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.
- F-00338 Survey Guide - Hospice Direct Inpatient Unit Survey (PDF, 25 KB)
- F-62232 Hospice Contracts and Agreements Review (PDF, 20 KB)
- F-62233 Hospice Personnel Record Review (PDF, 14 KB)
- F-62236 Hospice Clinical Record Review (PDF, 14 KB)
- F-62316 Hospice Patient Rights (PDF, 14 KB)
- F-62318 Hospice Quality Assessment and Performance Improvement Review (PDF, 14 KB)
- F-62319 Hospice Volunteer Program Review (PDF, 13 KB)
- F-62320 Hospice Survey Information (PDF, 14 KB)
- F-62321 Hospice Program Review (PDF, 13 KB)
- F-62322 Hospice Inpatient Clinical Record Review (PDF, 22 KB)
- F-62641 Contract or Agreement Review (PDF, 16 KB)
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).