Wis. Admin. Code DHS § DHS 118.04

Current through November 25, 2024

Section DHS 118.04 - Lead agency

(1) DESIGNATION. The department shall be the lead agency for the development, implementation and monitoring of the statewide trauma care system.

(2) LEAD AGENCY DUTIES. The lead agency shall do all of the following:

(a)General duties. Develop and revise guidelines and administrative rules for the statewide trauma care system.

(b)Organize and structure RTACs.

1. Approve the designation of all trauma care geographic regions based on consideration of what represents the best care of the trauma patient.

Note: Wisconsin is divided into 9 trauma care geographic regions. Each region has an RTAC. A trauma care region is defined by the location of the health care providers that have selected a particular RTAC for primary membership and in which the majority of each provider's trauma care and prevention occurs.

2. Review the geographic distribution and organization of regional trauma advisory councils and ensure executive councils that promote the optimal operation of the statewide trauma care system.

3. Approve regional trauma advisory councils under sub. (6) (c).

4. Approve coordinating facilities, fiscal agents, executive councils and resource hospitals under sub. (6) (c).

(c)Classify trauma care facilities.

1. Establish and revise the assessment and classification criteria for characterizing a hospital as a trauma facility.

2. Review and approve hospital requests for trauma care facility classification in accordance with standards and guidance provided by the criteria in appendix A and according to the process under sub. (6) (a).

Note: Hospitals are verified by the ACS as level I or II trauma care facilities based on conformance with the standards and guidelines established by the ACS. The department determines its classification of hospitals as level III or IV trauma care facilities in accordance with the standards and guidelines provided in appendix A of this chapter.

Note: Subd. 2. is shown as affected eff. 10-1-21 by CR 19-086. Prior to 10-1-21 it reads:

2. Review and approve hospital applications to be a trauma care facility in accordance with standards and guidance given by the American college of surgeons in the publication Resources for Optimal Care of the Injured Patient: 1999 and the criteria in appendix A and according to the process under sub. (6) (a).

Notes: 1. The publication, Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons (1998), is on file in the Department's Division of Public Health and the Legislative Reference Bureau, and is available for purchase from the American College of Surgery, 633 W. Saint Clair St., Chicago, Illinois 60611-3211.

2. Hospitals are verified by the American College of Surgeons as level I or II trauma care facilities based on conformance with the standards and guidelines contained in the publication, Resources for Optimal Care of the Injured Patient: 1999. The Department bases its classification of hospitals as level III or IV trauma care facilities on appendix A of this chapter.

3. Review and approve a hospital's selection of an RTAC with which the hospital will participate under s. DHS 118.08(1).

(d)Guide RTAC plan development.

1. With the advice of the STAC, establish the guidelines for RTAC needs assessments and trauma plans developed pursuant to s. DHS 118.06(3) (L) and triage and transport protocols developed pursuant to s. DHS 118.06(3) (o).

2. Review and approve regional trauma needs assessments, triage and transport protocols and plans under sub. (6) (c).

(e)Develop and operate state trauma registry.

1. Develop, implement and maintain the state trauma registry under s. DHS 118.09.

2. Develop and prepare standard reports on Wisconsin's trauma system using the state trauma registry as described in s. DHS 118.09(4).

(f)Guide improvement of regional trauma care performance.

1. Provide all of the following reports to RTACs:

a. Quarterly standard reports of trauma registry results for the region.

b. Other reports as requested by RTACs.

2. Develop guidelines for a regional performance improvement program under s. DHS 118.10 that includes all of the following:

a. The purpose and principles of the program.

b. How to establish and maintain the program.

c. The requirements for membership of the regional performance improvement committee.

d. The authority and responsibilities of the performance improvement committee.

(g)Maintain statewide trauma care system.

1. Resolve conflicts concerning trauma care and prevention issues between the RTAC and trauma care providers and any other entity within the RTAC's geographic region according to the process specified under sub. (3).

2. Maintain awareness of national trends in trauma care and periodically report on those trends to RTACs and trauma care system participants.

3. Encourage public and private support of the statewide trauma care system.

4. Assist the RTACs with developing injury prevention, training and education programs.

5. Seek the advice of the statewide trauma advisory council in developing and implementing the statewide trauma care system.

(h)Enforce chapter requirements.

1. Regulate and monitor trauma care facilities.

2. Investigate complaints and alleged violations of this chapter.

3. Enforce the requirements of this chapter.

(3) COMPLAINT AND DISPUTE RESOLUTION.

(a)

1. Upon receipt of a complaint about the trauma system, the department shall either investigate the complaint or request one or more RTACs to initially investigate and respond to the complaint. The department shall monitor how the RTAC or RTACs are addressing and responding to the complaint. When the RTAC has completed its investigation and has prepared its response, the RTAC shall communicate its response to the department.

2. Regardless of whether the department has requested one or more RTACs to investigate and respond to the complaint, the department may initiate an investigation of and response to a complaint within 2 business days following the department's receipt of the complaint.

Note: The time within which the Department resolves a complaint depends on the nature of the complaint and the resources required to investigate and resolve the complaint.

(b)

1. The department shall maintain a record of every complaint and how each complaint was addressed and resolved.

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.

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.

(4) INVESTIGATIONS.

(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.

(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.

(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).

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.

(6) DEPARTMENT REVIEW PROCESS.

(a)Department review of and decision on hospital trauma care facility applications.

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.

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.

2. The department shall review each hospital application submitted pursuant to s. DHS 118.08(2).

3. The department may require a hospital to document the basis for the hospital's professed level of trauma care facility.

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:

a. The department shall select the site visit team.

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.

b. The department's site visit shall be to determine whether the facility meets the assessment and classification criteria in appendix A.

c. The site visit team shall submit their findings to the department within 30 calendar days of completing the site visit.

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.

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.

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).

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.

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.

(b)Department review of and decision on a hospital's selection of an RTAC for primary membership.

1. The department shall review each hospital selection of an RTAC for primary membership pursuant to s. DHS 118.08(1) (a) 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.

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).

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.

(c)Department review of and decision on RTAC applications, selections, needs assessments, triage and transport protocols and plans.

1. An RTAC requesting department approval of any of the following shall submit it to the department:

a. An application under s. DHS 118.06(3) (a).

b. A selection of an executive council, coordinating facility, fiscal agent and resource hospital under s. DHS 118.06(3) (c), (d), (e) and (f).

c. A needs assessment of its trauma region under s. DHS 118.06(3) (L), and a triage and transport protocol or plan under s. DHS 118.06(3) (o).

2. The department shall review each RTAC submission made under subd. 1.

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.

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).

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.

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).

(d)Department withdrawal of RTAC approval.

1. The department may withdraw its approval of an RTAC's operations if the department makes a finding of any of the following:

a. The RTAC does not meet the eligibility requirements established in s. 256.15, Stats., and this chapter.

b. The department approval was obtained through error or fraud.

c. The RTAC violated any provision or timeline of s. 256.15, Stats., or this chapter.

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.

(7) APPEALS OF DEPARTMENT DECISIONS.

(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.

(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.

(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.

Wis. Admin. Code Department of Health Services DHS 118.04

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.

Amended by, corrections in (2) (c) 2. and (Note [1], [2]) made under s. 13.92(4) (b) 7, Stats., Register May 2021 No. 785, eff. 6/1/2021

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.