DHS 35.13
DHS 35.13
Personnel policies. The clinic shall have and implement written personnel policies and procedures that ensure all of the following:
DHS 35.13(1)
(1) Each staff member who provides psychotherapy or who prescribes medications is evaluated to determine if the staff member possesses current qualifications and demonstrated competence, training, experience and judgment for the privileges granted to provide psychotherapy or to prescribe medications for the clinic.
DHS 35.13(2)
(2) 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.
DHS 35.13 Note
Note: Forms for conducting a caregiver background check including the background information disclosure form may be obtained from the department's website at
http://dhs.wisconsin.gov/caregiver/index.htm or by writing the department at Office of Caregiver Quality, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969. Phone: (608) 266-8481, Fax: (608) 267-0352.
DHS 35.13(3)
(3) A record is maintained for each staff member and includes all of the following:
DHS 35.13(3)(a)
(a) Confirmation of an applicant's current training or professional license or certification, if a training or professional license or certification is necessary for the staff member's prescribed duties or position. All limitations and restrictions on a staff member's license shall be documented by the clinic.
DHS 35.13(3)(b)
(b) The results of the caregiver background check 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.
DHS 35.13(3)(c)
(c) A vita of training, work experience and qualifications for each prescriber and each person who provides psychotherapy.
DHS 35.13 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09.
DHS 35.14
DHS 35.14
Clinical supervision and clinical collaboration. DHS 35.14(1)(a)
(a) The clinic administrator shall have responsibility for administrative oversight of the job performance and actions of each staff member and require each staff member to adhere to all laws and regulations governing the care and treatment of consumers and the standards of practice for their individual professions.
DHS 35.14(1)(b)
(b) Each clinic shall implement a written policy for clinical supervision as defined under s.
DHS 35.03 (5), and clinical collaboration as defined under s.
DHS 35.03 (4). Each policy shall address all of the following:
DHS 35.14(1)(b)1.
1. A system to determine the status and achievement of consumer outcomes, which may include a quality improvement system or a peer review system to determine if the treatment provided is effective, and a system to identify any necessary corrective actions.
DHS 35.14(1)(b)2.
2. Identification of clinical issues, including incidents that pose a significant risk of an adverse outcome for one or more consumers of the outpatient mental health clinic that should warrant clinical collaboration, or clinical supervision that is in addition to the supervision specified under ch.
MPSW 4,
12, or
16, or
Psy 2, or for a recognized psychotherapy practitioner, in accordance with s.
DHS 35.03 (5) (a), whichever is applicable.
DHS 35.14(2)
(2) Except as provided under sub.
(4) (b), the clinic's policy on clinical supervision shall be in accordance with ch.
MPSW 4,
12, or
16, or
Psy 2, or for a recognized psychotherapy practitioner, whichever is applicable. The clinic's policy on clinical collaboration shall require one or more of the following:
DHS 35.14(2)(a)
(a) Individual sessions, with staff case review, to assess performance and provide feedback.
DHS 35.14(2)(b)
(b) Individual side-by-side session while a staff member provides assessments, service planning meetings or outpatient mental health services and in which other staff member assesses, and gives advice regarding staff performance.
DHS 35.14(2)(c)
(c) Group meetings to review and assess quality of services and provide staff members advice or direction regarding specific situations or strategies.
DHS 35.14(2)(d)
(d) Any other form of professionally recognized method of clinical collaboration designed to provide sufficient guidance to assure the delivery of effective services to consumers by the staff member.
DHS 35.14(3)
(3) Clinical supervision and clinical collaboration records shall be dated and documented with the signature of the person providing these functions in a supervision or collaboration record, or in the staff record of each staff member who attends the session or review. If clinical supervision or clinical collaboration results in a recommendation for a change to a consumer's treatment plan, the recommendation shall be documented in the consumer file.
DHS 35.14(4)(a)(a) A qualified treatment trainee who provides psychotherapy shall receive clinical supervision.
DHS 35.14(4)(b)
(b) If any staff member, including a staff member who is a substance abuse counselor-in training, substance abuse counselor, or clinical abuse counselor, provides services to consumers who have a primary diagnosis of substance abuse, the staff member shall receive clinical supervision from a clinical supervisor as defined under s.
SPS 160.02 (7).
DHS 35.14 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09; correction in (4) (b) made under s.
13.92 (4) (b) 7., Stats.,
Register November 2011 No. 671.
DHS 35.15
DHS 35.15
Orientation and training. DHS 35.15(1)(1)
General requirement. The clinic administrator shall ensure each staff member receives initial and continuing training that enables the staff member to perform staff member's duties effectively, efficiently, and competently. Documentation of training shall be made available to department staff upon request.
DHS 35.15(2)(a)
(a) The clinic shall maintain documentation that
each staff member who is a mental health professional and who is new to the clinic has completed the training requirements specified under par.
(b), either as part of orientation to the clinic or as part of prior education or training. The clinic administrator shall require all other staff members to complete only the orientation training requirements specified under par.
(b) that are necessary, as determined by the clinic administrator, for the staff member to successfully perform the staff member's assigned job responsibilities.
DHS 35.15(2)(b)
(b) The orientation training requirements under this subsection are:
DHS 35.15(2)(b)1.
1. A review of the pertinent parts of this chapter and other applicable statutes and regulations.
DHS 35.15(2)(b)3.
3. Cultural factors that need to be taken into consideration in providing outpatient mental health services for the clinic's consumers.
DHS 35.15(2)(b)4.
4. The signs and symptoms of substance use disorders and reactions to psychotropic drugs most relevant to the treatment of mental illness and mental disorders served by the clinic.
DHS 35.15(2)(b)5.
5. Techniques for assessing and responding to the needs of consumers who appear to have problems related to trauma; abuse of alcohol, drug abuse or addiction; and other co-occurring illnesses and disabilities.
DHS 35.15(2)(b)6.
6. How to assess a consumer to detect suicidal tendencies and to manage persons at risk of attempting suicide or causing harm to self or others.
DHS 35.15(2)(b)7.
7. Recovery concepts and principles that ensure services, and supports connection to others and to the community.
DHS 35.15(2)(b)7m.
7m. Appropriate delivery of telehealth services, including issues ensuring privacy and confidentiality of recipient information and communications.
DHS 35.15(2)(b)8.
8. Any other subject that the clinic determines is necessary to enable the staff member to perform the staff member's duties effectively, efficiently, and competently.
DHS 35.15(3)
(3) Maintaining orientation and training policies. A clinic shall maintain in its central administrative records the most current copy of its orientation and training policies.
DHS 35.15 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09;
CR 23-053: am. (2) (b) 7m. Register September 2023 No. 813, eff. 10-1-23. DHS 35.16(1)(1)
The clinic shall establish written selection criteria for use when screening a consumer for possible admission. The criteria may include any of the following limitations as applicable:
DHS 35.16(1)(a)
(a) Sources from which referrals may be accepted by the clinic.
DHS 35.16(1)(b)
(b) Restrictions on acceptable sources of payment for services, or the ability of a consumer or a consumer's family to pay.
DHS 35.16(1)(c)
(c) The age range of consumers whom the clinic will serve based on the expertise of the clinic staff members.
DHS 35.16(1)(d)
(d) Diagnostic or behavioral requirements that the clinic will apply in deciding whether or not to admit a consumer for treatment.
DHS 35.16(1)(e)
(e) Any consumer characteristics for which the clinic has been specifically designed, including the nature or severity of disorders that can be managed on an outpatient basis by the clinic, and the expected length of time that services may be necessary.
DHS 35.16(2)
(2) A clinic shall refer any consumer not meeting the clinic's selection criteria for admission to appropriate services.
DHS 35.16(3)
(3) If a clinic establishes priorities for consumers to be served, a waiting list for consumers to be admitted, or a waiting list for consumers who have been admitted but resources to provide services to these consumers are not yet available, the priorities or the procedures for the operation of the waiting list shall be maintained in writing and applied fairly and uniformly.
DHS 35.16(4)
(4) Only a licensed treatment professional, or a recognized psychotherapy practitioner, may diagnose a mental illness of a consumer on behalf of a clinic. The licensed treatment professional, or recognized psychotherapy practitioner shall document, in the consumer file, the recommendation for psychotherapy specifying the diagnosis; the date of the recommendation for psychotherapy; the length of time of the recommendation; the services that are expected to be needed; and the name and signature of the person issuing the recommendation for psychotherapy.
DHS 35.16(5)
(5) If a clinic provides substance use services to a consumer, the clinic shall use a department approved placement criteria tool to determine if a consumer who has a co-occurring substance use disorder requires substance abuse treatment services. If the consumer is determined to need a level of substance use services that are above the level of substance use services that can be provided by the clinic, the consumer shall be referred to an appropriate department certified provider.
DHS 35.16 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09;
CR 14-066: renum. (4) (a) to (4), r. (4) (b)
Register August 2015 No. 716, eff. 9-1-15.
DHS 35.165(1)(1)
The clinic shall have and implement a written policy on how the clinic will provide or arrange for the provision of services to address a consumer's mental health emergency or crisis during hours when its offices are closed, or when staff members are not available to provide outpatient mental health services.
DHS 35.165 Note
Note: The phrase “available to provide outpatient mental health services" is defined under s.
DHS 35.03 (2).
DHS 35.165(2)
(2) The clinic shall include, in its written policies, the procedures for identifying risk of attempted suicide or risk of harm to self or others.
DHS 35.165 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09.
DHS 35.17(1)(a)
(a) A mental health professional, shall complete an initial assessment of a consumer before a second meeting with a staff member. The information collected during the initial assessment shall be sufficient to identify the consumer's need for outpatient mental health services.
DHS 35.17(1)(b)
(b) A comprehensive assessment shall be valid, accurately reflect the consumer's current needs, strengths and functioning, be completed before beginning treatment under the treatment plan established under s.
DHS 35.19 (1), and include all of the following:
DHS 35.17(1)(b)2.
2. A diagnosis, which shall be established from the current Diagnostic and Statistical Manual of Mental Disorders, or for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.
DHS 35.17 Note
Note: The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC, American Psychiatric Association, 2013. The Diagnostic and Statistical Manual of Mental Disorders may be ordered through
http://www.appi.org/Pages/DSM.aspx or other sources. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is published by the National Center for Clinical Infant Programs: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Arlington, VA, National Center for Clinical Infant Programs, 1994. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood may be ordered
https://secure2.convio.net/zttcfn/site/Ecommerce?VIEW_PRODUCT=true&product_id=1681&store_id=1121 or other sources.
DHS 35.17(1)(b)4.
4. Information on the consumer's strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive functioning; past and present trauma; and substance abuse.
DHS 35.17(1)(b)5.
5. The consumer's unique perspective and own words about how the consumer views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.
DHS 35.17 Note
Note: Nothing in this chapter is intended to interfere with the right of providers under s.
51.61 (6), Stats., to use customary and usual treatment techniques and procedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system.
DHS 35.17(2)
(2) If a consumer is determined to have one or more co-occurring disorders, a licensed treatment professional, mental health practitioner, or a recognized psychotherapy practitioner, shall document the treatments and services concurrently received by the consumer through other providers; whether the clinic can serve the consumer's needs using qualified staff members or in collaboration with other providers; and any recommendations for additional services, if needed. If a clinic cannot serve a consumer's needs, independently, or in collaboration with other providers, the clinic shall refer the consumer, with the consumer's consent, to an appropriate provider.
DHS 35.17 History
History: CR 06-080: cr.
Register May 2009 No. 641, eff. 6-1-09.
DHS 35.18
DHS 35.18
Consent for outpatient mental health services. DHS 35.18(1)(1)
If a clinic determines that a consumer is appropriate for receiving outpatient mental health services through the clinic, the clinic shall inform the consumer or the consumer's legal representative of the results of the assessment. In addition, the clinic shall inform the consumer or the consumer's legal representative, orally and in writing, of all of the following:
DHS 35.18(1)(c)
(c) Possible outcomes and side effects of treatment recommended in the treatment plan.
DHS 35.18(1)(d)
(d) Treatment recommendations and benefits of the treatment recommendations.
DHS 35.18(1)(e)
(e) Approximate duration and desired outcome of treatment recommended in the treatment plan.
DHS 35.18(1)(f)
(f) The rights of a consumer receiving outpatient mental health services, including the consumer's rights and responsibilities in the development and implementation of an individual treatment plan.
DHS 35.18(1)(g)
(g) The outpatient mental health services that will be offered under the treatment plan.
DHS 35.18(1)(h)
(h) The fees that the consumer or responsible party will be expected to pay for the proposed services.
DHS 35.18 Note
Note: Consumers receiving Medicaid covered services may not be charged any amount in connection with services other than the applicable cost share, if any, specified by the Wisconsin Medicaid Program.
DHS 35.18(1)(j)
(j) The means by which a consumer may obtain emergency mental health services during periods outside the normal operating hours of the clinic.
DHS 35.18(1)(k)
(k) The clinic's discharge policy, including circumstances under which a patient may be involuntarily discharged for inability to pay or for behavior reasonably the result of mental health symptoms.
DHS 35.18(2)
(2) If a consumer wishes to receive services through the clinic, the consumer or the consumer's legal representative, where the consent of the
legal representative is required for treatment, shall sign a clinic form to indicate the consumer's informed consent to receive outpatient mental health services.
DHS 35.18(3)
(3) If a consumer is prescribed medication as part of the consumer's treatment plan developed under s.
DHS 35.19 (1), the clinic shall obtain a separate consent that indicates that the prescriber has explained to the consumer, or the consumer's legal representative, if the legal representative's consent is required, the nature, risks and benefits of the medication and that the consumer, or legal representative, understands the explanation and consents to the use of the medication.
DHS 35.18 Note
Note: The consent of the patient or legal representative is not required where treatment is ordered pursuant to a court order for involuntary commitment order.
