Header:
WISCONSIN ADMINISTRATIVE CODE
DEPARTMENT OF HEALTH SERVICES
CHAPTER DHS 124 HOSPITALS
SUBCHAPTER II -- MANAGEMENT
Date:
08/31/2009
Document:
DHS 124.05 Governing body.
(1) GENERAL REQUIREMENT. 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.
(2) RESPONSIBILITIES. (a) By-laws. 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:
1. Stipulate the basis upon which members are selected, their terms of office and their duties and requirements;
2. 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;
3. 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;
4. Specify the frequency with which meetings shall be held;
5. Provide for the appointment of members of the medical staff; and
6. Provide mechanisms for the formal approval of the organization, by-laws and rules of the medical staff.
(b) Meetings. 1. The governing body shall meet at regular intervals as stated in its by-laws.
2. 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.
3. Minutes of meetings shall reflect pertinent business conducted, and shall be distributed to members of the governing body.
(c) Committees. 1. The governing body shall appoint committees. There shall be an executive committee and others as needed.
2. The number and types of committees shall be consistent with the size and scope of activities of the hospital.
3. 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.
4. Written minutes or reports which reflect business conducted by the executive committee shall be maintained for review by the governing body.
5. 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:
1. 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); and
2. 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:
1. A formal procedure shall be established, governed by written rules covering application for medical staff membership and the method of processing applications;
2. 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;
3. 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;
4. Action taken by the governing body on applications for medical staff appointments shall be in writing;
5. Written notification of applicants shall be made by either the governing body or its designated representative;
6. Applicants selected for medical staff appointment shall sign an agreement to abide by the medical staff by-laws and rules; and
7. The governing body shall establish a procedure for appeal and hearing by the governing body or a committee designated by the governing body if the applicant or the medical staff wishes to contest the decision on an application for medical staff appointment.
(f) Appointment of chief executive officer. The governing body shall appoint a chief executive officer for the hospital. The governing body shall annually review the performance of the chief executive officer.
(g) Patient care. The governing body shall establish a policy which requires that every patient be under the care of a physician, dentist or podiatrist. The policy shall provide that:
1. A person may be admitted to a hospital only on the recommendation of a physician, dentist or podiatrist, with a physician designated to be responsible for the medical aspects of care; and
2. A member of the house staff or another physician shall be on duty or on call at all times.
(h) Physical plant requirements. 1. The governing body shall be responsible for providing a physical plant equipped and staffed to maintain the needed facilities and services for patients.
2. The governing body shall receive periodic written reports from appropriate inside and outside sources about the adequacy of the physical plant and equipment and the personnel operating the physical plant and equipment, as well as about any deficiencies.
(i) Finances. The governing body shall arrange financing for the physical plant and for staffing and operating the hospital, and shall adopt an annual budget for the institution.
(j) Discharge planning. 1. The governing body shall ensure that the hospital maintains an effective, ongoing program coordinated with community resources to facilitate the provision of follow-up care to patients who are discharged.
2. The governing body shall ensure that the hospital has current information on community resources available for continuing care of patients following their discharge.
3. The discharge planning program shall:
a. Be reviewed periodically for timely initiation of discharge planning on an individual patient basis;
b. Provide that every patient receive relevant information concerning continuing health needs and is appropriately involved in his or her own discharge planning;
c. Be reviewed at least once a year and more often if necessary to ensure the appropriate disposition of patients; and
d. Allow for the timely and effective transmittal of all appropriate medical, social, and economic information concerning the discharged patient to persons or facilities responsible for the subsequent care of the patient.
(3) POLICIES. (a) Patient rights and responsibilities. 1. Every hospital shall have written policies established by the governing board on patient rights and responsibilities which shall provide that:
a. A patient may not be denied appropriate hospital care because of the patient's race, creed, color, national origin, ancestry, religion, sex, sexual orientation, marital status, age, newborn status, handicap or source of payment;
b. Patients shall be treated with consideration, respect and recognition of their individuality and personal needs, including the need for privacy in treatment;
c. The patient's medical record, including all computerized medical information, shall be kept confidential;
d. The patient or any person authorized by law shall have access to the patient's medical record;
e. Every patient shall be entitled to know who has overall responsibility for the patient's care;
f. Every patient, the patient's legally authorized representative or any person authorized in writing by the patient shall receive, from the appropriate person within the facility, information about the patient's illness, course of treatment and prognosis for recovery in terms the patient can understand;
g. Every patient shall have the opportunity to participate to the fullest extent possible in planning for his or her care and treatment;
h. Every patient or his or her designated representative shall be given, at the time of admission, a copy of the hospital's policies on patient rights and responsibilities;
i. Except in emergencies, the consent of the patient or the patient's legally authorized representative shall be obtained before treatment is administered;
j. Any patient may refuse treatment to the extent permitted by law and shall be informed of the medical consequences of the refusal;
k. The patient or the patient's legally authorized representative shall give prior informed consent for the patient's participation in any form of research;
L. Except in emergencies, the patient may not be transferred to another facility without being given a full explanation for the transfer, without provision being made for continuing care and without acceptance by the receiving institution;
m. Every patient shall be permitted to examine his or her hospital bill and receive an explanation of the bill, regardless of source of payment, and every patient shall receive, upon request, information relating to financial assistance available through the hospital;
n. Every patient shall be informed of his or her responsibility to comply with hospital rules, cooperate in the patient's own treatment, provide a complete and accurate medical history, be respectful of other patients, staff and property, and provide required information concerning payment of charges;
o. Every patient shall be informed in writing about the hospital's policies and procedures for initiation, review and resolution of patient complaints, including the address where complaints may be filed with the department; and
p. Every patient may designate persons who are permitted to visit the patient during the patient's hospital stay.
Note: In reference to subd. 1. c. and d, ss. 146.81 to 146.83, Stats., permit the patient and certain other persons to have access to the patient's health care records. Access to the records of a patient receiving treatment for mental illness, a developmental disability, alcohol abuse or drug abuse is governed by s. 51.30 (4), Stats.
Note: In reference to subd. 1. o., complaints may be sent to the Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969.
2. A patient who receives treatment for mental illness, a developmental disability, alcohol abuse or drug abuse shall be recognized as having, in addition, the rights listed under s. 51.61, Stats., and ch. DHS 94.
3. Hospital staff assigned to direct patient care shall be informed of and demonstrate their understanding of the policies on patient rights and responsibilities through orientation and appropriate inservice training activities.
(b) Movement of visitors. Every hospital shall have written policies established by the governing board to control the movement of visitors. The hospital shall control traffic and access to each patient care unit to ensure patient privacy and infection control.
(c) Use of volunteers. Every hospital shall have written policies established by the governing board on the use of volunteers, which:
1. Delineate the scope of volunteer activities;
2. Provide that volunteers may assist with patient care only under the direct supervision of appropriate hospital personnel and after appropriate inservice training which is documented. Volunteers may not assist with patient care if this involves functions that require performance by licensed practical or registered nurses; and
3. Provide that no volunteer under 16 years of age may give direct patient care.
(d) Identification of employees and patients. Every hospital shall have written policies established by the governing board on identification of employees and patients.
(e) Maintenance of personnel records and patient files. Every hospital shall have written policies established by the governing board on maintenance of personnel records and patient files.
(f) Post-mortem examinations. 1. Every hospital shall have written policies established by the governing board to protect hospital and mortuary personnel in the performance of necropsy or other postmortem procedures on individuals who have been treated with radioactive materials or are known to have had an infection or communicable disease at the time of death, or in those cases in which an unrecognized postmortem infection is found at the time of the postmortem examination.
2. Delay in releasing a dead human body to a funeral director or other person authorized to make the removal, pending an autopsy, shall be as provided in s. DHS 135.04 (3).
(g) Tagging of bodies. If a dead human body to be removed from a hospital was treated for or is suspected of having a communicable or infectious disease or contains radioactive materials, the body shall be tagged by staff of the hospital to indicate the possibility of the presence of the communicable or infectious disease or radioactive materials. If the body is in a container, a tag shall also be applied to the outside of the container.
(h) Cancer reporting. Every hospital shall report to the department all malignant neoplasms the hospital diagnoses and all malignant neoplasms diagnosed elsewhere if the individual is subsequently admitted to the hospital. The hospital shall report each malignant neoplasm on a form the department prescribes or approves and shall submit the report to the department within 6 months after the diagnosis is made or within 6 months after the individual's first admission to the hospital if the neoplasm is diagnosed elsewhere, as appropriate. In this paragraph, "malignant neoplasm" means an in situ or invasive tumor of the human body, but does not include a squamous cell carcinoma or basal cell carcinoma arising in the skin or an in situ carcinoma of the cervix uteri.
Note: Copies of the Department's reporting form, Neoplasm Record/Report (F-45500), may be obtained without charge from the Center for Health Statistics, P.O. Box 309, Madison WI 53701 (608-266-8926).
(i) Anatomical gifts. Every hospital shall comply with the Anatomical Gift Act under s. 157.06, Stats.
(j) Use of automated external defibrillators. Before providing emergency services in a hospital, medical and nursing personnel shall have proficiency in the use of an automated external defibrillator as defined in s. 256.15 (1) (cr), Stats., achieved through instruction provided by an individual, organization, or institution of higher education that is approved under s. 46.03 (38), Stats., to provide such instruction.
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