Wisconsin Legislature: DHS 131.23(3)(b)

(2) Program scope.

(a) The program shall at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services.

(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.

(3) Program data.

(a) The program shall use quality indicator data, including patient care, and other relevant data, in the design of its program.

(b) The hospice shall use the data collected to do all of the following:

1. Monitor the effectiveness and safety of services and quality of care.

2. Identify opportunities and priorities for improvement.

(4) Program activities.

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

1. Focus on high risk, high volume, or problem-prone areas.

2. Consider incidence, prevalence, and severity of problems in those areas.

3. Affect palliative outcomes, patient safety, and quality of care.

(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.

(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.

(5) Performance improvement projects. The hospice shall develop, implement, and evaluate performance improvement projects.

(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.

(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.

(6) Executive responsibilities. The hospice’s governing body is responsible for ensuring all of the following:

(a) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually.

(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.

(c) That one or more individuals who are responsible for operating the quality assessment and performance improvement program are designated.

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

DHS 131.23 Infection control.

(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.

(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.

(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:

(a) Is an integral part of the hospice’s quality assessment and performance improvement program; and

(b) Includes all of the following:

1. A method of identifying infectious and communicable disease problems.

2. A plan for implementing the appropriate actions that are expected to result in improvement and disease prevention.

(4) Education.

(a) The hospice shall provide infection control education to employees, contracted providers, patients, and family members and other caregivers.

(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.

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

Subchapter IV — Management

DHS 131.24 Employee health.

(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.

(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.

(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.

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

DHS 131.25 Core services.

(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.

(2) Core team.

(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).

(b) With respect to services provided to a patient, each core team member shall do all of the following:

1. Assess patient and family needs.

2. Promptly notify the registered nurse of any change in patient status that suggests a need to update the plan of care.

3. Provide services consistent with the patient plan of care.

4. Provide education and counseling to the patient and, as necessary, to the patient’s family, consistent with the plan of care.

5. Participate in developing and revising written patient care policies and procedures.

(c) The hospice may contract for physician services as specified in par. (a). A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice staff to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care and temporary travel of a patient outside of the hospice’s service area.

(3) Physician services. The hospice medical director, physician employees, and contracted physicians of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness.

(a) All physician employees and those under contract must function under the supervision of the hospice medical director.

(b) All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. If the attending physician is unavailable, the medical director, contracted physician, and or hospice physician employee is responsible for meeting the medical needs of the patient.

(4) Nursing services.

(a) Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following:

1. Regularly assessing the patient’s nursing needs, implementing the plan of care provisions to meet those needs and reevaluating the patient’s nursing needs.

2. Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides.

3. Evaluating the effectiveness of delegated acts performed under the registered nurse’s supervision.

(b) Highly specialized nursing services that are provided so infrequently that the provision of such services by direct hospice employees would be impracticable and prohibitively expensive, may be provided under contract.

(c) Licensed practical nursing services. If licensed practical nursing services are provided, the licensed practical nurse shall function under the supervision of a registered nurse with duties specified in writing and updated by a registered nurse.

(5) Social services.

(a) Social services shall be provided by a qualified social worker and shall consist of all of the following:

1. Regularly assessing the patient’s social service needs, implementing the plan of care to meet those needs and reevaluating the patient’s needs and providing ongoing psychosocial assessment of the family’s coping capacity relative to the patient’s terminal condition.

2. Linking patient and family with needed community resources to meet ongoing social, emotional and economic needs.

(6) Counseling services. Counseling services shall be available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process.

(a) Bereavement services. Bereavement services shall be provided to families of hospice patients. Each hospice shall have its own bereavement program. Bereavement services shall be:

1. Coordinated by an individual who possesses the capacity by training and experience to provide for the bereavement needs of families, including the ability to organize a program of directed care services provided to family members. DHS 131.25 (6).

2. Compatible with the core team’s direction within the plan of care for the patient.

3. Available for one year following the patient’s death as part of an organized program and provide all of the following:

a. Orientation and training to individuals providing bereavement services to ensure that there is continuity of care.

b. Service intervention either directly or through trained bereavement counselors.

c. Assignment, supervision and evaluation of individuals performing bereavement services.

d. Referrals of family members to non-hospice community programs where appropriate.

(b) Dietary counseling. Dietary counseling services shall be provided only as authorized by the hospice and in conjunction with the plan of care. The services shall be provided by a registered dietitian or an individual who has documented equivalency in education or training. Dietary services shall be supervised and evaluated by a registered dietitian or other individual qualified under this paragraph who may delegate acts to other employees. Dietary counseling services shall consist of all of the following:

1. Assessment of nutritional needs and food patterns;

2. Planning diets appropriate for meeting patient needs and preferences; and

3. Providing nutrition education and counseling to meet patient needs, as well as necessary consultation to hospice employees.

1. Provide an assessment of the patient’s and family’s spiritual needs.

2. Provide spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service, and in a manner consistent with patient and family beliefs and desires.

3. Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient’s spiritual needs to the best of its ability.

4. Advise the patient and family of this service.

History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (6) (a) 1., (b) Register July 2020 No. 775, eff. 8-1-20.

DHS 131.26 Non-core services.

(a) Therapy services. Therapy services are provided in accordance with the plan of care for the patient and by individuals who meet qualification requirements for therapy service delivery such as evidence of current licensure or registration and academic training. Therapy services shall consist of all of the following: