Wisconsin Legislature: DHS 40.04(2)(i)

10) How the program will arrange for food service to any youth who is in the program for four or more hours during a day.

(c) Initial on-site inspection. Upon receipt of all application materials described in sub. (2), the applicant shall do all of the following:

1. Permit the department to conduct an on-site inspection of the program’s physical settings to determine compliance with this chapter.

2. Make available for review by the department any documentation necessary to determine compliance with the standards in this chapter.

(d) Certification determination.

1. The department shall make a certification determination within 60 days of receiving all completed application materials.

2. The department may grant certification if all the requirements of this chapter are met.

3. If the department determines that a program applying for certification does not comply with the requirements of this chapter, has a major deficiency, or the program description is not approved, the department may deny certification. A denial of certification shall be in writing and shall contain the reason for the denial and notice of appeal rights.

(e) Scope of certification. Certification granted by the department shall only be valid for the program described in the application materials.

(2) Ongoing oversight provisions.

(a) Notification of changes. A program that has received certification from the department shall notify the department of any change of administration, ownership, program name, required staff, or any other program change that may affect compliance with this chapter before the effective date of the change. A new application will be required if, upon notification, the department determines there is a substantial change in the program.

Note: Program notifications should be made to: Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969 or by emailing DHSDQAMentalHealthAODA@wisconsin.gov.

(b) Duration of certification.

1g. Certification is valid until suspended or terminated by the department under sub. (2) (f).

1r. Certification may be suspended or terminated under sub. (2) (f).

2. Any program that intends to close shall notify the department in writing at least 30 days before closing and comply with s. DHS 40.15 (9).

(c) Biennial report and fees. Every 24 months, by the date of renewal, the program shall submit a biennial report on the form provided by the department, and shall submit payment of certification continuation fees for the purpose of renewing certification of the program for two years.

(d) Ongoing on-site inspections. The program shall permit unannounced, on-site inspections of the program by the department to conduct program reviews, to conduct complaint or death investigations involving any aspect of the program, or to determine a program’s progress in correcting a deficiency or major deficiency cited by the department. All of the following conditions apply to an on-site inspection:

1. The department shall use a random selection process for reviewing client records during program reviews.

2. The department shall conduct client interviews as part of the program review process.

(e) Notice of deficiencies.

1. If the department determines that a program has a deficiency, the department shall issue a notice of deficiency to the program. The notice of deficiency may place restrictions on the activities of the program, or suspend or terminate the program’s certification.

2. The program shall submit a plan of correction to the department as indicated in the notice of deficiency. The plan of correction shall identify the specific steps the program will take to correct the deficiency, the timelines within which the corrections will be made, and the staff members who will implement the plan and monitor for future compliance.

3. If the department determines that the plan of correction submitted by the program does not adequately address deficiencies listed in the notice of deficiency, the department may impose a plan of correction.

(f) Termination and suspension of certification.

1. The department may terminate certification at any time for any major deficiency by issuing a notice of major deficiency to the program. The notice shall specify the reason for the department action and contain appeal information.

2. The department may summarily suspend a program’s certification if the department determines that immediate action is required to protect the health, safety, or welfare of youth. Notice of suspension may be written or verbal and shall specify the reason for the department action and the date the action becomes effective. Within 10 working days after the order is issued, the department shall either lift the suspension on the program’s certification or proceed to terminate the program’s certification.

(g) Appeals. If the department denies or terminates certification, the program may request a hearing under ch. 227, Stats.

(h) Reapplication. If an application for certification is denied, the program may not reapply for certification for one year following the date on which certification was denied.

(i) Dissemination of results. Upon completing action on an application for certification, staff of the department shall provide a summary of the results of the process to the applicant, to the subunit within the department responsible for monitoring community mental health programs, and to the department of community programs under s. 51.42, Stats., in the county in which the program is located.

History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in numbering of (2) (b) 1g., 1r. made under s. 13.92 (4) (b) 1., Stats., and correction in (1) (c) (intro.), (2) (a), (b) 2., (c), (d) made under s. 35.17, Stats., Register June 2020 No. 774; correction in (2) (b) 1g., 1r. made under s. 13.92 (4) (b) 7., Stats., Register December 2020 No. 780.

DHS 40.05 Waivers and variances.

(1) Request. A program may request a waiver or a variance from the department. A request shall be made in writing and include all of the following:

(a) The name of the program.

(b) The rule provision from which the waiver or variance is requested.

(d) If the request is for a variance, the specific alternative action that the program proposes.

(e) The reasons for the request and a supporting justification.

(f) 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 or emailed to DHSDQAMentalHealthAODA@wisconsin.gov.

(2) Requirements.

(a) The department may grant a waiver or variance requested by a program, or may impose additional conditions on the proposed waiver or variance, including limiting their duration, or providing that the waiver or variance may be withdrawn for any of the reasons specified in par. (b) if the department determines all of the following:

1. The waiver or variance is not likely to adversely affect the health, safety, or welfare of any youth.

2. The waiver or variance is likely to improve services, or management and operation of the program, or permit piloting of new services.

(b) The department may revoke a waiver or variance granted under par. (a) if any of the following occurs:

1. The program fails to comply with the variance as granted.

2. The program notifies the department that it wishes to relinquish the waiver or variance.

3. There is a change in applicable state or federal law.

4. The department determines the revocation is necessary to protect the health, safety, or welfare of a youth.

(3) Notification.

(am) Within 60 days of the receipt of a request for a waiver or variance, the department shall notify the program in writing of its decision to do any of the following:

1. Extend the department’s review period for the request.

2. Grant or deny the waiver or variance as requested.

3. Grant the waiver or variance with additional conditions imposed by the department.

(bm) If the department denies a request for a waiver or variance, or revokes a waiver or variance, the department shall notify the program in writing of the reason for the denial or revocation.

History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in numbering in (3) made under s. 13.92 (4) (b) 1., Stats., Register June 2020 No. 774.

DHS 40.06 Coordination with educational services.

(1) Programs shall make reasonable efforts to provide care coordination by executing memoranda of understanding or other forms of interagency agreement with local educational agencies or other services or programs that provide services to program youth.

(2) This chapter does not modify the educational rights and obligations of the youth in the program, any legal representative, or any local educational agency providing services in coordination with a mental health day treatment program certified under this chapter.

History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.

DHS 40.07 Program components.

(1) Required policies and procedures. A program shall develop and implement written policies and procedures for:

(a) Admission and orientation.

(b) Fee agreements.

(d) Contents and implementation of individualized treatment plans.

(e) Implementation of person-centered care, including:

1. Cultural responsiveness.

2. Developmentally appropriate and age-appropriate service planning and delivery.

3. Legal representative involvement.

4. Strength-based approaches and planning.

5. Trauma-informed and responsive approaches and planning.

(f) Care coordination.

(fm) 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.

(g) Confidentiality and compliance with 42 CFR part 2, 45 CFR parts 160, 162, and 164, s. 51.30, Stats., and ch. DHS 92.

(h) Compliance with Title 2 of the Americans with Disabilities Act of 1990.

(i) Client rights and grievance processes under s. 51.61, Stats., and ch. DHS 94.

(j) Crisis prevention and response, including the program’s use of support services, seclusion, and physical restraint and the process for obtaining a written authorization from a physician that allows seclusion and physical restraint for a youth prior to utilizing any emergency intervention with that youth.

(k) Services for minor youth transitioning to adulthood.

(L) Discharge, transfer, and continuity of care.

(m) Quality assurance and performance improvement.

(n) Written personnel policies.

(2) Involvement in treatment planning for youth.

(a) A program shall provide all of the following to a youth or legal representative upon request:

1. Copies of the policies and procedures, required under sub. (1).

2. Written documentation of each staff member’s qualifications per s. DHS 40.09 (2) to (4).

3. Admission paperwork that explains the program and forms required for enrollment prior to the admission meeting, and assistance with understanding the paperwork.

4. A copy of ch. DHS 40.

5. Information about fees, payment sources, and how to access any applicable financial resources, and other community resources that are potentially helpful and how to access them.