicating the name of the attending physician responsible for the patient’s care. Hospices that provide residential services must submit drawings for the proposed hospice residence for review and must be in compliance with the requirements of the NFPA 101, Chapter 33, Existing Board and Care Occupancies. Hospice must be in full compliance with the local building codes and fire safety protection requirements. Additional standards are provided related to exits, number of patients per bedroom, toilet and bathroom facilities, isolation areas, waste disposal, water supply, sewage disposal and plumbing systems. Iowa:
Iowa hospice regulations consist of Iowa Administrative Code 481, Chapter 53 Hospice License Standards. Services provided to the hospice patient and his or her family include, nursing services, patient care coordination, social services, counselling services, volunteer services, spiritual counseling and bereavement services. The patient or family must designate an attending physician who is responsible for managing necessary medical care. The attending physician is responsible for the medical component of the plan of care, participating in developing and revising the plan of care, arranging for continuity of the medical management and monitoring the condition of the patient and family. Prior to or on the day of admission the attending physician and at least one member of the interdisciplinary team must develop a initial plan based on the needs of the patient and family. Within seven days of admission the interdisciplinary team must assess the needs of the patient and family and develop a comprehensive written plan of care. Bereavement services must be available to each family after the death of the patient and must be provided in accordance with family needs. Bereavement series must include identification of the types of help or intervention to be provided, contact with the family after the death as requested by their needs as documented in the plan of care, a process to assess family reaction and hospice referrals for intervention deemed appropriate. Michigan:
Michigan regulates hospices in Hospice and Hospice Residences R 325. At the time of admission to a hospice, the patient must be under the care of a physician who is responsible for providing for medical care. The hospice must enter all physician orders and services rendered in the patient and family record. The hospice registered nurse must complete an initial assessment of the patient’s condition within 48 hours after the election of hospice care. The interdisciplinary group must complete a comprehensive assessment no later than 5 calendar days after the election of hospice care and identify the patient’s immediate physical, psychosocial, emotional and spiritual needs. The development of comprehensive patient care plan of care for each hospice patient and family must commence within 24 hours of admission. Bereavement and spiritual services must be available 7 days a week and must be available to the family for not less than 13 months following the death of the patient. All plans, specification and operation narratives of new buildings, additions, major building changes and conversion of existing facilities to use as a hospice residence shall be submitted to the Department of Licensing and Regulatory Affairs for review to assure compliance with the laws and rules for Hospice and Hospice Residences. The Department of Licensing and Regulatory Affairs must approve plans and specifications if they meet the requirements of section 20145 of the code, MCL 333.20145, and these rules for Hospice and Hospice Residences. Construction of new buildings, additions and major building changes and conversion may not begin until the plans and specification have been approved by the department and a construction permit has been issued for the construction to begin. Additional standards are provided for resident bedrooms, light fixtures, toilet and bathing facility, nurse call system and isolation rooms. The water system, and the disposal of sewage and liquid and solid waste must be in compliance with state regulation. Fire safety and disaster planning must comply with sections 20156 and 21413 (3) (c) of 1978 PA 368, MCL 333.20156 and 333.20156 and 333.21413 (3) (c).
Minnesota:
Minnesota regulates hospices in Minn. Stat. 4664. No hospice may accept a person as a hospice patient unless the licensee has staff sufficient to qualifications and numbers to adequately provide hospice services. If the licensee discharges or transfers a hospice patient the reason for the discharge or transfer must be documented in the clinical record and include the reason why the transfer is necessary and why the patient’s needs cannot be met by the hospice. A written notice must be given to the patient or responsible person at least ten days in advance of termination of services. The hospice provider must ensure that each hospice patient and hospice patient’s family has a current assessment. The assessment must address the physical, nutritional, emotional, social, spiritual, pain, symptom management, medication and social needs of the hospice patient and hospice patient’s family during the final stages of illness, dying and bereavement. Counseling services must be adequate in frequency to meet the needs of the patient and the patient’s family. The hospice provider must provide a planned program of supportive services and bereavement counseling under the supervision of a qualified professional according to the qualifications identified by hospice policy. The service must be available to families following the death of the hospice patient. Physical services must be available and adequate in frequency to meet the general medical needs of the hospice patient to the extent that these needs are not met by the attending physician.
Summary of factual data and analytical methodologies
The department formed an advisory committee composed of representatives of the Hospice Organization and Palliative Experts (HOPE) of Wisconsin and hospices. Representatives from these organizations were provided a copy of the initial draft of the rule and asked for comments. The department also solicited information and advice from individuals, businesses, associations representing businesses, and local governmental units who may be affected by the proposed rule for use in analyzing and determining the economic impact that the rules would have on businesses, individuals, public utility rate payers, local governmental units, and the state’s economy as a whole from 05/28/19-06/11/19. The department received no comments.
Analysis and supporting documents used to determine effect on small business
See Fiscal Estimate & Economic Impact Analysis.
Effect on small business
Based on the foregoing analysis, the rules are anticipated to have little to no economic impact on small businesses.
Agency contact person
Statement on quality of agency data
The data used by the Department to prepare these proposed rules and analysis comply with § 227.14 (2m), Wis. Stats. Place where comments are to be submitted and deadline for submission
Comments may be submitted to the agency contact person that is listed above until the deadline given in the upcoming notice of public hearing. The notice of public hearing and deadline for submitting comments will be published in the Wisconsin Administrative Register and to the department’s website, at https://www.dhs.wisconsin.gov/rules/permanent.htm. Comments may also be submitted through the Wisconsin Administrative Rules Website, at: https://docs.legis.wisconsin.gov/code/chr/active. RULE TEXT
SECTION 1. DHS 131.13 (3) is repealed and recreated to read:
DHS 131.13 (3) “Attending physician" means a person who is either a doctor of medicine or osteopathy legally authorized to practice medicine and surgery under ch. 448, Stats., physician assistant or a nurse practitioner who meets the training, education, and experience requirements specified in s. DHS 105.20 (1) and the person is identified by the patient, at the time he or she elects to receive hospice care, as having the greatest overall role in the determination and delivery of the individual’s medical care.
SECTION 2. DHS 131.13 (11m), (12m), and (20m) are created to read: DHS 131.13 (11m) “Nonambulatory” means unable to walk.
DHS 131.13 (12m) “Nursing assistant" means a person who is employed primarily to provide direct care services to residents but is not registered or licensed under ch. 441, Stats. DHS 131.13 (20m) “Semiambulatory” means able to walk with difficulty or able to walk only with the assistance of an aid, such as crutches, a cane, or a walker.
SECTION 3. DHS 131.18 (2) (a) 4. and 7. are amended to read:
DHS 131.18 (2) (a) 4. If the patient moves beyond out of the geographical area served by the hospice or into a facility that does not have a contract with the hospice.
DHS 131.18 (2) (a) 7. For the patient’s safety and welfare or the safety and welfare of others, if the hospice determines that the behavior of the patient or other persons in the patient’s home is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired.
SECTION 4. DHS 131.18 (3) is repealed and recreated to read:
DHS 131.18 (3) NOTICE. (a) When a patient is being discharged for a reason given in sub. (2) (a) 1.,2., 3., 4., 5., 7., or 8., the hospice shall give written notice of the discharge to the patient or patient's representative, if any, a family representative and the attending physician. DHS 131.18 (3) (b) When a patient is being discharged for the reason given in sub. (2) (a) 6., the hospice shall give written notice of the discharge at least 14 days prior to the date of discharge, and indicate a proposed date for pre-discharge planning. The written notice shall be given to the patient or patient's representative, if any, a family representative and the attending physician. SECTION 5. DHS 131.18 (4) and (title), DHS 131.20DHS 131.20(1) (1) (a), DHS 131.21 (2) (d), DHS 131.25 (6) (a) 1., (b), and DHS 131.35 (1) and (4) are amended to read: DHS 131.18 (4) Planning conference. The hospice shall conduct the pre-discharge planning conference with the patient or the patient's representative and review the need for discharge, assess the effect of discharge on the patient, discuss alternative placements and develop a comprehensive discharge plan.
DHS 131.20DHS 131.20(1) (1) DHS 131.20(1)(a)(a) If the hospice determines that it has the general capability to meet the prospective patient's described needs, then before services are provided, a registered nurse shall perform an initial assessment of the person's condition and immediate needs and shall describe in writing the person's current status, including physical condition, present pain status, emotional status, pertinent psychosocial and spiritual concerns and coping ability of the prospective patient and family support system, and shall determine the appropriateness or inappropriateness of admission to the hospice based on the assessment. DHS 131.21 (2) (d) The registered nurse shall immediately record and sign a physician's oral orders and shall obtain the physician's counter-signature within 20 working days.
DHS 131.25 (6) (a) 1. Coordinated by an individual recognized by the governing body to possess who possesses the capacity by training and experience to provide for the bereavement needs of families, including the ability to organize a program of directed care services provided to family members.
DHS 131.25 (6) (b) Dietary counseling. Dietary counseling services shall be provided only as authorized by the hospice and in conjunction with the plan of care. The services shall be provided by a registered dietician dietitian or an individual who has documented equivalency in education or training. Dietary services shall be supervised and evaluated by a registered dietician dietitian or other individual qualified under this paragraph who may delegate acts to other employees. Dietary counseling services shall consist of all of the following:
DHS 131.35 (1)DHS 131.35(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 October 1, 2010 the effective date of this rule. DHS 131.35(4)DHS 131.35 (4) “New construction" means construction for the first time of any building or addition to an existing building, the plans for which are approved on or after October 1, 2010. the effective date of this rule.
SECTION 7. DHS 131.37 (5) (a) is amended to read:
DHS 131.37 (5) (a) Design and location. Patient bedrooms shall be designed and equipped for the comfort and privacy of the patient and shall be equipped with or conveniently located near toilet and bathing facilities.
DHS 131.37 (5) (b) 1. A patient bedroom may accommodate no more than 3 2 patients except that in new construction a patient bedroom may accommodate no more than 2 persons. Patients of the opposite sex may not be required to occupy the same sleeping room. DHS 131.37 (5) (d) Semiambulatory and nonambulatory patients. For rooms with semiambulatory or nonambulatory patients, mobility space at the end and one side of each bed may not be not less than 4 feet. Adequate accessible space for storage of a patient's wheelchair or other adaptive or prosthetic equipment shall be provided and shall be readily accessible to the patient. In this paragraph, “semiambulatory" means able to walk with difficulty or able to walk only with assistance of an aid such as crutches, a cane or a walker, and “nonambulatory" means not able to walk at all. DHS 131.37 (5) (e) 3. Closet or wardrobe space with clothes racks and shelves in the bedroom. Closets or wardrobes shall have an enclosed space of not less than 15 inches wide by 18 inches deep by 5 feet in height for each patient. DHS 131.37 (7) (a) Minimum size. Every living and sleeping room shall have one or more outside-facing windows with a total sash area of at least 8% of the floor area of the room. The openable area of a window shall be equal to not less than 4% of the floor area of the room. DHS 131.37 (7) (c) Storm windows and Window screens. All openable windows serving in habitable rooms shall be provided with storm windows in winter, except insulated windows, and openable windows serving habitable rooms shall be provided with have insect-proof screens in summer.
