Chapter DHS 131

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.

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 DHS 131.23 Infection control.

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) (b) Includes all of the following:

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) (4) Education.

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.

subch. IV of ch. DHS 131 Subchapter IV — Management

DHS 131.24 DHS 131.24 Employee health.

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 DHS 131.25 Core services.

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) (2) Core team.

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)1. 1. Assess patient and family needs.

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.