DHS 118.04(3)(b)1.1. The department shall maintain a record of every complaint and how each complaint was addressed and resolved.
DHS 118.04(3)(b)2.
2. Within the constraints imposed by laws protecting patient confidentiality, the department shall make available its complaint record under subd.
1. to any person requesting to review it.
DHS 118.04 Note
Note: To request review of the Department's complaint record, contact the Statewide Trauma Care Coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
DHS 118.04(4)(a)(a) An authorized employee or agent of the department, upon presentation of identification, shall be permitted to examine equipment or vehicles or enter the offices of an RTAC, a hospital seeking or having department recognition as a trauma care facility or an ambulance service provider during business hours with 24 hour advance notice or at any other reasonable prearranged time. The authorized employee or agent of the department shall be permitted to inspect and review all equipment and vehicles and inspect, review and reproduce records of the trauma care facility, ambulance service provider or RTAC pertinent to the nature of the complaint, including, but not limited to, administrative records, personnel records, training records and vehicle records. The right to inspect, review and reproduce records applies regardless of whether the records are maintained in written, electronic or other form.
DHS 118.04(4)(b)
(b) If, based on the department's investigation, the department determines that corrective action by the trauma care facility is necessary, the trauma care facility shall make the corrective actions. The department may subsequently conduct a final investigation following corrective action and notify the trauma facility of the results.
DHS 118.04(5)
(5)
Waivers. The department may waive any nonstatutory requirement under this chapter, upon written request, if the department finds that strict enforcement of the requirement will create an unreasonable hardship for the provider in meeting the emergency medical service needs of an area and that waiver of the requirement will not adversely affect the health, safety or welfare of patients or the general public. The department's denial of a request for a waiver shall constitute the final decision of the department and is not subject to a hearing under sub.
(7).
DHS 118.04 Note
Note: To request a waiver from a nonstatutory requirement under this chapter, contact the statewide trauma care coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
DHS 118.04(6)(a)
(a)
Department review of and decision on hospital trauma care facility applications. DHS 118.04(6)(a)1.1. A hospital requesting department approval to act or advertise as a trauma care facility shall submit an application to the department on a form provided by the department.
DHS 118.04 Note
Note: For a copy of the Department's assessment and classification criteria application form for approval as a trauma care facility, write to the Wisconsin Trauma Care System Coordinator, Division of Public Health, P.O. Box 2659, Madison WI 53701–2659 or download the form from the DHS website at:
http://www.dhs.wisconsin.gov/forms/F4/F47479.doc.
DHS 118.04(6)(a)3.
3. The department may require a hospital to document the basis for the hospital's professed level of trauma care facility.
DHS 118.04(6)(a)4.
4. The department may perform a site visit of a level III or IV trauma facility to determine compliance with the trauma facility assessment and classification criteria in accordance with all of the following conditions:
DHS 118.04 Note
Note: The Department recommends that a trauma surgeon, emergency room physician and a trauma coordinator, all from a Level I or II verified trauma care facility, minimally comprise the site visit team.
DHS 118.04(6)(a)4.b.
b. The department's site visit shall be to determine whether the facility meets the assessment and classification criteria in appendix A.
DHS 118.04(6)(a)4.c.
c. The site visit team shall submit their findings to the department within 30 calendar days of completing the site visit.
DHS 118.04(6)(a)5.a.a. Except as provided under subd.
5. b., within 60 business days of receiving a complete application for department approval to be a trauma care facility, the department shall either approve or deny the application and notify the applicant hospital in writing. In this subdivision paragraph, “complete application" means a completed application form and the documentation necessary to establish that the hospital is a level I, II, III or IV trauma care facility.
DHS 118.04(6)(a)5.b.
b. If the department determines a need to conduct a site visit of the applicant hospital, the department shall notify the applicant hospital of its level of trauma care within 10 business days following the department's receipt of the site visit findings under subd.
4. c. DHS 118.04(6)(a)5.c.
c. If the department does not approve the applicant hospital's application, the department shall give the applicant reasons, in writing, for the denial and shall inform the applicant of the right to appeal the department's decision under sub.
(7).
DHS 118.04(6)(a)5.d.
d. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5
th day following the date the department mails the notice.
DHS 118.04(6)(a)6.
6. If the department determines the applicant hospital's trauma care capabilities do not warrant the hospital being approved as a trauma care facility, the department shall consider the hospital to be an unclassified hospital.
DHS 118.04(6)(b)
(b) Department review of and decision on a hospital's selection of an RTAC for primary membership. DHS 118.04(6)(b)2.
2. If the department does not notify the hospital of its approval or disapproval within 30 calendar days of receiving a hospital RTAC selection for department approval, the hospital may consider their selection approved by the department.
DHS 118.04(6)(b)3.
3. If the department does not approve the hospital's selection of an RTAC, the department shall give the applicant reasons, in writing, for the denial and shall inform the applicant of the right to appeal the department's decision under sub.
(7).
DHS 118.04(6)(b)4.
4. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5
th day following the date the department mails the notice.
DHS 118.04(6)(c)
(c) Department review of and decision on RTAC applications, selections, needs assessments, triage and transport protocols and plans. DHS 118.04(6)(c)1.1. An RTAC requesting department approval of any of the following shall submit it to the department:
DHS 118.04(6)(c)3.a.a. Within 90 business days of receiving an RTAC submission under subd.
1., the department shall either approve or deny the RTAC submission and notify the RTAC in writing.
DHS 118.04(6)(c)3.b.
b. If the department does not approve an RTAC's submission, the department shall give the RTAC reasons, in writing, for the denial. The department shall also inform the applicant of the right to appeal the department's decision under sub.
(7).
DHS 118.04(6)(c)3.c.
c. In the absence of other evidence of receipt, receipt of the department's notice under this subdivision is presumed on the 5
th day following the date the department mails the notice.
DHS 118.04(6)(c)4.
4. In response to the department's non-approval under subd.
3., the RTAC may modify its submission and submit the revision to the department for subsequent department review or appeal the department's decision pursuant to sub.
(7).
DHS 118.04(6)(d)1.1. The department may withdraw its approval of an RTAC's operations if the department makes a finding of any of the following:
DHS 118.04(6)(d)2.
2. The department shall send written notice of the department's proposed action and of the right to request a hearing under sub.
(7) to the RTAC within 48 hours after the withdrawal takes place. In the absence of other evidence of receipt, receipt of the department's notice is presumed on the 5
th day following the date the department mails the notice.
DHS 118.04(7)(a)
(a) If under sub.
(6), the department does not approve a hospital's application under sub.
(6) (a) or selection under sub.
(6) (b), or an RTAC's submission under sub.
(6) (c) or the department withdraws its approval of an RTAC under sub.
(6) (d), the hospital or RTAC may request a hearing under s.
227.42, Stats. The request for a hearing shall be submitted in writing to and received by the department of administration's division of hearings and appeals within 30 days after the date of the notice required under sub.
(6). A request is considered filed when received by the division of hearings and appeals.
DHS 118.04(7)(b)
(b) The division of hearings and appeals shall hold the hearing no later than 30 days after receiving the request for the hearing unless both parties agree to a later date and shall provide at least 10 days prior notification of the date, time and place for the hearing.
DHS 118.04(7)(c)
(c) The hearing examiner shall issue a proposed or final decision within 30 days after the hearing. The department decision shall remain in effect until a final decision is rendered.
DHS 118.04 Note
Note: A hearing request should be addressed to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707. Hearing requests may be delivered in person to that office at 5005 University Ave., Room 201, Madison, WI or submitted by facsimile to 608-264-9885.
DHS 118.04 History
History: CR 04-055: cr.
Register December 2004 No. 588, eff. 1-1-05;
corrections in (6) (d) 1. a. and c. made under s.
13.92 (4) (b) 7., Stats.,
Register January 2009 No. 637;
CR 19-086: am. (2) (c) 2.
Register May 2021 No. 785, eff. 10-1-21.
DHS 118.05
DHS 118.05 Statewide trauma advisory council. The statewide trauma advisory council shall be responsible for all of the following:
DHS 118.05(1)
(1) Advising the department on issues related to the development, implementation and evaluation of the statewide trauma care system.
DHS 118.05(2)
(2) Reviewing and approving the department's proposed format and content of RTAC trauma plans.
DHS 118.05 History
History: CR 04-055: cr.
Register December 2004 No. 588, eff. 1-1-05.
DHS 118.06
DHS 118.06 Regional trauma advisory councils. DHS 118.06(1)(1)
Purpose. The purpose of a regional trauma advisory council is to develop, implement, monitor and improve the regional trauma system.
DHS 118.06(2)
(2)
Participation in RTAC activities. A regional trauma advisory council may include facilities or organizations located in a neighboring state that provide trauma care to Wisconsin residents.
DHS 118.06(3)
(3)
Regional trauma advisory council responsibilities. A regional trauma advisory council shall do all of the following:
DHS 118.06 Note
Note: To obtain an application, contact the statewide trauma care coordinator by calling 608-266-0601 or by writing to Statewide Trauma Care System Coordinator, Bureau of Local Public Health Practice and Emergency Medical Services, Room 118, 1 West Wilson St., Madison, WI 53701, or by sending a fax to 608-261-6392.
DHS 118.06(3)(b)1.1. Establish an executive council that has all of the following characteristics:
DHS 118.06(3)(b)1.a.
a. Reflects professional representation from out-of-hospital trauma care providers, trauma care facilities, education and injury prevention.
DHS 118.06 Note
Note: Out-of-hospital trauma care providers include emergency medical services practitioners, emergency medical responders, or air medical personnel.
DHS 118.06(3)(b)1.b.
b. May have representation of an out-of-state hospital or ambulance service provider if the hospital or ambulance service provider regularly provides care for persons injured in Wisconsin.
DHS 118.06(3)(b)1.d.
d. Does not have more than 50 percent of its representation from any single organization. In this subdivision paragraph, “organization" means corporate affiliation, entity or ownership.
DHS 118.06 Note
Note: The Department believes that limiting primary service to the executive council of one RTAC will promote a representative's focus on and allegiance to that RTAC. Any person, however, may participate in the activities of more than one RTAC.
DHS 118.06(3)(c)1.1. Select a coordinating facility. The coordinating facility shall be or do all of the following:
DHS 118.06(3)(c)1.a.
a. Work in collaboration with the department and the regional trauma advisory council to meet the needs required for the development, implementation, maintenance and evaluation of the regional trauma system.
DHS 118.06(3)(c)1.c.
c. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, the coordinating facility may be an entity that provides written commitment to the department that the entity will become an ACS-verified level I or II trauma facility within 3 years of that assurance.
DHS 118.06(3)(c)1.d.
d. If a regional trauma advisory council area contains no ACS-verified level I or II trauma facility, and no entity can provide the department the assurance under subd.
1. c., the coordinating facility may be an entity that assures the department in writing that the entity will obtain the department's recognition as a level III trauma facility within the time frame specified in the RTAC application.
DHS 118.06(3)(c)1.e.
e. Have an ACS-verified level I or II hospital, or an equivalent hospital from an adjoining state, serving as its resource hospital if a level III hospital is serving as the coordinating facility.
DHS 118.06(3)(c)1.f.
f. If 2 facilities agree to serve as co-coordinating facilities, one of the facilities shall be an ACS-verified level I or II trauma facility.
DHS 118.06(3)(c)3.
3. Notify the department and the RTAC executive council at least 30 days before relinquishing the title of coordinating facility if the coordinating facility is unable to fulfill the duties required by the regional trauma advisory council.
