“Legally authorized person" means a parent of a minor, a court appointed guardian or a person authorized by the patient in accordance with law to act on the patient's behalf.
“Licensed practical nurse" means a person licensed as a trained practical nurse under ch. 441
“Medical staff" means the hospital's organized component of physicians, podiatrists and dentists appointed by the governing body of the hospital and granted specific medical privileges for the purpose of providing adequate medical, podiatric and dental care for the patients of the hospital.
"Medicare" means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395
ccc and 42 CFR ch. IV, subch.
“Physician" means a person licensed to practice medicine or osteopathy under ch. 448
“Physician assistant" means a person certified under ch. 448
, Stats., to perform patient services under the supervision and direction of a licensed physician.
“Podiatrist" means a person licensed to practice podiatry or podiatric medicine and surgery under ch. 448
“Practitioner" means a physician, dentist, podiatrist or other person permitted by Wisconsin law to distribute, dispense and administer medications in the course of professional practice.
“Qualified occupational therapist" means a person who meets the standards for registration as an occupational therapist of the American occupational therapy association.
“Qualified physical therapist" means a person licensed to practice physical therapy under ch. 448
“Qualified respiratory therapist" means a person who meets the standards for registration as a respiratory therapist of the national board for respiratory therapy, inc., or who meets the training and experience requirements necessary for registration and is eligible to take the registry examination.
“Qualified speech pathologist" means a person who meets the standards for a certificate of clinical competence granted by the American speech and hearing association or who meets the educational requirements for certification and is in the process of acquiring the supervised experience required for certification.
“Registered nurse" means a person who is licensed as a registered nurse under ch. 441
“Respiratory therapy technician" means a person who meets the standards for certification as a respiratory therapy technician of the national board for respiratory therapy, inc., or who meets the training and experience requirements necessary for certification and is eligible to take the certification examination.
“Special hospital" means a hospital that provides a limited type of medical or surgical care, such as an orthopedic hospital, a children's hospital, a critical access hospital, a psychiatric hospital or a maternity hospital.
“Tissue" means a substance consisting of cells and intercellular material that is removed from a patient's body during a surgical procedure.
DHS 124.02 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; correction in (3) made under s. 13.93 (2m) (b) 6., Stats., Register, August, 1996, No. 488
; emerg. cr. (1m), am. (6), (12 and (19), r. and recr. (21), eff. 9-12-98; cr. (1m) and (10m), am. (6), (12) and (19) and r. and recr. (21), Register, January, 1999, No. 517
, eff. 2-1-99; correction in (3) made under s. 13.92 (4) (b) 6., Stats., Register January 2009 No. 637
No hospital may operate in Wisconsin unless it is approved by the department.
To be approved by the department, a hospital shall comply with this chapter and with all other applicable state laws and local ordinances, including all state laws and local ordinances relating to fire protection and safety, reporting of communicable disease, cancer reporting and post-mortem examination, and professional staff of the hospital shall be licensed or registered, as appropriate, in accordance with applicable laws.
An application for approval shall be submitted to the department on a form prescribed by the department.
DHS 124.03 Note
Note: For a copy of the hospital approval application form, write Division of Quality Assurance, P.O. Box 2969, Madison, Wisconsin 53701-2969.
The department shall review and make a determination on a complete application for approval within 90 working days after receiving the application.
Approval by the department applies only to the owner of a hospital who may not transfer or assign the approval to anyone else. When there is a change in the ownership of the hospital, the new owner shall submit a new application to the department.
If at any time the department determines that there has been a failure to comply with a requirement of this chapter, it may withhold, suspend or revoke the certificate of approval consistent with s. 50.35
Every 12 months, on a schedule determined by the department, a hospital shall submit to the department an annual report in the form and containing the information that the department requires, including payment of the fee required under s. 50.135 (2) (a)
, Stats. If a complete annual report is not timely filed, the department shall issue a warning to the holder of the certificate of approval. If a hospital that has not filed a timely report fails to submit a complete report to the department within 60 days after the date established under the schedule determined by the department, the department may revoke the approval of the hospital.
DHS 124.03 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; cr. (7), Register, August, 2000, No. 536
, eff. 9-1-00.
“Variance" means an alternative requirement in place of a requirement of this chapter.
“Waiver" means an exception from a requirement of this chapter.
(2) Requirements for waivers and variances.
A hospital may ask the department to grant a waiver or variance. The department may grant the waiver or variance if the department finds that the waiver or variance will not adversely affect the health, safety or welfare of any patient and that:
Strict enforcement of a requirement would result in unreasonable hardship on the hospital or on a patient; or
An alternative to a rule, which may involve a new concept, method, procedure or technique, new equipment, new personnel qualifications or the conduct of a pilot project, is in the interests of better care or management.
All applications for the grant of a waiver or variance shall be made in writing to the department, specifying the following:
If the request is for a variance, the specific alternative action which the facility proposes;
The department may require additional information from the hospital prior to acting on the request.
The department shall grant or deny each request for waiver or variance in writing. Notice of a denial shall contain the reasons for denial.
The terms of a requested variance may be modified upon agreement between the department and the hospital.
The department may impose whatever conditions on the granting of a waiver or variance it considers necessary.
A hospital may contest the department's action on the hospital's application for a waiver or variance by requesting a hearing as provided by ch. 227
The hospital shall sustain the burden of proving that the denial of a waiver or variance is unreasonable.
The department may revoke a waiver or variance, subject to the hearing requirement in par. (c)
The department determines that the waiver or variance is adversely affecting the health, safety or welfare of the patients;
The hospital has failed to comply with the variance as granted or with a condition of the waiver or variance;
The person who has received the certificate of approval notifies the department in writing that the hospital wishes to relinquish the waiver or variance and be subject to the rule previously waived or varied; or
DHS 124.04 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88.
The hospital shall have an effective governing body or a designated person who functions as the governing body which is legally responsible for the operation and maintenance of the hospital.
The governing body shall adopt by-laws. The by-laws shall be in writing and shall be available to all members of the governing body. The by-laws shall:
Stipulate the basis upon which members are selected, their terms of office and their duties and requirements;
Specify to whom responsibilities for operation and maintenance of the hospital, including evaluation of hospital practices, may be delegated, and the methods established by the governing body for holding these individuals responsible;
Provide for the designation of officers, if any, their terms of office and their duties, and for the organization of the governing body into committees;
Provide mechanisms for the formal approval of the organization, by-laws and rules of the medical staff.
The governing body shall meet at regular intervals as stated in its by-laws.
Meetings shall be held frequently enough for the governing body to carry on necessary planning for hospital growth and development and to evaluate the performance of the hospital, including the care and utilization of physical and financial assets and the procurement and direction of personnel.
Minutes of meetings shall reflect pertinent business conducted, and shall be distributed to members of the governing body.
The governing body shall appoint committees. There shall be an executive committee and others as needed.
The number and types of committees shall be consistent with the size and scope of activities of the hospital.
The executive committee or the governing body as a whole shall establish policies for the activities and general policies of the various hospital services and committees established by the governing body.
Written minutes or reports which reflect business conducted by the executive committee shall be maintained for review by the governing body.
Other committees, including the finance, joint conference, and plant and safety management committees, shall function in a manner consistent with their duties as assigned by the governing body and shall maintain written minutes or reports which reflect the performance of these duties. If the governing body does not appoint a committee for a particular area, a member or members of the governing body shall assume the duties normally assigned to a committee for that area.
(d) Medical staff liaison.
The governing body shall establish a formal means of liaison with the medical staff by means of a joint conference committee or other appropriate mechanism, as follows:
A direct and effective method of communication with the medical staff shall be established on a formal, regular basis, and shall be documented in written minutes or reports which are distributed to designated members of the governing body and the active medical staff under s. DHS 124.12 (3) (a)
Liaison shall be a responsibility of the joint conference committee, the executive committee or designated members of the governing body.
(e) Medical staff appointments.
The governing body shall appoint members of the medical staff in accordance with s. 50.36 (3)
, Stats., as follows:
A formal procedure shall be established, governed by written rules covering application for medical staff membership and the method of processing applications;
The procedure related to the submission and processing of applications shall involve the administrator, the credentials committee of the medical staff or its counterpart, and the governing body;
The selection of physicians, dentists and podiatrists and definition of their medical, dental or podiatric privileges, both for new appointments and reappointments, shall be based on written criteria;
Action taken by the governing body on applications for medical staff appointments shall be in writing;
Written notification of applicants shall be made by either the governing body or its designated representative;
Applicants selected for medical staff appointment shall sign an agreement to abide by the medical staff by-laws and rules; and