Chapter DHS 131

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.

DHS 131.33 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.34 DHS 131.34 Personnel qualifications.

DHS 131.34(1) (1) Personnel qualifications. All professionals who furnish services directly, under an individual contract, or under arrangements with a hospice, shall be legally authorized, licensed, certified or registered in accordance with applicable federal, state and local laws, and shall act only within the scope of his or her state license, or state certification, or registration. Personnel qualifications shall be kept current at all times.

DHS 131.34 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

subch. V of ch. DHS 131 Subchapter V — Physical Environment

DHS 131.35 DHS 131.35 Definitions. In this subchapter:

DHS 131.35(1) (1) “Existing construction” or “existing facility” means a building which is in place or is being constructed with plans approved by the department prior to August 1, 2020.

DHS 131.35(2) (2) “Freestanding hospice facility” means a residential facility serving 3 or more patients which is not located in a licensed hospital or nursing home.

DHS 131.35(3) (3) “Life Safety Code” means the National Fire Protection Association’s Standard 101.

DHS 131.35(4) (4) “New construction” means construction for the first time of any building or addition to an existing building, the plans for which are approved on or after August 1, 2020.

DHS 131.35(5) (5) “NFPA” means the National Fire Protection Association.

DHS 131.35 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (1), (3), (4), r. and recr. (5) Register July 2020 No. 775, eff. 8-1-20; correction in (1), (5) made under s. 13.92 (4) (b) 14., Stats., Register July 2020 No. 775.

DHS 131.36 DHS 131.36 Scope. This subchapter applies to freestanding hospice facilities.

DHS 131.36 Note Note: Inpatient hospices located in nursing homes or hospitals must meet applicable administrative codes.

DHS 131.36 History History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10.

DHS 131.37 DHS 131.37 Physical plant.

DHS 131.37(1) (1) General requirements. The building of a freestanding hospice shall be constructed and maintained so that it is functional for the delivery of hospice services, appropriate to the needs of the community and protects the health and safety of the patients. The provisions of this section apply to all new, remodeled and existing construction unless otherwise noted. Wherever a requirement in this section is in conflict with the applicable Life Safety Code under s. DHS 131.38, the Life Safety Code shall take precedence.

DHS 131.37(5) (5) Patient bedrooms.

DHS 131.37(5)(a) (a) Design and location. Patient bedrooms shall be designed and equipped for the comfort and privacy of the patient and shall be equipped with or located near toilet and bathing facilities.

DHS 131.37(5)(b) (b) Capacity.

DHS 131.37(5)(b)1. 1. A patient bedroom may accommodate no more than 2 patients. Patients of the opposite sex may not be required to occupy the same sleeping room.

DHS 131.37(5)(b)2. 2. The minimum floor area per bed shall be 80 square feet in multiple patient rooms and 100 square feet in single patient rooms. The distance between patient beds in multipatient rooms shall be at least 3 feet.

DHS 131.37(5)(c) (c) Bed arrangements.

DHS 131.37(5)(c)2. 2. There shall be at least 3 feet between beds where the space is necessary for patient or staff access.

DHS 131.37(5)(c)3. 3. Visual privacy shall be provided for each patient in multibed patient rooms. In new or remodeled construction, cubicle curtains shall be provided.

DHS 131.37(5)(d) (d) Semiambulatory and nonambulatory patients. For rooms with semiambulatory or nonambulatory patients, mobility space at the end and one side of each bed may not be not less than 4 feet. Adequate accessible space for storage of a patient’s wheelchair or other adaptive or prosthetic equipment shall be provided and shall be readily accessible to the patient.

DHS 131.37(5)(e) (e) Equipment and supplies. Each patient shall be provided with all of the following:

DHS 131.37(5)(e)1. 1. A separate bed of proper size and height for the convenience of the patient. Beds shall be at least 36 inches wide and shall be maintained in good condition.

DHS 131.37(5)(e)2. 2. Drawer space available in the bedroom for personal clothing and possessions.

DHS 131.37(5)(e)3. 3. Closet or wardrobe space with clothes racks and shelves in the bedroom.

DHS 131.37(7) (7) Windows.

DHS 131.37(7)(a) (a) Minimum size. Every living and sleeping room shall have one or more outside-facing windows.

DHS 131.37(7)(b) (b) Openable bedroom window. At least one outside window in a bedroom shall be openable from the inside without the use of tools.

DHS 131.37(7)(c) (c) Window screens. All openable windows in habitable rooms shall have insect-proof screens.