Wisconsin Legislature: DHS 131.20(3)(c)

(d) The hospice’s criteria for discharging the individual from the program.

(2) rights of patients. In addition to rights to the information under sub. (1), each patient shall have all of the following rights:

(a) To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness.

(b) To participate in planning care and in planning changes in care.

(d) To choose his or her attending physician.

(e) To confidential treatment of personal and clinical record information and to approve or refuse release of information to any individual outside the hospice, except in the case of transfer to another health care facility, or as required by law or third party payment contract.

(f) To request and receive an exact copy of one’s clinical record.

(g) To be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property.

(h) To be free from restraints and seclusion except as authorized in writing by the attending physician to provide palliative care for a specified and limited period of time and documented in the plan of care.

(i) To be treated with courtesy, respect and full recognition of the patient’s dignity and individuality and to choose physical and emotional privacy in treatment, living arrangements and the care of personal needs.

(j) To privately communicate with others without restrictions.

(k) To receive visitors at any hour, including small children, and to refuse visitors.

(L) To be informed prior to admission of the types of services available from the hospice, including contracted services and specialized services for unique patient groups such as children.

(m) To be informed of those items and services that the hospice offers and for which the resident may be charged, and the amount of charges for those services.

(3) Patient complaint procedure. Each patient shall have the right, on his or her own behalf or through others, to do all of the following:

(a) Express a complaint to hospice employees, without fear of reprisal, about the care and services provided and to have the hospice investigate the complaint in accordance with an established complaint procedure. The hospice shall document both the existence of the complaint and the resolution of the complaint.

(b) Express complaints to the department, and to receive a statement provided by the department setting forth the right to and procedure for filing verbal or written complaints with the department.

(c) Be advised of the availability of a toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under s. 16.009, Stats.

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

Subchapter III — Patient Care

DHS 131.20 Assessment.

(1) Initial assessment.

(a) If the hospice determines that it has the general capability to meet the prospective patient’s described needs, a registered nurse shall perform an initial assessment of the person’s immediate needs and shall describe in writing the person’s current status, including physical condition, present pain status, emotional status, pertinent psychosocial and spiritual concerns and coping ability of the prospective patient and family support system, and shall determine the appropriateness or inappropriateness of admission to the hospice based on the assessment.

(b) The designated hospice employee shall confer with at least one other core team member and receive that person’s views in order to start the initial plan of care.

(2) Time frame for completion of the comprehensive assessment. The hospice interdisciplinary group, in consultation with the individual’s attending physician, if any, shall complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

(3) Content of the comprehensive assessment. The comprehensive assessment shall identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that shall be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. The comprehensive assessment shall take into consideration all of the following factors:

(a) The nature and condition causing admission including the presence or lack of objective data and subjective complaints.

(b) Complications and risk factors that affect care planning.

(d) Imminence of death.

(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.