Chapter DHS 124

Ch. DHS 124 Note Note: Chapter H 24 as it existed on January 31, 1988 was repealed and a new chapter HSS 124 was created effective February 1, 1988. Chapter HSS 124 was renumbered chapter HFS 124 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 7., Stats., Register, August, 1996, No. 488. Chapter HFS 124 was renumbered chapter DHS 124 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.

subch. I of ch. DHS 124 Subchapter I — General

DHS 124.01 DHS 124.01 Authority, purpose and applicability. This chapter establishes standards for the construction, maintenance and operation of hospitals. The chapter is promulgated under the authority of s. 50.36 (1), Stats., to ensure that hospital patients receive safe and adequate care and treatment and that the health and safety of patients and hospital employees are protected. The provisions of this chapter apply to all facilities meeting the definition of hospital in s. 50.33 (2), Stats., that are not specifically exempt under s. 50.39, Stats., except for those provisions that apply only to particular types of hospitals.

DHS 124.01 Note Note: Among facilities that are specifically exempt under s. 50.39, Stats., from being treated as hospitals for purposes of regulation under ss. 50.32 to 50.39 and this chapter are physicians’ clinics and offices, nursing homes, the Milwaukee County Mental Health Center and correctional institutions operated by the Wisconsin department of corrections.

DHS 124.01 History History: Cr. Register, January, 1988, No. 385, eff. 2-1-88.

DHS 124.02 DHS 124.02 Definitions. In this chapter:

DHS 124.02(1m) (1m) “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 (e).

DHS 124.02(2) (2) “Dentist” means a person licensed to practice dentistry under ch. 447, Stats.

DHS 124.02(3) (3) “Department” means the Wisconsin department of health services.

DHS 124.02(5) (5) “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.

DHS 124.02(6) (6) 

DHS 124.02(6)(a) (a) “Hospital” means any building, structure, institution or place that does all of the following:

DHS 124.02(6)(a)1. 1. 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.

DHS 124.02(6)(a)2. 2. 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.

DHS 124.02(6)(a)3. 3. 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.

DHS 124.02(6)(b) (b) “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.

DHS 124.02(6)(c) (c) “Hospital” includes a special hospital.

DHS 124.02(9) (9) “Licensed practical nurse” means a person licensed as a trained practical nurse under ch. 441, Stats.

DHS 124.02(10) (10) “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.

DHS 124.02(10m) (10m) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395 ccc and 42 CFR ch. IV, subch. B.

DHS 124.02(11) (11) “Physician” means a person licensed to practice medicine or osteopathy under ch. 448, Stats.

DHS 124.02(12) (12) “Physician assistant” means a person certified under ch. 448, Stats., to perform patient services under the supervision and direction of a licensed physician.

DHS 124.02(13) (13) “Podiatrist” means a person licensed to practice podiatry or podiatric medicine and surgery under ch. 448, Stats.

DHS 124.02(14) (14) “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.

DHS 124.02(19) (19) “Registered nurse” means a person who is licensed as a registered nurse under ch. 441, Stats.

DHS 124.02(22) (22) “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 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.

DHS 124.03 DHS 124.03 Approval by the department.

DHS 124.03(1) (1) No hospital may operate in Wisconsin unless it is approved by the department.

DHS 124.03(2) (2) 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.

DHS 124.03(3) (3) 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.

DHS 124.03(4) (4) The department shall review and make a determination on a complete application for approval within 90 working days after receiving the application.

DHS 124.03(5) (5) 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.

DHS 124.03(6) (6) 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, Stats.

DHS 124.03(7) (7) 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 History: Cr. Register, January, 1988, No. 385, eff. 2-1-88; cr. (7), Register, August, 2000, No. 536, eff. 9-1-00.

DHS 124.04 DHS 124.04 Waivers and variances.

DHS 124.04(1) (1) Definitions. In this section:

DHS 124.04(1)(a) (a) “Variance” means an alternative requirement in place of a requirement of this chapter.

DHS 124.04(1)(b) (b) “Waiver” means an exception from a requirement of this chapter.

DHS 124.04(2) (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:

DHS 124.04(2)(a) (a) Strict enforcement of a requirement would result in unreasonable hardship on the hospital or on a patient.

DHS 124.04(2)(b) (b) 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.

DHS 124.04(3) (3) Procedures.

DHS 124.04(3)(a) (a) Applications.

DHS 124.04(3)(a)1. 1. All applications for the grant of a waiver or variance shall be made in writing to the department, specifying the following:

DHS 124.04(3)(a)1.a. a. The rule from which the waiver or variance is requested;

DHS 124.04(3)(a)1.b. b. The time period for which the waiver or variance is requested;

DHS 124.04(3)(a)1.c. c. If the request is for a variance, the specific alternative action which the facility proposes;

DHS 124.04(3)(a)1.d. d. The reasons for the request; and

DHS 124.04(3)(a)1.e. e. Justification that sub. (2) would be satisfied.

DHS 124.04(3)(a)2. 2. Requests for a waiver or variance may be made at any time.

DHS 124.04(3)(a)3. 3. The department may require additional information from the hospital prior to acting on the request.

DHS 124.04(3)(b) (b) Grants and denials.

DHS 124.04(3)(b)1. 1. The department shall grant or deny each request for waiver or variance in writing. Notice of a denial shall contain the reasons for denial.

DHS 124.04(3)(b)2. 2. The terms of a requested variance may be modified upon agreement between the department and the hospital.

DHS 124.04(3)(b)3. 3. The department may impose whatever conditions on the granting of a waiver or variance it considers necessary.

DHS 124.04(3)(b)4. 4. The department may limit the duration of any waiver or variance.

DHS 124.04(3)(c) (c) Hearings.

DHS 124.04(3)(c)1. 1. 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, Stats.

DHS 124.04(3)(c)2. 2. The hospital shall sustain the burden of proving that the denial of a waiver or variance is unreasonable.

DHS 124.04(3)(d) (d) Revocation. The department may revoke a waiver or variance, subject to the hearing requirement in par. (c), if:

DHS 124.04(3)(d)1. 1. The department determines that the waiver or variance is adversely affecting the health, safety or welfare of the patients;

DHS 124.04(3)(d)2. 2. The hospital has failed to comply with the variance as granted or with a condition of the waiver or variance;

DHS 124.04(3)(d)3. 3. 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(3)(d)4. 4. The revocation is required by a change in state law.

DHS 124.04 History 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.

subch. II of ch. DHS 124 Subchapter II — Requirements

DHS 124.05 DHS 124.05 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.

DHS 124.05(2) (2) 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.

DHS 124.05(3) (3) 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 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.

DHS 124.06 DHS 124.06 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:

DHS 124.06(1)(a) (a) 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, disability, or source of payment.

DHS 124.06(1)(b) (b) 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.

DHS 124.06(1)(c) (c) The patient’s medical record, including all computerized medical information, shall be kept confidential as required by law.

DHS 124.06(1)(d) (d) 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.

DHS 124.06(1)(e) (e) The patient shall be entitled to know who has overall responsibility for the patient’s care.

DHS 124.06(1)(f) (f) 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.

DHS 124.06(1)(g) (g) The patient shall have the opportunity to participate to the fullest extent possible in planning for the patient’s care and treatment.

DHS 124.06(1)(h) (h) 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.

DHS 124.06(1)(i) (i) 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.

DHS 124.06(1)(j) (j) The patient may refuse treatment to the extent permitted by law and shall be informed of the medical consequences of the refusal.

DHS 124.06(1)(k) (k) 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.

DHS 124.06(1)(L) (L) 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.