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(e) Severity of symptoms.
(f) Drug profile. A review of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:
1. Effectiveness of drug therapy.
2. Drug side effects.
3. Actual or potential drug interactions.
4. Duplicate drug therapy.
5. Drug therapy currently associated with laboratory monitoring.
(g) Bereavement. An initial bereavement assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment shall be incorporated into the plan of care and considered in the bereavement plan of care.
(h) The need for referrals and further evaluation by appropriate health professionals.
(4) Update of the comprehensive assessment. The update of the comprehensive assessment shall be accomplished by the hospice interdisciplinary group in collaboration with the individual’s attending physician, if any, and shall consider changes that have taken place since the initial assessment. The comprehensive assessment shall include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care. The assessment update shall be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The hospice interdisciplinary group shall primarily meet in person to conduct the update of the comprehensive assessment.
(5) Patient outcome measures.
(a) The comprehensive assessment shall include data elements that allow for measurement of outcomes. The hospice shall measure and document data in the same way for all patients.
(b) The data elements shall do all of the following:
1. Take into consideration aspects of care related to hospice and palliation.
2. Be an integral part of the comprehensive assessment.
3. Be documented in a systematic and retrievable way for each patient.
(c) The data elements for each patient shall be used in individual patient care planning and in the coordination of services, and shall be used in the aggregate for the hospice’s quality assessment and performance improvement program.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (1) (a) Register July 2020 No. 775, eff. 8-1-20.
DHS 131.21 Plan of care.
(1) General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient’s family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient’s family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient’s family shall be in accordance with the plan of care.
(2) Initial plan of care.
(a) The hospice shall develop an initial plan of care that does all of the following:
1. Defines the services to be provided to the patient and the patient’s family.
2. Incorporates physician orders and medical procedures.
(b) The initial plan of care shall be developed upon conclusion of the assessment under s. DHS 131.20 (1) (a).
(c) The initial plan of care shall be developed jointly by the employee who performed the initial assessment and at least one other member of the core team.
(d) The registered nurse shall immediately record and sign a physician’s oral orders and shall obtain the physician’s counter-signature within 20 business days.
(3) Plan of care.
(a) Integrated plan of care. The hospice core team shall develop an integrated plan of care for the new patient within 5 days after the admission. The core team shall use the initial plan of care as a basis for team decision-making and shall update intervention strategies as a result of core team assessment and planning collaboration.
(b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following:
1. Interventions to manage pain and symptoms.
2. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.
3. Measurable outcomes anticipated from implementing and coordinating the plan of care.
4. Drugs and treatment necessary to meet the needs of the patient.
5. Medical supplies and appliances necessary to meet the needs of the patient.
6. The interdisciplinary group’s documentation of the patient’s or representative’s, if any, level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice’s own policies, in the clinical record.
(c) Review of the plan of care. The hospice interdisciplinary group in collaboration with the individual’s attending physician, if any, shall review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care shall include information from the patient’s updated comprehensive assessment and shall note the patient’s progress toward outcomes and goals specified in the plan of care. The hospice interdisciplinary group shall primarily meet in person to review and revise the individualized plan of care.
(d) Bereavement plan of care. The hospice core team shall review and update the bereavement plan of care, at minimum:
1. Fifteen calendar days following a patient’s death.
2. Within 60 calendar days following the patient’s death.
3. As often as necessary based on identified family needs.
4. At the termination of bereavement services.
(e) Contents of the bereavement plan of care. The bereavement plan of care shall include all of the following:
1. The family and caregiver’s specific needs or concerns.
2. Intervention strategies to meet the identified needs.
3. Employees responsible for delivering the care.
4. Established timeframes for evaluating and updating the interventions.
5. The effect of the intervention in meeting established goals.
(f) Record of notes. The core team shall develop a system for recording and maintaining a record of notes within the plan of care.
History: CR 10-034: cr. Register September 2010 No. 657, eff. 10-1-10; CR 19-092: am. (2) (d) Register July 2020 No. 775, eff. 8-1-20.
DHS 131.22 Quality assessment and performance improvement.
(1) Program standards.
(a) The hospice shall develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program.
(b) The hospice’s governing body shall ensure that the program reflects the complexity of its organization and services, involves all hospice services including those services furnished under contract or arrangement, focuses on indicators related to improved palliative outcomes, and takes actions to demonstrate improvement in hospice performance.
(c) The hospice shall maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to the department.
(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.
(c) The frequency and detail of the data collection shall be approved by the hospice’s governing body.
(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.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.