Chapter DHS 131

DHS 131.28 DHS 131.28 Governing body.

DHS 131.28(1) (1) Each hospice shall have a governing body that assumes full legal responsibility for determining, implementing and monitoring the overall conduct and operation of the program, including the quality of the care and services.

DHS 131.28(2) (2) The governing body shall do all of the following:

DHS 131.28(2)(a) (a) Be responsible for the establishment and maintenance of policies and for the management, operation and evaluation of the hospice.

DHS 131.28(2)(b) (b) Adopt a statement that designates the services the hospice will provide and the setting or settings in which the hospice will provide care.

DHS 131.28(2)(c) (c) Ensure that all services are provided consistent with accepted standards of professional practice.

DHS 131.28(2)(d) (d) Appoint an administrator and delegate to the administrator the authority to operate the hospice in accordance with policies established by the governing body.

DHS 131.28(2)(e) (e) Ensure that nursing and physician services and drugs and biologicals are routinely available on a 24 hour basis 7 days a week.

DHS 131.28(2)(f) (f) Ensure that other covered services are available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family.

DHS 131.28 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.29 DHS 131.29 Administration.

DHS 131.29(1) (1) Administrator. The administrator shall be responsible for day-to-day operation of the hospice.

DHS 131.29(2) (2) Duties of the administrator. The administrator shall do all of the following:

DHS 131.29(2)(a) (a) Implement and regularly evaluate policies for the management and operation of the hospice and evaluation of the overall program performance of the hospice, and implement and regularly evaluate procedures consistent with those policies.

DHS 131.29(2)(b) (b) Establish an organizational structure appropriate for directing the work of the hospice’s employees in accordance with the program’s policies and procedures.

DHS 131.29(2)(c) (c) Maintain a continuous liaison between the governing body and the hospice employees.

DHS 131.29(2)(d) (d) Ensure that employees are oriented to the program and their responsibilities, that they are continuously trained and that their performance is evaluated.

DHS 131.29(2)(e) (e) Designate in writing, with the knowledge of the governing body, a qualified person to act in his or her absence.

DHS 131.29 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.30 DHS 131.30 Professional management responsibility.

DHS 131.30(1) (1) Responsibility. The hospice is responsible for providing services to the patient or family, or both, based on assessed need and as established by the plan of care.

DHS 131.30(2) (2) Contract services. The hospice may contract with other providers for the provision of services to a patient or the patient’s family, or both, in which case the hospice shall retain responsibility for the quality, availability, safety, effectiveness, documentation and overall coordination of the care provided to the patient or the patient’s family, or both, as directed by the hospice plan of care. The hospice shall:

DHS 131.30(2)(a) (a) Ensure that there is continuity of care for the patient or the patient’s family, or both, in the relevant care setting.

DHS 131.30(2)(b) (b) Be responsible for all services delivered to the patient or the patient’s family, or both, through the contract. The written contract shall include all of the following:

DHS 131.30(2)(b)1. 1. Identification of the services to be provided.

DHS 131.30(2)(b)2. 2. Stipulation that services are to be provided only with the authorization of the hospice and as directed by the hospice plan of care for the patient.

DHS 131.30(2)(b)3. 3. The manner in which the contracted services are coordinated and supervised by the hospice.

DHS 131.30(2)(b)4. 4. The delineation of the roles of the hospice and service provider in the admission process, assessment, interdisciplinary group meetings and ongoing provision of palliative and supportive care.

DHS 131.30(2)(b)5. 5. A method of evaluation of the effectiveness of those contracted services through the quality assurance program under s. DHS 131.22.

DHS 131.30(2)(b)6. 6. The qualifications of the personnel providing the services.

DHS 131.30(2)(c) (c) Evaluate the services provided under a contractual arrangement on an annual basis.

DHS 131.30 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.31 DHS 131.31 Employees.

DHS 131.31(1) (1) Caregiver background checks. Each hospice shall comply with the caregiver background check and misconduct reporting requirements in s. 50.065, Stats., and ch. DHS 12, and the caregiver misconduct reporting and investigation requirements in ch. DHS 13.

DHS 131.31(2) (2) General requirements. Prior to beginning patient care, every employee or contracted staff shall be oriented to the hospice program and the job to which he or she is assigned.

DHS 131.31(3) (3) Orientation program. A hospice’s orientation program shall include all of the following:

DHS 131.31(3)(a) (a) An overview of the hospice’s goal in providing palliative care.

DHS 131.31(3)(b) (b) Policies and services of the program.

DHS 131.31(3)(c) (c) Information concerning specific job duties.

DHS 131.31(3)(d) (d) The role of the plan of care in determining the services to be provided.

DHS 131.31(3)(e) (e) Ethics, confidentiality of patient information, patient rights and grievance procedures.

DHS 131.31(4) (4) Duties. Hospice employees or contracted staff may be assigned only those duties for which they are capable, as evidenced by documented training or possession of a license or certificate.

DHS 131.31(5) (5) Continuous training. A program of continuing training directed at maintenance of appropriate skill levels shall be provided for all hospice employees providing services to patients and their families.

DHS 131.31(6) (6) Evaluation. A hospice shall evaluate every employee annually for quality of performance and adherence to the hospice’s policies. Evaluations shall be followed up with appropriate action.

DHS 131.31(7) (7) Personnel practices.

DHS 131.31(7)(a) (a) Hospice personnel practices shall be supported by appropriate written personnel policies.

DHS 131.31(7)(b) (b) Personnel records shall include evidence of qualifications, licensure, performance evaluations and continuing training, and shall be kept up-to-date.

DHS 131.31 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.32 DHS 131.32 Medical director.

DHS 131.32(1) (1) The hospice shall have a medical director who shall be a medical doctor or a doctor of osteopathy.

DHS 131.32(2) (2) The medical director shall do all of the following:

DHS 131.32(2)(a) (a) Direct the medical components of the program.

DHS 131.32(2)(b) (b) Ensure that the terminal status of each individual admitted to the program has been established.

DHS 131.32(2)(c) (c) Ensure that medications are used within accepted standards of practice.

DHS 131.32(2)(d) (d) Ensure that a system is established and maintained to document the disposal of controlled drugs.

DHS 131.32(2)(e) (e) Ensure that the medical needs of the patients are being met.

DHS 131.32(2)(f) (f) Provide liaison as necessary between the core team and the attending physician.

DHS 131.32(2)(g) (g) Ensure that a system is established for the disposal of controlled drugs.

DHS 131.32 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.33 DHS 131.33 Clinical record.

DHS 131.33(1) (1) General. A hospice shall establish a single and complete clinical record for every patient. Clinical record information shall remain confidential except as required by law or a third-party payment contract.

DHS 131.33(2) (2) Documentation and accessibility. The clinical record shall be completely accurate and up-to-date, readily accessible to all individuals providing services to the patient or the patient’s family, or both, and shall be systematically organized to facilitate prompt retrieval of information.

DHS 131.33(3) (3) Content. A patient’s clinical record shall contain all of the following:

DHS 131.33(3)(a) (a) The initial, integrated and updated plans of care prepared under s. DHS 131.21.

DHS 131.33(3)(b) (b) The initial, comprehensive and updated comprehensive assessments.

DHS 131.33(3)(c) (c) Complete documentation of all services provided to the patient or the patient’s family or both, including:

DHS 131.33(3)(c)1. 1. Assessments.

DHS 131.33(3)(c)2. 2. Interventions.

DHS 131.33(3)(c)3. 3. Instructions given to the patient or family, or both.

DHS 131.33(3)(c)4. 4. Coordination of activities.

DHS 131.33(3)(d) (d) Signed copies of the notice of patient rights under s. DHS 131.19 (1) (a) and service authorization statement under s. DHS 131.17 (4) (b).

DHS 131.33(3)(e) (e) A current medications list.

DHS 131.33(3)(f) (f) Responses to medications, symptom management, treatments, and services.

DHS 131.33(3)(g) (g) Outcome measure data elements, as described in s. DHS 131.20 (5).

DHS 131.33(3)(h) (h) Physician certification and recertification of terminal illness.

DHS 131.33(3)(i) (i) A statement of whether or not the patient, if an adult, has prepared an advance directive; and a copy of the advance directive, if prepared.

DHS 131.33(3)(j) (j) Physician orders.

DHS 131.33(3)(k) (k) Patient and family identification information.

DHS 131.33(3)(L) (L) Referral information, medical history and pertinent hospital discharge summaries.

DHS 131.33(3)(m) (m) Transfer and discharge summaries.

DHS 131.33(4) (4) Authentication.

DHS 131.33(4)(a) (a) Entries. All entries shall be legible, permanently recorded, dated and authenticated by the person making the entry, and shall include that person’s name and title.

DHS 131.33(4)(b) (b) Written record. A written record shall be made for every service provided on the date the service is provided. This written record shall be incorporated into the clinical record no later than 7 calendar days after the date of service.

DHS 131.33(4)(c) (c) Medical symbols. Medical symbols and abbreviations may be used in the clinical records if approved by a written program policy which defines the symbols and abbreviations and controls their use.

DHS 131.33(4)(d) (d) Protection of information. Written record policies shall ensure that all record information is safeguarded against loss, destruction and unauthorized usage.

DHS 131.33(4)(e) (e) Retention and destruction.

DHS 131.33(4)(e)1. 1. An original clinical record and legible copy or copies of court orders or other documents, if any, authorizing another person to speak or act on behalf of the patient shall be retained for a period of at least 5 years following a patient’s discharge or death when there is no requirement in state law. All other records required by this chapter shall be retained for a period of at least 2 years.

DHS 131.33(4)(e)2. 2. A hospice shall arrange for the storage and safekeeping of records for the periods and under the conditions required by this paragraph in the event the hospice closes.

DHS 131.33(4)(e)3. 3. If the ownership of a hospice changes, the clinical records and indexes shall remain with the hospice.