Chapter DHS 40

DHS 40.04(1)(c)2. 2. Make available for review by the department any documentation necessary to determine compliance with the standards in this chapter.

DHS 40.04(1)(d) (d) Certification determination.

DHS 40.04(1)(d)1. 1. The department shall make a certification determination within 60 days of receiving all completed application materials.

DHS 40.04(1)(d)2. 2. The department may grant certification if all the requirements of this chapter are met.

DHS 40.04(1)(d)3. 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.

DHS 40.04(1)(e) (e) Scope of certification. Certification granted by the department shall only be valid for the program described in the application materials.

DHS 40.04(2) (2) Ongoing oversight provisions.

DHS 40.04(2)(a) (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.

DHS 40.04 Note 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 [e-mail].

DHS 40.04(2)(b) (b) Duration of certification.

DHS 40.04(2)(b)1g. 1g. Certification is valid until suspended or terminated by the department under sub. (2) (f).

DHS 40.04(2)(b)1r. 1r. Certification may be suspended or terminated under sub. (2) (f).

DHS 40.04(2)(b)2. 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).

DHS 40.04(2)(c) (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.

DHS 40.04(2)(d) (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:

DHS 40.04(2)(d)1. 1. The department shall use a random selection process for reviewing client records during program reviews.

DHS 40.04(2)(d)2. 2. The department shall conduct client interviews as part of the program review process.

DHS 40.04(2)(e) (e) Notice of deficiencies.

DHS 40.04(2)(e)1. 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.

DHS 40.04(2)(e)2. 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.

DHS 40.04(2)(e)3. 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.

DHS 40.04(2)(f) (f) Termination and suspension of certification.

DHS 40.04(2)(f)1. 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.

DHS 40.04(2)(f)2. 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.

DHS 40.04(2)(g) (g) Appeals. If the department denies or terminates certification, the program may request a hearing under ch. 227, Stats.

DHS 40.04(2)(h) (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.

DHS 40.04(2)(i) (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.

DHS 40.04 History 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 DHS 40.05 Waivers and variances.

DHS 40.05(1) (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:

DHS 40.05(1)(a) (a) The name of the program.

DHS 40.05(1)(b) (b) The rule provision from which the waiver or variance is requested.

DHS 40.05(1)(c) (c) The time period for which the waiver or variance is requested.

DHS 40.05(1)(d) (d) If the request is for a variance, the specific alternative action that the program proposes.

DHS 40.05(1)(e) (e) The reasons for the request and a supporting justification.

DHS 40.05(1)(f) (f) Any other information requested by the department.

DHS 40.05 Note 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 [e-mail].

DHS 40.05(2) (2) Requirements.

DHS 40.05(2)(a) (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:

DHS 40.05(2)(a)1. 1. The waiver or variance is not likely to adversely affect the health, safety, or welfare of any youth.

DHS 40.05(2)(a)2. 2. The waiver or variance is likely to improve services, or management and operation of the program, or permit piloting of new services.

DHS 40.05(2)(b) (b) The department may revoke a waiver or variance granted under par. (a) if any of the following occurs:

DHS 40.05(2)(b)1. 1. The program fails to comply with the variance as granted.

DHS 40.05(2)(b)2. 2. The program notifies the department that it wishes to relinquish the waiver or variance.

DHS 40.05(2)(b)3. 3. There is a change in applicable state or federal law.

DHS 40.05(2)(b)4. 4. The department determines the revocation is necessary to protect the health, safety, or welfare of a youth.

DHS 40.05(3) (3) Notification.

DHS 40.05(3)(am) (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:

DHS 40.05(3)(am)1. 1. Extend the department’s review period for the request.

DHS 40.05(3)(am)2. 2. Grant or deny the waiver or variance as requested.

DHS 40.05(3)(am)3. 3. Grant the waiver or variance with additional conditions imposed by the department.

DHS 40.05(3)(bm) (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.

DHS 40.05 History 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 DHS 40.06 Coordination with educational services.

DHS 40.06(1) (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.

DHS 40.06(2) (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.

DHS 40.06 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.

DHS 40.07 DHS 40.07 Program components.

DHS 40.07(1) (1) Required policies and procedures. A program shall develop and implement written policies and procedures for:

DHS 40.07(1)(a) (a) Admission and orientation.

DHS 40.07(1)(b) (b) Fee agreements.

DHS 40.07(1)(c) (c) Assessments.

DHS 40.07(1)(d) (d) Contents and implementation of individualized treatment plans.

DHS 40.07(1)(e) (e) Implementation of person-centered care, including:

DHS 40.07(1)(e)1. 1. Cultural responsiveness.

DHS 40.07(1)(e)2. 2. Developmentally appropriate and age-appropriate service planning and delivery.

DHS 40.07(1)(e)3. 3. Legal representative involvement.

DHS 40.07(1)(e)4. 4. Strength-based approaches and planning.

DHS 40.07(1)(e)5. 5. Trauma-informed and responsive approaches and planning.

DHS 40.07(1)(f) (f) Care coordination.

DHS 40.07(1)(fm) (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.

DHS 40.07(1)(g) (g) Confidentiality and compliance with 42 CFR part 2, 45 CFR parts 160, 162, and 164, s. 51.30, Stats., and ch. DHS 92.

DHS 40.07(1)(h) (h) Compliance with Title 2 of the Americans with Disabilities Act of 1990.

DHS 40.07(1)(i) (i) Client rights and grievance processes under s. 51.61, Stats., and ch. DHS 94.

DHS 40.07(1)(j) (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.

DHS 40.07(1)(k) (k) Services for minor youth transitioning to adulthood.

DHS 40.07(1)(L) (L) Discharge, transfer, and continuity of care.

DHS 40.07(1)(m) (m) Quality assurance and performance improvement.

DHS 40.07(1)(n) (n) Written personnel policies.

DHS 40.07(2) (2) Involvement in treatment planning for youth.

DHS 40.07(2)(a) (a) A program shall provide all of the following to a youth or legal representative upon request:

DHS 40.07(2)(a)1. 1. Copies of the policies and procedures, required under sub. (1).

DHS 40.07(2)(a)2. 2. Written documentation of each staff member’s qualifications per s. DHS 40.09 (2) to (4).

DHS 40.07(2)(a)3. 3. Admission paperwork that explains the program and forms required for enrollment prior to the admission meeting, and assistance with understanding the paperwork.

DHS 40.07(2)(a)4. 4. A copy of ch. DHS 40.

DHS 40.07(2)(a)5. 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.

DHS 40.07(2)(b) (b) A program shall include the youth or legal representative throughout all parts of the treatment process, including screening, assessment, treatment, and discharge. A program shall make reasonable efforts to include any persons or family members that the youth or legal representative has authorized to participate in treatment or treatment planning. All of the following apply to the program’s engagement of the youth or legal representative:

DHS 40.07(2)(b)1. 1. The assessment process shall engage the youth or legal representative to recognize the strengths and needs of the youth, and ensure that the youth or legal representative’s perspectives, opinions, and preferences are included as part the treatment plan.

DHS 40.07(2)(b)2. 2. A program shall inform the youth or legal representative of the proposed services and supports within the treatment plan and provide a written copy of the plan.