DHS 131.22
DHS 131.22 Quality assessment and performance improvement. DHS 131.22(1)(a)(a) The hospice shall develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program.
DHS 131.22(1)(b)
(b) The hospice's governing body shall ensure that the program reflects the complexity of its organization and services, involves all hospice services including those services furnished under contract or arrangement, focuses on indicators related to improved palliative outcomes, and takes actions to demonstrate improvement in hospice performance.
DHS 131.22(1)(c)
(c) The hospice shall maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to the department.
DHS 131.22(2)(a)
(a) The program shall at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services.
DHS 131.22(2)(b)
(b) The hospice shall measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations.
DHS 131.22(3)(a)
(a) The program shall use quality indicator data, including patient care, and other relevant data, in the design of its program.
DHS 131.22(3)(b)
(b) The hospice shall use the data collected to do all of the following:
DHS 131.22(3)(b)1.
1. Monitor the effectiveness and safety of services and quality of care.
DHS 131.22(3)(c)
(c) The frequency and detail of the data collection shall be approved by the hospice's governing body.
DHS 131.22(4)(a)
(a) The hospice's performance improvement activities shall include all of the following:
DHS 131.22(4)(a)2.
2. Consider incidence, prevalence, and severity of problems in those areas.
DHS 131.22(4)(b)
(b) Performance improvement activities track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice.
DHS 131.22(4)(c)
(c) The hospice shall take actions aimed at performance improvement and, after implementing those actions. The hospice shall measure its success and track performance to ensure that improvements are sustained.
DHS 131.22(5)
(5) Performance improvement projects. The hospice shall develop, implement, and evaluate performance improvement projects.
DHS 131.22(5)(a)
(a) The number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice's population and internal organizational needs, and shall reflect the scope, complexity, and past performance of the hospice's services and operations.
DHS 131.22(5)(b)
(b) The hospice shall document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.
DHS 131.22(6)
(6) Executive responsibilities. The hospice's governing body is responsible for ensuring all of the following:
DHS 131.22(6)(a)
(a) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually.
DHS 131.22(6)(b)
(b) That the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.
DHS 131.22(6)(c)
(c) That one or more individuals who are responsible for operating the quality assessment and performance improvement program are designated.
DHS 131.22 History
History: CR 10-034: cr.
Register September 2010 No. 657, eff. 10-1-10.
DHS 131.23(1)(1)
Infection control program. The hospice shall maintain and document an effective infection control program that protects patients, families, visitors, and hospice employees by preventing and controlling infections and communicable diseases.
DHS 131.23(2)
(2) Prevention. The hospice shall follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.
DHS 131.23(3)
(3) Control. The hospice shall maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that:
DHS 131.23(3)(a)
(a) Is an integral part of the hospice's quality assessment and performance improvement program; and
DHS 131.23(3)(b)1.
1. A method of identifying infectious and communicable disease problems.
DHS 131.23(3)(b)2.
2. A plan for implementing the appropriate actions that are expected to result in improvement and disease prevention.
DHS 131.23(4)(a)
(a) The hospice shall provide infection control education to employees, contracted providers, patients, and family members and other caregivers.
DHS 131.23(4)(b)
(b) The hospice shall develop and implement initial orientation and ongoing education and training for all hospice workers having direct patient contact, including students, trainees and volunteers, in the epidemiology, modes of transmission, prevention of infection and the need for routine use of current infection control measures as recommended by the U.S. centers for disease control and prevention.
DHS 131.23 History
History: CR 10-034: cr.
Register September 2010 No. 657, eff. 10-1-10.
DHS 131.24(1)(1)
Disease surveillance. Agencies shall develop and implement written policies for control of communicable diseases which take into consideration control procedures incorporated by reference in ch.
DHS 145 and which ensure that employees with symptoms or signs of communicable disease or infected skin lesions are not permitted to work unless authorized to do so by a physician, physician assistant or advanced practice nurse.
DHS 131.24(2)
(2) Physical health of new employees. Each new employee, prior to having direct patient contact, shall be certified in writing by a physician, physician assistant or registered nurse as having been screened for tuberculosis, and clinically apparent communicable disease that may be transmitted to a patient during the normal employee's duties. The screening shall occur within 90 days prior to the employee having direct patient contact.
DHS 131.24(3)
(3) Continuing employees. Each employee having direct patient contact shall be screened for clinically apparent communicable disease by a physician, physician assistant, or registered nurse based on the likelihood of their exposure to a communicable disease, including tuberculosis. The exposure to a communicable disease may have occurred in the community or in another location.
DHS 131.24 History
History: CR 10-034: cr.
Register September 2010 No. 657, eff. 10-1-10.
DHS 131.25(1)(1)
General requirements. A hospice is responsible for providing care and services to a patient and, as necessary, the patient's family, based on the plan of care developed by the core team. Volunteers shall participate in the delivery of program services.
DHS 131.25(2)(a)
(a) Each member of the core team shall be an employee, including a volunteer of the hospice or be under a contract with the hospice as specified in par.
(c).
DHS 131.25(2)(b)
(b) With respect to services provided to a patient, each core team member shall do all of the following:
DHS 131.25(2)(b)2.
2. Promptly notify the registered nurse of any change in patient status that suggests a need to update the plan of care.
DHS 131.25(2)(b)4.
4. Provide education and counseling to the patient and, as necessary, to the patient's family, consistent with the plan of care.
DHS 131.25(2)(b)5.
5. Participate in developing and revising written patient care policies and procedures.
DHS 131.25(2)(c)
(c) The hospice may contract for physician services as specified in par.
(a). A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice staff to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care and temporary travel of a patient outside of the hospice's service area.
DHS 131.25(3)
(3) Physician services. The hospice medical director, physician employees, and contracted physicians of the hospice, in conjunction with the patient's attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness.
DHS 131.25(3)(a)
(a) All physician employees and those under contract must function under the supervision of the hospice medical director.
DHS 131.25(3)(b)
(b) All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. If the attending physician is unavailable, the medical director, contracted physician, and or hospice physician employee is responsible for meeting the medical needs of the patient.
DHS 131.25(4)(a)
(a) Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following:
DHS 131.25(4)(a)1.
1. Regularly assessing the patient's nursing needs, implementing the plan of care provisions to meet those needs and reevaluating the patient's nursing needs.
DHS 131.25(4)(a)2.
2. Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides.
DHS 131.25(4)(a)3.
3. Evaluating the effectiveness of delegated acts performed under the registered nurse's supervision.
DHS 131.25(4)(b)
(b) Highly specialized nursing services that are provided so infrequently that the provision of such services by direct hospice employees would be impracticable and prohibitively expensive, may be provided under contract.
DHS 131.25(4)(c)
(c) Licensed practical nursing services. If licensed practical nursing services are provided, the licensed practical nurse shall function under the supervision of a registered nurse with duties specified in writing and updated by a registered nurse.
DHS 131.25(5)(a)(a) Social services shall be provided by a qualified social worker and shall consist of all of the following:
DHS 131.25(5)(a)1.
1. Regularly assessing the patient's social service needs, implementing the plan of care to meet those needs and reevaluating the patient's needs and providing ongoing psychosocial assessment of the family's coping capacity relative to the patient's terminal condition.
DHS 131.25(5)(a)2.
2. Linking patient and family with needed community resources to meet ongoing social, emotional and economic needs.
DHS 131.25(6)
(6) Counseling services. Counseling services shall be available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process.
DHS 131.25(6)(a)
(a) Bereavement services. Bereavement services shall be provided to families of hospice patients. Each hospice shall have its own bereavement program. Bereavement services shall be:
DHS 131.25(6)(a)1.
1. Coordinated by an individual 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).
DHS 131.25(6)(a)2.
2. Compatible with the core team's direction within the plan of care for the patient.
DHS 131.25(6)(a)3.
3. Available for one year following the patient's death as part of an organized program and provide all of the following:
DHS 131.25(6)(a)3.a.
a. Orientation and training to individuals providing bereavement services to ensure that there is continuity of care.
DHS 131.25(6)(a)3.b.
b. Service intervention either directly or through trained bereavement counselors.
DHS 131.25(6)(a)3.c.
c. Assignment, supervision and evaluation of individuals performing bereavement services.
DHS 131.25(6)(a)3.d.
d. Referrals of family members to non-hospice community programs where appropriate.
DHS 131.25(6)(b)
(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 dietitian or an individual who has documented equivalency in education or training. Dietary services shall be supervised and evaluated by a registered 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 131.25(6)(b)2.
2. Planning diets appropriate for meeting patient needs and preferences; and
DHS 131.25(6)(b)3.
3. Providing nutrition education and counseling to meet patient needs, as well as necessary consultation to hospice employees.
DHS 131.25(6)(c)
(c) Spiritual counseling. The hospice shall do all of the following:
DHS 131.25(6)(c)1.
1. Provide an assessment of the patient's and family's spiritual needs.
DHS 131.25(6)(c)2.
2. Provide spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service, and in a manner consistent with patient and family beliefs and desires.
DHS 131.25(6)(c)3.
3. Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of its ability.
