TABLE DHS 75.03
X = required O = not required
Each service that receives funds under ch. 51
, Stats., is approved by the state methadone authority, is funded through the department's bureau of prevention, treatment, and recovery, or receives other substance abuse prevention and treatment funding or other funding specifically designated to be used for providing services described under ss. DHS 75.04
, shall be certified by the department under this chapter.
An individual or organization seeking certification of a service under this chapter shall apply to the department for certification on a form provided by the department.
DHS 75.03 Note
Note: For a copy of the application for certification, write to Behavioral Health Certification Section, P.O. Box 2969, Madison, WI 53701-2969.
Upon receipt of a completed application for certification the department shall review the application for compliance with this chapter, which may include an on-site survey. Within 45 days after receiving a completed application, the department shall either approve or deny the application. If the application for certification is denied, the department shall give the individual or organization applying for certification reasons, in writing, for the denial and shall inform the individual or organization of a right to appeal that decision under par. (h)
The department may issue a certification for a period of up to 2 years. The certification shall remain in effect for that period unless suspended or revoked prior to expiration.
The department shall send a renewal notice and instructions to the certificate holder 60 days before expiration of the certification.
The department may refuse to issue a certification if an applicant fails to meet all requirements of this chapter or may refuse to renew a certification if the applicant no longer meets or has violated any provision of this chapter.
The department may refuse to issue a certification if the applicant has previously had a certification revoked for failure to comply with rules promulgated by the department or a comparable agency in another state.
Suspension or revocation.
The department may at any time upon written notice to a certificate holder suspend or revoke the certificate if the department finds that the service does not comply with this chapter. The notice shall state the reasons for the suspension or revocation and shall inform the certificate holder of the right under par. (h)
to appeal that decision.
(h) Responsibility for interpretation.
The department's bureau of prevention, treatment and recovery is responsible for the interpretation of the meaning and intent of the provisions of this chapter.
If the department denies, refuses to renew, suspends or revokes a certification, the individual, organization or service applying for certification or renewal may request an administrative hearing under ch. 227
, Stats. If a timely request for hearing is made on a decision to suspend or
revoke or not renew a certification, that action is stayed pending the decision on the appeal except when the department finds that the health, safety or welfare of patients requires that the action take effect immediately. A finding of a requirement for immediate action shall be made in writing by the department.
A client shall file his or her request for a fair hearing in writing with the division of hearings and appeals in the department of administration within 30 days after the date of the notice of adverse action under par. (c)
. If a request is not received within 30 days, no hearing is available. A request is considered filed when received by the division of hearings and appeals. Receipt of notice is presumed within 5 days of the date the notice was mailed.
DHS 75.03 Note
Note: The mailing address of the Division of Hearings and Appeals is P.O. Box 7875, Madison, WI, 53707, 608-266-3096. Hearing requests may be delivered in person to the office at 5005 University Avenue, Room 201, Madison, WI.
In accordance with ch. HA 3
, the division of hearings and appeals shall consider and apply all standards and requirements of this chapter.
(3) Governing authority.
The governing authority or legal owner of a service shall do all of the following:
Establish written policies and procedures for the operation of the service and exercise general direction over the service.
Appoint a director whose qualifications, authority and duties are defined in writing.
Develop and provide a policy manual that describes the policies and procedures for the delivery of services.
Establish a written policy stating that the service will comply with patient rights requirements as specified in this chapter and in ch. DHS 94
Establish written policies and procedures stating that services will be available and accessible and, that with the exception of par. (g)
, no person will be denied service or discriminated against on the basis of sex, race, color, creed, sexual orientation, handicap or age, in accordance with Title VI of the Civil Rights Act of 1964, as amended, 42 USC 2000d
, Title XI of the Education Amendments of 1972, 20 USC 1681-1686
and s. 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794
, and the Americans with Disabilities Act of 1990, as amended, 42 USC 12101-12213
State clearly in writing the criteria for determining the eligibility of individuals for admission, with first priority for services given to pregnant women who are alcohol or drug abusers.
Develop written policies and procedures stating that, in the selection of staff, consideration will be given to each applicant's competence, responsiveness and sensitivity toward and training in serving the characteristics of the service's patient population, including gender, age, cultural background, sexual orientation, developmental, cognitive or communication barriers and physical or sensory disabilities.
Develop written policies and procedures to ensure that recommendations relating to a patient's initial placement, continued stay, level of care transfer and discharge recommendations are determined through the application of approved uniform placement criteria.
A service shall have a director appointed by the governing authority or legal owner. The director is responsible for administration of the service.
A service shall comply with chs. DHS 12
. Chapter DHS 12
directs the service to perform background information checks on applicants for employment and persons with whom the service contracts and who have direct, regular contact with patients and, periodically, on existing employees, and not hire or retain persons who because of specified past actions are prohibited from working with patients. Chapter DHS 13
directs the service to report to the department all allegations that come to the attention of the service that a staff member or contracted employee has misappropriated property of a patient or has abused or neglected a patient.
If a service uses volunteers, the service shall have written policies and procedures governing their activities.
All staff who provide substance abuse counseling, except physicians knowledgeable in the practice of addiction medicine and psychologists knowledgeable in psychopharmacology and addiction treatment, shall be substance abuse counselors.
DHS 75.03 Note
According to s. SPS 160.03
, a person may use the title “addiction counselor," “substance abuse counselor," “alcohol and drug counselor," “substance use disorder counselor" or “chemical dependency counselor" only if he or she is certified as a substance abuse counselor or a clinical substance abuse counselor under s. 440.88
, Stats., or as allowed under the provisions of s. 457.02 (5m)
Any staff who provides clinical supervision, as defined in s. SPS 160.02 (6)
, shall be a clinical supervisor, as defined in s. SPS 160.02 (7)
, except for a physician knowledgeable in addiction treatment, licensed psychologist with a knowledge of psychopharmacology and addiction treatment, or professional possessing a clinical social worker, marriage and family therapist, or professional counselor license granted under ch. 457
, Stats., and knowledgeable in addiction treatment.
All staff who provide mental health treatment services to dually diagnosed clients shall meet the appropriate qualifications under appendix B.
Provision of clinical supervision for a substance abuse counselor shall be evidenced in that person's personnel file by documentation which identifies hours of supervision provided, issues addressed in the areas of counselor development, counselor skill assessment and performance evaluation, management and administration and professional responsibility and plans for problem resolution. The documentation shall be signed by the clinical supervisor.
(5) Staff development.
A service shall have written policies and procedures for determining staff training needs, formulating individualized training plans and documenting the progress and completion of staff development goals.
(6) Training staff in assessment and management of suicidal individuals. DHS 75.03(6)(a)
Each service shall have a written policy requiring each new staff person who may have responsibility for assessing or treating patients who present significant risks for suicide to do one of the following:
Receive documented training in assessment and management of suicidal individuals within two months after being hired by the service.
Provide written documentation of past training or supervised experience in assessment and management of suicidal individuals.
Staff who provide crisis intervention or are on call to provide crisis intervention shall, within one month of being hired to provide these services, receive specific training in crisis assessment and treatment of persons presenting a significant risk for suicide or document that they have already received the training. The service shall have written policies and procedures covering the nature and extent of this training to ensure that crisis and on-call staff will be able to provide the necessary services given the range of needs and symptoms generally exhibited by patients receiving care through the service.
Staff employed by the program on August 1, 2000, shall either receive training in assessment and management of suicidal individuals within one year from that date or provide documentation of past training.
Services shall have written policies, procedures and staff training to ensure compliance with provisions of 42 CFR Part 2
, confidentiality of alcohol and drug abuse patient records, and s. 51.30
, Stats., and ch. DHS 92
, confidentiality of records. Each staff member shall sign a statement acknowledging his or her responsibility to maintain confidentiality of personal information about patients.
There shall be a case record for each patient. For a person receiving only emergency services under s. DHS 75.06
, the case record requirements are found in sub. (9)
A staff person of the service shall be designated to be responsible for the maintenance and security of patient case records.
Patient case records shall be safeguarded as provided in sub. (7)
and maintained with the security precautions specified in 42 CFR Part 2
The case record format shall provide for consistency and facilitate information retrieval.
A patient's case record shall include all of the following:
Consent for treatment forms signed by the patient or, as appropriate, the patient's legal guardian.
An acknowledgment by the patient or the patient's legal guardian, if any, that the service policies and procedures were explained to the patient or the patient's legal guardian.
A copy of the signed and dated patient notification that was reviewed with and provided to the patient and patient's legal guardian, if any, which identifies patient rights, and explains provisions for confidentiality and the patient's recourse in the event that the patient's rights have been abused.
Results of all screening, examinations, tests and other assessment information.
A completed copy of the most current placement criteria summary for initial placement or for documentation of the applicable approved placement criteria or WI-UPC assets and needs criteria if the patient has been transferred to a level of care different from the initial placement. Alternative forms that include all the information from the WI-UPC summary or other approved placement criteria may be used in place of the actual scoring document.
Medication records that allow for ongoing monitoring of all staff-administered medications and the documentation of adverse drug reactions.
All medication orders. These shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication.
Reports from referring sources, each to include the name of the referral source, the date of the report and the date the patient was referred to the service.
Records of referral by the service, including documentation that referral follow-up activities occurred.
Multi-disciplinary case conference and consultation notes signed by the primary counselor.
Correspondence relevant to the patient's treatment, including all letters and dated notations of telephone conversations.
Consent forms authorizing disclosure of specific information about the patient.
Progress notes, including staffings, in accordance with the service's policies and procedures.
A record of services provided that includes documentation of all case management, education, services and referrals.
Staffing notes signed by the primary counselor and the clinical supervisor, and by the mental health professional if the patient is dually diagnosed.
Documentation of transfer from one level of care to another. Documentation shall identify the applicable criteria from approved placement criteria, and shall include the dates the transfer was recommended and initiated.
A service shall have policies and procedures to ensure the security and confidentiality of all case records when clinical supervision is provided off site.
DHS 75.03 Note
Note: An example of when clinical supervision may be provided off site is a staffing held at a central location attended by counselors from one or more branch clinics.
If the service discontinues operations or is taken over by another service, records containing patient identifying information may be turned over to the replacement service or any other service provided the patient consents in writing. If no patient consent is obtained, the records shall be sealed and turned over to the department to be retained for 7 years and then destroyed.
A patient's case record shall be maintained by the service for a period of 7 years from the date of termination of treatment or service.
A service is the custodian and owner of the patient file and may release information only in compliance with sub. (7)
(9) Case records for persons receiving emergency services. DHS 75.03(9)(a)(a)
A service shall keep a case record for every person requesting or receiving emergency services under s. DHS 75.06
, except where the only contact made is by telephone.
A case record prepared under this subsection shall comply with requirements under s. DHS 124.14
, if the service is operated by a hospital, or include all of the following:
Time of the individual's arrival, means of arrival and method of transportation.
Pertinent history of the problem, including details of first aid or emergency care given to the individual before being seen by the emergency service.