For questions regarding hospices, you may email the Division of Quality Assurance
- Wisconsin Client Rights and Grievance Procedure
- Construction/Remodeling of Health Care Facilities - Plan Review Requirements (including forms)
The following forms are used throughout the survey process. Surveyors use these forms to evaluate your program during the initial licensing process as well as any future onsite compliance surveys. They are linked here to assist your agency in self assessment and quality improvement.
- Survey Guide - Hospice Direct Inpatient Unit Survey, F-00338 (PDF)
- Hospice Contracts and Agreements Review, F-62232 (PDF)
- Hospice Personnel Record Review, F-62233 (PDF)
- Hospice Clinical Record Review, F-62236 (PDF)
- Hospice Patient Rights, F-62316 (PDF)
- Hospice Quality Assessment and Performance Improvement Review, F-62318 (PDF)
- Hospice Volunteer Program Review, F-62319 (PDF)
- Hospice Survey Information, F-62320 (PDF)
- Hospice Inpatient Facility Plan Review, F-62333 (Word)
- Hospice Inpatient Clinical Record Review, F-62322 (PDF)
- Contract or Agreement Review, F-62641 (PDF)
All fires in a licensed health or residential care facility in Wisconsin must be reported to the Department of Health Services within 72 hours (check specific rule requirements).