Chapter DHS 131

DHS 131.19(3) (3) Patient complaint procedure. Each patient shall have the right, on his or her own behalf or through others, to do all of the following:

DHS 131.19(3)(a) (a) Express a complaint to hospice employees, without fear of reprisal, about the care and services provided and to have the hospice investigate the complaint in accordance with an established complaint procedure. The hospice shall document both the existence of the complaint and the resolution of the complaint.

DHS 131.19(3)(b) (b) Express complaints to the department, and to receive a statement provided by the department setting forth the right to and procedure for filing verbal or written complaints with the department.

DHS 131.19(3)(c) (c) Be advised of the availability of a toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under s. 16.009, Stats.

DHS 131.19 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

subch. III of ch. DHS 131 Subchapter III — Patient Care

DHS 131.20 DHS 131.20 Assessment.

DHS 131.20(1) (1) Initial assessment.

DHS 131.20(1)(a) (a) If the hospice determines that it has the general capability to meet the prospective patient’s described needs, a registered nurse shall perform an initial assessment of the person’s 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 131.20(1)(b) (b) The designated hospice employee shall confer with at least one other core team member and receive that person’s views in order to start the initial plan of care.

DHS 131.20(2) (2) Time frame for completion of the comprehensive assessment. The hospice interdisciplinary group, in consultation with the individual’s attending physician, if any, shall complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

DHS 131.20(3) (3) Content of the comprehensive assessment. The comprehensive assessment shall identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that shall be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. The comprehensive assessment shall take into consideration all of the following factors:

DHS 131.20(3)(a) (a) The nature and condition causing admission including the presence or lack of objective data and subjective complaints.

DHS 131.20(3)(b) (b) Complications and risk factors that affect care planning.

DHS 131.20(3)(c) (c) Functional status, including the patient’s ability to understand and participate in his or her own care.

DHS 131.20(3)(d) (d) Imminence of death.

DHS 131.20(3)(e) (e) Severity of symptoms.

DHS 131.20(3)(f) (f) Drug profile. A review of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:

DHS 131.20(3)(f)1. 1. Effectiveness of drug therapy.

DHS 131.20(3)(f)2. 2. Drug side effects.

DHS 131.20(3)(f)3. 3. Actual or potential drug interactions.

DHS 131.20(3)(f)4. 4. Duplicate drug therapy.

DHS 131.20(3)(f)5. 5. Drug therapy currently associated with laboratory monitoring.

DHS 131.20(3)(g) (g) Bereavement. An initial bereavement assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment shall be incorporated into the plan of care and considered in the bereavement plan of care.

DHS 131.20(3)(h) (h) The need for referrals and further evaluation by appropriate health professionals.

DHS 131.20(4) (4) Update of the comprehensive assessment. The update of the comprehensive assessment shall be accomplished by the hospice interdisciplinary group in collaboration with the individual’s attending physician, if any, and shall consider changes that have taken place since the initial assessment. The comprehensive assessment shall include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care. The assessment update shall be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The hospice interdisciplinary group shall primarily meet in person to conduct the update of the comprehensive assessment.

DHS 131.20(5) (5) Patient outcome measures.

DHS 131.20(5)(a) (a) The comprehensive assessment shall include data elements that allow for measurement of outcomes. The hospice shall measure and document data in the same way for all patients.

DHS 131.20(5)(b) (b) The data elements shall do all of the following:

DHS 131.20(5)(b)1. 1. Take into consideration aspects of care related to hospice and palliation.

DHS 131.20(5)(b)2. 2. Be an integral part of the comprehensive assessment.

DHS 131.20(5)(b)3. 3. Be documented in a systematic and retrievable way for each patient.

DHS 131.20(5)(c) (c) The data elements for each patient shall be used in individual patient care planning and in the coordination of services, and shall be used in the aggregate for the hospice’s quality assessment and performance improvement program.

DHS 131.20 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (1) (a) Register July 2020 No. 775, eff. 8-1-20.

DHS 131.21 DHS 131.21 Plan of care.

DHS 131.21(1) (1) General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient’s family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient’s family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient’s family shall be in accordance with the plan of care.

DHS 131.21(2) (2) Initial plan of care.

DHS 131.21(2)(a) (a) The hospice shall develop an initial plan of care that does all of the following:

DHS 131.21(2)(a)1. 1. Defines the services to be provided to the patient and the patient’s family.

DHS 131.21(2)(a)2. 2. Incorporates physician orders and medical procedures.

DHS 131.21(2)(b) (b) The initial plan of care shall be developed upon conclusion of the assessment under s. DHS 131.20 (1) (a).

DHS 131.21(2)(c) (c) The initial plan of care shall be developed jointly by the employee who performed the initial assessment and at least one other member of the core team.

DHS 131.21(2)(d) (d) The registered nurse shall immediately record and sign a physician’s oral orders and shall obtain the physician’s counter-signature within 20 business days.

DHS 131.21(3) (3) Plan of care.

DHS 131.21(3)(a) (a) Integrated plan of care. The hospice core team shall develop an integrated plan of care for the new patient within 5 days after the admission. The core team shall use the initial plan of care as a basis for team decision-making and shall update intervention strategies as a result of core team assessment and planning collaboration.

DHS 131.21(3)(b) (b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following:

DHS 131.21(3)(b)1. 1. Interventions to manage pain and symptoms.

DHS 131.21(3)(b)2. 2. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

DHS 131.21(3)(b)3. 3. Measurable outcomes anticipated from implementing and coordinating the plan of care.

DHS 131.21(3)(b)4. 4. Drugs and treatment necessary to meet the needs of the patient.

DHS 131.21(3)(b)5. 5. Medical supplies and appliances necessary to meet the needs of the patient.

DHS 131.21(3)(b)6. 6. The interdisciplinary group’s documentation of the patient’s or representative’s, if any, level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice’s own policies, in the clinical record.

DHS 131.21(3)(c) (c) Review of the plan of care. The hospice interdisciplinary group in collaboration with the individual’s attending physician, if any, shall review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care shall include information from the patient’s updated comprehensive assessment and shall note the patient’s progress toward outcomes and goals specified in the plan of care. The hospice interdisciplinary group shall primarily meet in person to review and revise the individualized plan of care.

DHS 131.21(3)(d) (d) Bereavement plan of care. The hospice core team shall review and update the bereavement plan of care, at minimum:

DHS 131.21(3)(d)1. 1. Fifteen calendar days following a patient’s death.

DHS 131.21(3)(d)2. 2. Within 60 calendar days following the patient’s death.

DHS 131.21(3)(d)3. 3. As often as necessary based on identified family needs.

DHS 131.21(3)(d)4. 4. At the termination of bereavement services.

DHS 131.21(3)(e) (e) Contents of the bereavement plan of care. The bereavement plan of care shall include all of the following:

DHS 131.21(3)(e)1. 1. The family and caregiver’s specific needs or concerns.

DHS 131.21(3)(e)2. 2. Intervention strategies to meet the identified needs.

DHS 131.21(3)(e)3. 3. Employees responsible for delivering the care.

DHS 131.21(3)(e)4. 4. Established timeframes for evaluating and updating the interventions.

DHS 131.21(3)(e)5. 5. The effect of the intervention in meeting established goals.

DHS 131.21(3)(f) (f) Record of notes. The core team shall develop a system for recording and maintaining a record of notes within the plan of care.

DHS 131.21 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (2) (d) Register July 2020 No. 775, eff. 8-1-20.

DHS 131.22 DHS 131.22 Quality assessment and performance improvement.

DHS 131.22(1) (1) Program standards.

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) (2) Program scope.

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) (3) Program data.

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)(b)2. 2. Identify opportunities and priorities for improvement.

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) (4) Program activities.

DHS 131.22(4)(a) (a) The hospice’s performance improvement activities shall include all of the following:

DHS 131.22(4)(a)1. 1. Focus on high risk, high volume, or problem-prone areas.

DHS 131.22(4)(a)2. 2. Consider incidence, prevalence, and severity of problems in those areas.

DHS 131.22(4)(a)3. 3. Affect palliative outcomes, patient safety, and quality of care.

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.