Wisconsin Legislature: DHS 36.07(3)(c)

4. The reasons for the request.

5. Supporting justification.

6. Any other information requested by the department.

Note: An application for a waiver or variance should be addressed to the Behavioral Health Certification Section, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969.

(b) A waiver or variance may be granted if the department finds that the waiver or variance will not adversely affect the health, safety, or welfare of any consumer and any one of the following applies:

1. Strict enforcement of a requirement would result in unreasonable hardship on the CCS or on a consumer.

2. An alternative to a rule, including new concepts, methods, procedures, techniques, equipment, personnel qualifications, or the conducting of pilot projects is in the interest of better care or management.

(c) A determination on a request for a waiver or variance shall be made to the CCS in writing. If the decision is to deny the waiver or variance, the reason for the denial shall be included in the notice.

(d) The terms of a variance may be modified upon agreement between the department and the CCS. The department may impose any condition on a waiver or variance which the department deems necessary.

(e) The department may limit the duration of any waiver or variance.

(f) The department may revoke a waiver or variance if any one of the following occurs:

1. The waiver or variance adversely affects the health, safety or welfare of a consumer.

2. The CCS has failed to comply with the variance as granted.

3. The CCS notifies the department that it wishes to relinquish the waiver or variance.

4. There is a change in applicable law.

5. For any other reason necessary to protect the health, safety, and welfare of a consumer.

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04.

Subchapter III — Comprehensive Community Services Program

DHS 36.07 Comprehensive community services plan. Each CCS program shall have a written plan that shall include all of the following:

(1) A description of the organizational structure. The description shall include all of the following:

(a) Responsibilities of the staff members assigned to the functions described in s. DHS 36.10 (2) (e).

(b) Policies and procedures to implement a quality improvement plan consistent with the requirements in s. DHS 36.08.

(c) Policies and procedures to establish a coordination committee and work with a coordination committee consistent with the requirements in s. DHS 36.09.

(d) Criteria for recruiting and contracting with providers of psychosocial rehabilitation services.

(e) Policies and procedures for updating and revising the CCS plan to ensure that it accurately identifies current services provided and any changes in policies and procedures of the CCS.

(2) A written summary detailing the recommendations of the coordination committee made under s. DHS 36.09 (3) (a) and a written response by the CCS to the coordination committee’s recommendations.

(3) A description of the currently available mental health, substance-use disorder, crisis services, and other services in the county or tribe and how the CCS will interface and enhance these services. The description shall include policies and procedures for developing and implementing collaborative arrangements and interagency agreements addressing all of the following:

(a) Processes necessary to include the CCS in planning to support consumers who are discharged from a non-CCS program or facilities that include inpatient psychiatric or substance-use treatment, a nursing home, residential care center, day treatment provider, jail or prison.

(b) The role of the CCS when an emergency protective placement is being sought under s. 55.135, Stats., and when protective services or elder abuse investigations are involved.

(c) The role of the CCS when the CCS provides services in conjunction with any other care coordination service including protective services, integrated services projects, and schools.

(d) The role of the CCS when a consumer is living in the community under a ch. 51, Stats., commitment.

(e) Establishing contracts and agreements with community agencies providing psychosocial rehabilitation services.

(f) Establishing contracts when a needed service is not available in the existing array of services.

(g) Arrangements with the county or tribal emergency services program to ensure identification and referral of CCS consumers who are in crisis.

(4)

(a) A description of an array of psychosocial rehabilitation services and service providers to be available through the CCS. The services and service providers shall be determined by all of the following:

1. Identifying anticipated service needs of potential consumers, including minors and the elderly, that are based upon the assessment domains identified in s. DHS 36.16 (4).

2. Identifying treatment interventions to address the needs identified in subd. 1. Treatment interventions for minors and elderly consumers shall be identified separately from other consumers.

(b) The description in par. (a) shall include the methods that the CCS will use to identify and contract with service providers.

(5) Policies and procedures developed for each of the following:

(a) Consumer records that meet the requirements in s. DHS 36.18.

(b) Confidentiality requirements of this chapter.

(d) Consumer rights that meet the requirements of s. DHS 36.19.

(e) Monitoring compliance with this chapter and applicable state and federal law.

(f) Receiving and making referrals.

(g) Communication to the consumer of services offered by the CCS, costs to the consumer, grievance procedure, and requirements for informed consent for medication and treatment.

(h) Ensuring that a consumer’s cultural heritage and primary language are considered as primary factors when developing the consumer’s service plan and that activities and services are accessible in a language in which the consumer is fluent.

(i) Providing orientation and training that meets the requirements in s. DHS 36.12.

(j) Outreach services.

(k) Application and screening.

(L) Recovery team development and facilitation.

(m) Assessment.

(n) Service planning.

(o) Service coordination, referrals, and collaboration.

(p) Advocacy for the consumer.

(q) Support and mentoring for the consumer.

(r) Discharge planning and facilitation.

(s) Monitoring and documentation.

(t) Policy on telehealth, including when telehealth can be used and by whom, patient privacy and information security considerations, and the right to decline services provided via telehealth.

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 23-053: cr. (5) (t) Register September 2023 No. 813, eff. 10-1-23.

DHS 36.08 Quality improvement.

(1) The CCS shall develop and implement a quality improvement plan to assess consumer satisfaction and progress toward desired outcomes identified through the assessment process.

(2)

(a) The plan shall include procedures for protecting the confidentiality of persons providing opinions and include a description of the methods the CCS will use to measure consumer opinion on the services offered by the CCS, assessment, service planning, service delivery, and service facilitation activities.

(b) The plan shall also include a description of the methods the CCS will use to evaluate the effectiveness of changes in the CCS program based on results of the consumer satisfaction survey, recommendations for program improvement by the coordination committee, and other relevant information.

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04.

DHS 36.09 CCS coordination committee.

(1)

(a) The CCS shall appoint a coordination committee that includes representatives from various county or tribal departments, including individuals who are responsible for mental health and substance abuse services, service providers, community mental health and substance abuse advocates, consumers, family members and interested citizens.

(b) An existing committee within the county or tribe may serve as the coordinating committee if it has the membership required and agrees to undertake the responsibilities in sub. (3).

(2) At least one-third of the total membership of the coordination committee shall be consumers. No more than one-third of the total membership of the coordination committee may be county employees or providers of mental health or substance abuse services.

(3) The coordinating committee shall do all of the following:

(a) Review and make recommendations regarding the initial and any revised CCS plan required under s. DHS 36.07, the CCS quality improvement plan, personnel policies, and other policies, practices, or information that the committee deems relevant to determining the quality of the CCS program and protection of consumer rights.

(b) Maintain written minutes of meetings and a membership list.

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04.

Subchapter IV — Personnel

DHS 36.10 Personnel policies.

(1) Definitions. In this section, “supervised clinical experience” means a minimum of one hour of supervision per week by one or more staff members who meet the qualifications under sub. (2) (g) 1. to 8.

(2) Policies. The CCS shall have and implement written personnel policies and procedures that ensure all of the following:

(a) Discrimination prohibited. Employment practices of the CCS or any agency contracting or subcontracting with the CCS do not discriminate against any staff member or applicant for employment based on the individual’s age, race, religion, color, sexual orientation, national origin, disability, ancestry, marital status, pregnancy or childbirth, or arrest or conviction record.

(b) Credentials. Staff members have the professional certification, training, experience and abilities to carry out prescribed duties.

(c) Background checks and misconduct reporting and investigation. CCS and contracting agency compliance with the caregiver background check and misconduct reporting requirements in s. 50.065, Stats., and ch. DHS 12, and the caregiver misconduct reporting and investigation requirements in ch. DHS 13.

Note: Forms for conducting a caregiver background check including the background information disclosure form may be obtained from the Department’s website at http://www.dhs.wisconsin.gov/forms/DQAnum.asp or by writing or telephoning the Department at Office of Caregiver Quality, P.O. Box 2969, Madison, WI 53701-2969, (608) 261-8319.

(d) Staff records. Staff member records are maintained and include all of the following:

1. References for job applicants obtained from at least 2 people, including previous employers, educators or post-secondary educational institutions attended if available, and documented either by letter or verification of verbal contact with the reference, dates of contact, person making the contact, individuals contacted and nature and content of the contact.

2. Confirmation of an applicant’s current professional license or certification, if that license or certification is necessary for the staff member’s prescribed duties or position.

3. The results of the caregiver background check conducted in compliance with par. (c), including a completed background information disclosure form for every background check conducted, and the results of any subsequent investigation related to the information obtained from the background check.