Chapter DHS 124

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.

DHS 124.07(5)(b) (b) Delivery rooms shall be used only for delivery and operating procedures related to deliveries unless permitted by a written safety risk assessment that facilitates safe delivery of care.

DHS 124.07(6) (6) Tests for congenital disorders. The hospital shall establish and implement written policies that address the screening and testing of newborns for congenital and metabolic disorders consistent with s. 253.13, Stats., and ch. DHS 115.

DHS 124.07(7) (7) Security.

DHS 124.07(7)(a) (a) The hospital shall establish and implement written policies that address infant identification and security.

DHS 124.07(7)(b) (b) An infant may be discharged only to a parent who has lawful custody of the infant or to an individual who is legally authorized to receive the infant. If the infant is discharged to a legally authorized individual, that individual shall provide identification and, if applicable, the identification of the agency the individual represents. The hospital shall record the identity of the legally authorized individual to whom the infant is discharged.

DHS 124.07(8) (8) Labor-inducing medications.

DHS 124.07(8)(a) (a) Only a physician or a nurse-midwife may order the administration of a labor-inducing medication.

DHS 124.07(8)(b) (b) Only a physician or a nurse-midwife or a registered nurse who has adequate training and experience may administer a labor-inducing medication.

DHS 124.07(8)(c) (c) A registered nurse shall be present when administration of a labor-inducing medication is initiated and shall remain immediately available to monitor maternal and fetal well-being. Hospitals shall develop and implement policies allowing the registered nurse to discontinue the labor-inducing medication if circumstances warrant discontinuation and no standing orders by a physician or a nurse-midwife are in place authorizing their discontinuation.

DHS 124.07(8)(d) (d) A registered nurse shall closely monitor and document the administration of a labor-inducing medication. Monitoring shall include monitoring of the fetus and monitoring of uterine contraction during administration of a labor-inducing medication.

DHS 124.07(8)(e) (e) The physician or nurse-midwife, who prescribed the labor-inducing medication, or another physician or nurse-midwife, shall be readily available during its administration so that, if needed, he or she will arrive at the patient’s bedside within 30 minutes after being notified.

DHS 124.07(9) (9) Religious circumcisions. A separate room apart from the newborn nursery shall be provided when circumcisions are performed according to religious rites. A physician, physician’s assistant or registered nurse shall be present during the performance of the religious rite. Aseptic techniques shall be used when an infant is circumcised.

DHS 124.07 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; renum. (1) (b) to (d) under s. 13.92 (4) (b) 1., Stats., Register June 2020.

DHS 124.08 DHS 124.08 Forfeiture assessment.

DHS 124.08(1) (1) In this section, “victim” means a female who alleges or for whom it is alleged that she suffered sexual assault and who, as a result of the sexual assault, presents as a patient at a hospital that provides emergency services.

DHS 124.08(2) (2) The department may directly assess a forfeiture for each violation of a requirement under s. 50.375 (2) or (3), Stats., for care of a victim by a hospital that provides emergency services. The department may assess the forfeitures as follows:

DHS 124.08(2)(a) (a) $2,500 for a first violation of a requirement under s. 50.375 (2) or (3), Stats.

DHS 124.08(2)(b) (b) $5,000 for a subsequent violation of a requirement under s. 50.375 (2) or (3), Stats.

DHS 124.08 Note Note: Section 50.375 (2), Stats., requires a hospital that provides emergency services to a victim to 1) provide to the victim medically and factually accurate and unbiased written and oral information about emergency contraception and its use and efficacy; 2) orally inform the victim of her option to receive emergency contraception at the hospital, her option to report the sexual assault to a law enforcement agency, and any available options for her to receive an examination to gather evidence regarding the sexual assault; and 3) except as specified in s. 50.375 (4), Stats., immediately provide to the victim upon her request emergency contraception, in accordance with instructions approved by the federal food and drug administration. If the medication is taken in more than one dosage, the hospital shall provide all subsequent dosages to the victim for later self administration.

DHS 124.08 Note Note: Section 50.375 (3), Stats., requires a hospital that provides emergency care to ensure that each hospital employee who provides care to a victim has available medically and factually accurate and unbiased information about emergency contraception.

DHS 124.08(3) (3) If the department determines that a forfeiture should be assessed for a particular violation, the department shall send a notice of assessment to the hospital. The notice shall specify the amount of the forfeiture assessed, the violation and the statute or rule alleged to have been violated, and shall inform the hospital of the right to a hearing under sub. (4) pursuant to s. 50.377 (3), Stats.

DHS 124.08(4) (4) Pursuant to s. 50.377 (4), Stats., all forfeitures shall be paid to the department within 10 days after receipt of a notice of assessment or, if the forfeiture is contested under sub. (5), within 10 days after receipt of the final decision after exhaustion of administrative review, unless the final decision is appealed and the order is stayed by court order.

DHS 124.08(5) (5) Pursuant to s. 50.377 (3), Stats., a hospital may contest an assessment of a forfeiture by the department under sub. (2) by sending, within 10 days after receipt of notice under sub. (3), a written request for a hearing under s. 227.44, Stats., to the division of hearings and appeals. The administrator of the division may designate a hearing examiner to preside over the case and recommend a decision to the administrator under s. 227.46, Stats. The decision of the administrator of the division shall be the final administrative decision. The division shall commence the hearing within 30 days after receipt of the request for a hearing and shall issue a final decision within 15 days after the close of the hearing.

DHS 124.08 History History: CR 19-135: renum. from DHS 124.24 (3) Register June 2020 No. 774, eff. 7-1-20; correction in (1), (3) to (5) made under s. 13.92 (4) (b) 7., Stats., Register June 2020 No. 774.

DHS 124.09 DHS 124.09 Freestanding emergency departments.

DHS 124.09(1) (1) Definition. In this subchapter, “freestanding emergency department” means a dedicated location that is physically separate from a hospital campus that offers inpatient overnight care, with services and staff organized primarily for the purpose of delivering emergency medical services without requiring a previously scheduled appointment.

DHS 124.09(2) (2) Freestanding emergency departments.

DHS 124.09(2)(a) (a) A freestanding emergency department must comply with subs. (3), (4), and (5) and have provider-based status under 42 CFR 413.65 as a department of a hospital that offers inpatient overnight care.

DHS 124.09(2)(b) (b) A freestanding emergency department shall be under the direction of the emergency services department of a Wisconsin licensed hospital.

DHS 124.09(2)(c) (c) A freestanding emergency department shall provide emergency services 24 hours a day, 7 days a week, 365 days a year, on an outpatient basis.

DHS 124.09(3) (3) Physical environment.

DHS 124.09(3)(a) (a) A freestanding emergency department shall be identifiable to a patient.