Hospice: Policies and Procedures Needed to Meet DHS 131 Licensure Requirements
Background check applications for all users
To prepare for the transition to the new DHS DQA Provider Portal, the Division of Quality Assurance (DQA) will not accept any new background check applications for entity operators, non-client residents, or other required individuals for new or renewing entity license/certification applications, or for rehabilitation review applicants as of November 22, 2025.
DQA will resume accepting background check applications on December 15, 2025, through the DHS DQA Provider Portal. To prepare for this transition and for more information, visit our webpage. Caregiver background checks completed by entities for employees and contractors are not affected by this transition.
Prospective hospice applicants must submit supporting documentation on your agency's operating policies and procedures. If these items aren't prepared thoroughly, your application may be delayed or denied.
Learn more about the Hospice Application Process.
First, review and understand Wisconsin Administrative Rule requirements within Wis. Admin. Code ch. DHS 131. Then, you must develop policies related to each of the rule requirements listed below. Each policy must clearly be outlined and labeled with the corresponding rule.
Policies, procedures, and materials
- Patient Rights (DHS 131.19)
- Service Agreement (DHS 131.17(4)(b))
- Governing Body (DHS 131.28)
- Administrator (DHS 131.29)
- Orientation Program (DHS 131.31(3))
- Continuous Training (DHS 131.31(5))
- Infection Control (DHS 131.23)
- Evaluation (DHS 131.31(6))
- Personnel Practices (DHS 131.31(7))
- Volunteers (DHS 131.27)
- Health Care Records (DHS 131.33)
- Content
- Protection of Records
- Entries
- Medical Symbols and Abbreviations
- Quality Assessment and Performance Improvement (DHS 131.22)
- Admission (DHS 131.17)
- Plan of Care (DHS 131.21)
- Bereavement Program (DHS 131.25(6)(a))
- Discharge (DHS 131.18)
- Reporting & Investigation of Caregiver Misconduct (DHS 13)
Job descriptions
Include descriptions for the following key roles:
- Administrator (DHS 131.29)
- Volunteer (DHS 131.27)
- Medical Director (DHS 131.32)
- Nurses (DHS 131.25(4))
- Social Services (DHS 131.25(5))
- Bereavement (DHS 131.25(6)(a))
- Non-core Services (DHS 131.26)
Services
If you plan to provide these services, include documents to support the credentials of each person:
- Spiritual counselor
- Other counseling services
- Dietitian
- Therapist
- Licensed practical nurse
- Hospice aide
- Homemaker
- Companion
Contracts
See DHS 131.30(2) for information on these contracting relationships:
- Hospital
- Nursing home
- Community-based residential facility/assisted living
- Therapy
- Durable medical equipment (DME)
- Pharmaceutical
- Inpatient
- Respite
The applicant should develop forms that address these topics
- Patient rights
- Family rights
- Informed consent
- Service agreement
- Orientation program
- Assignment sheets applicable to hospice aides, volunteers, homemakers, and companions