DHS 75.08 History
History: CR 20-047
: cr. Register October 2021 No. 790
, eff. 10-1-22.
DHS 75.09 Ongoing compliance and enforcement actions. DHS 75.09(1)(a)
The department may make announced and unannounced inspections of a certified service to verify compliance with this chapter, to investigate complaints received regarding the services provided, or as part of an investigation into the cause of death of a client.
To ensure compliance with this chapter and other applicable statutes and regulations, the department shall have access to all service documents, open and closed client records, and staff member files at any time.
Statement of deficiency.
Upon determining that the service is in violation of any requirement of this chapter, the department shall promptly serve a statement of deficiency to the governing authority or entity owner or designated representative of the service.
Within 10 business days
of receipt of the statement of deficiency, the service shall submit a plan of correction to the department for approval, detailing how the service will correct the violation or how the service has corrected the violation. The department may require that a plan of correction be submitted for approval within a shorter specified time for violations the department determines may be harmful to the health, safety, welfare, or rights of clients.
The department may require the service to modify the proposed plan of correction before the department approves the plan of correction.
Failure to submit an approved plan of correction shall be grounds for denial, suspension, or revocation of the certification.
If the department denies, revokes, suspends, or refuses to renew certification, the service may request an administrative hearing under ch. 227
A request for a hearing shall be received in writing to the department of administration's division of hearings and appeals within 10 days after the date of the notice of the department's action under s. DHS 75.05
If a timely request for hearing is made, the department's decision to revoke, suspend, or refuse to renew certification is stayed pending the outcome of the appeal, unless 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.
DHS 75.09 History
History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22. DHS 75.10
DHS 75.10 Investigation, notification, and reporting requirements. DHS 75.10(1)(a)
Patient death related to physical restraint, psychotropic medication, or suicide.
No later than 24 hours after a service becomes aware of the death of a patient, the service shall report the death to the department if there is reasonable cause to believe the death was related to the use of a physical restraint or psychotropic medication, or was a suicide.
Patient death related to an accident or injury.
When a patient dies as a result of an incident or accident at the service location not related to the use of a physical restraint, psychotropic medication, or suicide, the service shall send a report to the department within 3 working days of the patient's death.
Investigating and reporting abuse, neglect, or misappropriation of property. DHS 75.10(2)(a)1.1.
When a service receives a report of an allegation of abuse or neglect of a client, or misappropriation of property at the service location, the service shall take immediate steps to ensure the safety of all clients.
The service shall investigate and document any allegation of abuse or neglect of a client, or misappropriation of property by a caregiver. If the service's investigation concludes that the alleged abuse or neglect of a client or misappropriation of property meets the definition of abuse or neglect of a client, or of misappropriation of property, the service shall report the incident to the department on a form provided by the department, within 7 calendar days from the date the service knew or should have known about the abuse, neglect, or misappropriation of property. The service shall maintain documentation of any investigation.
Filing a report under sub. (1)
does not relieve the service or other person of any obligation to report an incident to any other authority, including law enforcement, the coroner and DSPS.
Notification of changes affecting a client. DHS 75.10(3)(a)(a)
The service shall immediately notify the client's legal representative, as applicable, when there is an incident or injury to the client or a significant change in the client's physical or mental condition.
The service shall immediately notify the client's legal representative, as applicable, when there is an allegation of physical, sexual, or mental abuse, or neglect of a client. The service shall notify the client's legal representative within 72 hours when there is an allegation of misappropriation of property.
The service shall give the client or the client's legal representative, as applicable, a 30-day written notice of any change in charges for services that will be in effect for more than 30 days.
All written reports required under this section shall include, at a minimum, the time, date, place, individuals involved, details of the occurrence, and the action taken by the provider to ensure clients' health, safety and well-being.
DHS 75.10 History
History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22. DHS 75.11
DHS 75.11 General records and retention. DHS 75.11(1)(1)
The service shall retain all records required under this chapter for 7 years, unless otherwise specified in subs. (2)
Employee records shall be retained for 3 years following an employee's separation from employment at the service.
A service shall have a written policy and procedure for administrative review and maintenance of records related to incident reports.
DHS 75.11 History
History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (1) made under ss. 13.92 (4) (b) 4. and 35.17, Stats., and correction in (2) made under s. 35.17, Stats., Register October 2021 No. 790. DHS 75.12(1)(1)
All requirements in this chapter shall also be applicable to telehealth services delivered under this chapter.
Services delivered through telehealth shall be of sufficient quality to be functionally equivalent to face-to-face services.
DHS 75.12 History
History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22. DHS 75.13(1)(a)
The department may grant a waiver or variance if the department determines that the proposed waiver or variance will not jeopardize the health, safety, welfare, or rights of any client.
A written request for a waiver or variance shall be sent to the department on a form provided by the department and includes justification that the waiver or variance will not adversely affect the health, safety, or welfare of any client for the requested action.
A written request for a variance shall include a description of an alternative means planned to meet the intent of the requirement.
In considering whether to approve a waiver or variance, the department will consider whether the requested waiver or variance increases patient access to care or sufficiently supports the efficient and economic operation of a service.
Rescinding waiver or variance.
The department may rescind a waiver or variance if any of the following occurs:
The department determines the waiver or variance has adversely affected the health, safety, or welfare of a client.
The service fails to comply with any of the conditions of the waiver or variance as granted.
Rescinding the waiver or variance is required by federal or state law.
There is no longer sufficient justification that the waiver or variance increases patient access to care or sufficiently supports the efficient and economic operation of a service.
DHS 75.13 History
History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22. DHS 75.14(1)(1)
A prevention service makes use of universal, selective, and indicated prevention services as defined by s. DHS 75.14 (3)
. Prevention services may be focused on reducing behaviors and actions that increase the risk of misusing substances or being affected
by another person'
s substance use.
This section shall apply to prevention services when required by contract with the department, or when a prevention service requests certification.
“Prevention domain” refers to content areas that professionals working in substance use prevention shall be knowledgeable in. The prevention domains include any of the following:
“Prevention service” means the organized application of strategies and interventions that are provided to reduce the overall harms and burden of substance use for an identified community or group.
“Prevention strategy” means activities targeted to a specific population or the larger community that are designed to be implemented before the onset of problems as a means to prevent substance use or its detrimental effects from occurring.
“Target population” means the identified community or group that a prevention strategy is aimed to impact.
“Universal, selective, and indicated prevention strategy” means different levels of risk that are addressed through community-based substance use prevention efforts, where universal prevention efforts focus on general audiences who have not been identified based on substance use-related risk, selective prevention efforts focus on audiences with known risk factors for a substance use-related problem, and indicated prevention efforts focus on audiences who are already experiencing a substance use-related problem.
Governing authority or entity owner.
The governing authority or entity owner of a service shall do all of the following:
Designate a member or representative of the governing body that is legally responsible for the operation of a service that has the authority to conduct the policy, actions, and affairs of the service, to complete the entity owner background check and to be the entity owner responsible for a service.
Appoint a service director whose qualifications, authority, and duties are defined in writing.
Establish written policies and procedures for the operation of the service and exercise general direction over the service, to ensure the following:
That no person will be denied service or discriminated against on the basis of sex, race, color, creed, sexual orientation, disability, or age, in accordance with 45 CFR part 92
and 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
Caregiver background check.
At the time of hire, employment, or contract, and every 4 years after, the service shall conduct and document a caregiver background check following the procedures in s. 50.065
, Stats., and ch. DHS 12
. A service shall not employ or contract with a person who has been convicted of a crime or offense, or has a governmental finding of misconduct, found in s. 50.065
, Stats., and ch. DHS 12
, Appendix A
, unless the person has been approved under the department's rehabilitation process as defined in ch. DHS 12
Employee records shall be available upon request at the service for review by the department. A separate record for each employee shall be maintained, kept current, and at a minimum, include:
A written job description including duties, responsibilities and qualifications required for the employee.
A copy of a signed statement regarding confidentiality of client information.
A service shall have written policies, procedures, and staff training to ensure compliance with confidentiality provisions of 42 CFR part 2
, 45 CFR parts 164
, s. 51.30
, Stats., and ch. DHS 92
. Each staff member shall sign a statement acknowledging responsibility to maintain confidentiality of personal information about persons served.