Methods for evaluating and measuring the effectiveness of services and using the information for service improvement.
A service shall have a process in place for determining the effective utilization of staff and resources toward the attainment of patient treatment outcomes and the service's goals and objectives.
A service shall have a system for regular review of the appropriateness of the components of the treatment service and other factors that may contribute to the effective use of the service's resources.
A service shall obtain a completed patient satisfaction survey from a representative sample of all patients at or following their discharge from the service. The service shall keep all satisfaction surveys on file for 2 years and shall make them available for review by authorized representatives of the department upon request.
A service shall collect data on patient outcomes at patient discharge and may collect data on patient outcomes after discharge.
The service director shall complete an annual report on the service's progress in meeting goals, objectives and patient outcomes, and shall keep the report on file and shall make it available for review to an authorized representative of the department upon request.
The governing authority or legal owner of the service and the service director shall review all evaluation reports and make changes in service operations, as appropriate.
If a service holds current accreditation from a recognized accreditation organization, such as the joint commission on accreditation of health organizations, the commission on accreditation of rehabilitation facilities or the national committee for quality assurance, the requirements under this section may be waived by the department.
(21) Communicable disease screening.
Service staff shall discuss risk factors for communicable diseases with each patient upon admission and at least annually while the patient continues in the service and shall include in the discussion the patient's prior behaviors that could lead to sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), hepatitis B and C or tuberculosis (TB).
(22) Unlawful alcohol or psychoactive substance use.
The unlawful, illicit or unauthorized use of alcohol or psychoactive substances at the service location is prohibited.
(23) Emergency shelter and care.
A service that provides 24-hour residential care shall have a written plan for the provision of shelter and care for patients in the event of an emergency that would render the facility unsuitable for habitation.
(24) Reporting of deaths due to suicide or the effects of psychotropic medicine.
Each service shall adopt written policies and procedures for reporting deaths of patients due to suicide or the effects of psychotropic medicines, as required by s. 51.64 (2)
, Stats. A report shall be made on a form furnished by the department.
DHS 75.03 Note
Copies of Form DQA F-62470 for reporting deaths under this subsection may be obtained from any Division of Quality Assurance regional office or the department's website at: http://www.dhs.wisconsin.gov/forms/DQAnum.asp
. See Appendix C for the address and phone number of the Division of Quality Assurance Office.
DHS 75.03 History
Cr. Register, July, 2000, No. 535
, eff. 8-1-00; correction in (9) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546
; CR 06-035
: am. (1), (2), and Table 75.03, Register November 2006 No. 611
, eff. 12-1-06; corrections in (1), (3) (e), (4) (b), (7), and (9) (b) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
; CR 09-109
: am. (2) (a), (h) and (4) (e) Register May 2010 No. 653
, eff. 6-1-10; correction in (4) (e) made under s. 13.92 (4) (b) 6., 7., Stats., Register November 2011 No. 671
A prevention service makes use of universal, selective and indicated prevention measures described in appendix A. Preventive interventions may be focused on reducing behaviors and actions that increase the risk of abusing substances or being affected by another person's substance abuse.
To receive certification from the department under this chapter, a prevention service shall comply with all requirements included in s. DHS 75.03
that apply to a prevention service, as shown in Table 75.03, and, in addition, a prevention service shall comply with the requirements of this section. If a requirement in this section conflicts with an applicable requirement in s. DHS 75.03
, the requirement in this section shall be followed.
A professional employed by the service shall be knowledgeable and skilled in all areas of substance abuse prevention domains as required by DSPS.
Paraprofessional personnel shall be knowledgeable and skilled in the areas of substance abuse prevention domains as required by the DSPS.
Staff without previous experience in substance abuse prevention shall receive inservice training and shall be supervised in performing work activities identified in sub. (4)
by a professional qualified under par. (a)
A prevention service shall utilize all of the following strategies in seeking to prevent substance abuse and its effects:
1. `Information dissemination.'
This strategy aims at providing awareness and knowledge of the nature and extent of the identified problem and providing knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience. Examples of activities that may be conducted and methods used in carrying out this strategy include the following:
This strategy involves two-way communication and is distinguished from the information dissemination strategy by interaction between the educator or facilitator and the participants. Activities under this strategy are directed at affecting critical life and social skills, including decision-making, refusal skills, critical analysis, for instance, of media messages, and systematic judgment abilities. Examples of activities that may be conducted and methods used in carrying out this strategy are the following:
3. `Promotion of healthy activities.'
This strategy provides for the participation of target populations in activities that exclude alcohol, tobacco and other drug use or promote activities that lend themselves to the building of resiliency among youth and families. The assumption is that constructive and healthy activities offset the attraction to or otherwise meet the needs that may be fulfilled by alcohol, tobacco and other drugs. Alternative activities also provide a means of character-building and may promote healthy relationships between youth and adults in that participants may internalize the values and attitudes of the individuals involved in establishing the prevention services objectives. Examples of healthy activities that may be promoted or conducted under this strategy may include the following:
After-school activities such as participation in athletic activities, in music lessons, an art club or the school newspaper.
4. `Problem identification and referral.'
This strategy is to identify individuals who have demonstrated at-risk behavior, such as indulging in illegal or age-inappropriate use of tobacco or alcohol or indulging in the first use of illicit drugs, to determine if their behavior can be reversed through education. This strategy does not include activities designed to determine if a person is in need of treatment. Examples of activities that may be conducted and methods used in carrying out this strategy are the following:
Educational programs for individuals charged with driving while under the influence or driving while intoxicated.
This strategy aims at establishing written or unwritten community standards, codes and attitudes, thereby influencing the incidence and prevalence of at-risk behavior in the general population. This strategy distinguishes between activities that center on legal and regulatory initiatives and those which relate to the service and action-oriented initiatives. Examples of activities that may be conducted and methods used in carrying out this strategy are the following:
Promoting the establishment and review of policies for schools related to the use of alcohol, tobacco and drugs.
Providing technical assistance to communities to maximize local enforcement procedures governing availability and distribution of alcohol, tobacco and other drug use.
Establishing policies that create opportunities for youth to become involved in their communities.
6. `Community-based process'.
This strategy seeks to enhance the ability of the community to more effectively provide prevention, remediation and treatment services for behaviors that lead to intensive services. Activities under this strategy include organizing, planning, enhancing the efficiency and effectiveness of services implementation, interagency collaboration, coalition building and networking. Examples of activities that may be conducted and methods used in carrying out this strategy are the following:
Community and volunteer training, such as neighborhood action training and training of key people in the system.
Goals and objectives.
A prevention service shall have written operational goals and objectives and shall specify in writing the methods by which they will be achieved and the target populations.
Documentation of coordination.
A prevention service shall provide written documentation of coordination with other human service agencies, organizations or services that share similar goals.
A prevention service shall maintain records on the number of individuals served by implementation of each prevention strategy and retain records as necessary for meeting certification and funding requirements.
A prevention service shall have an evaluation process that measures the outcomes of the services provided.
A prevention service shall evaluate the views of consumers about the service as they are provided and shall adjust goals and objectives accordingly.
A prevention service shall have a written policy and a defined process to provide individuals with the opportunity to express opinions regarding ongoing services, staff and the methods by which individual prevention activities are offered.
DHS 75.04 History
Cr. Register, July, 2000, No. 535
, eff. 8-1-00; CR 09-109
: am. (3) (a) and (b) Register May 2010 No. 653
, eff. 6-1-10; correction in (3) (a), (b) made under s. 13.92 (4) (b) 6.
, Stats., Register November 2011 No. 671
Emergency outpatient service. DHS 75.05(1)
An emergency outpatient service operates an emergency phone service and provides on-site crisis intervention to deal with all outpatient emergencies related to substance abuse, including socio-emotional crises, attempted suicide and family crises; provides the examination required under s. 51.45 (11) (c)
, Stats.; and, if needed, provides or arranges for transportation of a patient to the emergency room of a general hospital for medical treatment.
To receive certification from the department under this chapter, an emergency outpatient service shall comply with all requirements included in s. DHS 75.03
that apply to an emergency outpatient service, as shown in Table 75.03, and, in addition, an emergency outpatient service shall comply with the requirements of this section. If a requirement in this section conflicts with an applicable requirement in s. DHS 75.03
, the requirement in this section shall be followed.
An emergency outpatient service shall have staff available who are capable of providing coverage for an emergency phone service and for providing on-site crisis intervention.
A service shall have a written plan for staffing the service and shall document that all of the following have been taken into consideration:
The nature of previously observed and anticipated emergencies and the probability of emergencies as related to geographical, seasonal, temporal and demographic factors.
The adequacy of the emergency communication system used by the service when consultation is required.
The estimated travel time for a staff member to arrive at an emergency care facility or at the location of an emergency.
An emergency outpatient service shall provide emergency telephone coverage 24 hours per day and 7 days a week, as follows: