Chapter DHS 124

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.

DHS 124.06(1)(m) (m) 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.

DHS 124.06(1)(n) (n) 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.

DHS 124.06(1)(o) (o) 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.

DHS 124.06(1)(p) (p) The patient may designate persons who are permitted to visit the patient during the patient’s stay at the critical access hospital.

DHS 124.06(2) (2) 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.

DHS 124.06(3) (3) 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.

DHS 124.06 History History: Cr. Register, January, 1988, No. 385, eff. 2-1-88; CR 19-135: r. and recr. Register June 2020 No. 774, eff. 7-1-20; CR 20-068: am. (1) (a) Register December 2021 No. 792, eff. 1-1-22.

DHS 124.07 DHS 124.07 Maternity and neonatal care.

DHS 124.07(1) (1) Definitions. In this section:

DHS 124.07(1)(a) (a) “Neonatal” means pertaining to the first 28 days following birth.

DHS 124.07(1)(c) (c) “Nurse-midwife” means an individual licensed under s. 441.15, Stats., and ch. N 4.

DHS 124.07(1)(d) (d) “Perinatal” means pertaining to the mother, fetus or infant, in anticipation of and during pregnancy and through the first 28 days following birth.

DHS 124.07(2) (2) Personnel.

DHS 124.07(2)(a) (a) A registered nurse shall be responsible for the admission assessment of the maternity patient in labor and continuing assessment and support of the mother and fetus during labor, delivery and the early postpartum period.

DHS 124.07(2)(b) (b) A registered nurse shall be responsible for the admission assessment of the newborn infant and continuing assessment until the newborn infant is stabilized as defined by current, accepted standards of practice.

DHS 124.07(2)(c) (c) Hospitals with maternity units shall have a qualified anesthesia provider available at all times to provide emergency care to maternity patients.

DHS 124.07(3) (3) Admission and patient placement. Hospitals with maternity units shall do all of the following:

DHS 124.07(3)(a) (a) The hospital shall establish and implement written policies for maternity and non-maternity patients who may be admitted to the maternity unit, including a policy that delineates medical staff responsibility for the admission of maternity patients in non-emergency situations.

DHS 124.07(3)(b) (b) The hospital’s infection prevention policies shall address patient placement and visitation in the maternity unit.

DHS 124.07(3)(c) (c) The hospital shall establish and implement written policies for admission of newborn infants, including newborn infants born outside the hospital, and criteria for identifying conditions for directly admitting or readmitting newborn infants to the newborn nursery or neonatal intensive care unit for further treatment and follow-up care. For an infant delivered outside the hospital, admission may be made directly to the newborn nursery or neonatal intensive care unit if the admission complies with infection control policies adopted by the hospital to protect patients from communicable disease or infection.

DHS 124.07(4) (4) Transfer. A maternity unit shall do all of the following:

DHS 124.07(4)(a) (a) Provide adequate facilities, personnel, and equipment and support services for the care of high-risk infants, including premature infants, or a plan for transfer of these infants to a neonatal or pediatric intensive care unit.

DHS 124.07(4)(b) (b) Establish and implement written policies and procedures for inter-hospital transfer of perinatal and neonatal patients.

DHS 124.07(4)(c) (c) Establish and implement written policies for the transfer of infants from one hospital to another hospital.

DHS 124.07(4)(d) (d) Have available personnel and equipment to transfer infants to another hospital. The execution of transfer is a joint responsibility of the sending and receiving hospitals.

DHS 124.07(5) (5) Delivery. Hospitals with maternity units shall do all of the following:

DHS 124.07(5)(a) (a) If cesarean deliveries are not performed in the maternity unit, equipment for neonatal stabilization and resuscitation shall be available during delivery.