Chapter DHS 40

DHS 40.08(6)(c)7. 7. Forcible take downs from a standing position to the floor.

DHS 40.08(6)(c)8. 8. Restraint in a prone position.

DHS 40.08(6)(c)9. 9. Restraint in a supine position.

DHS 40.08(6)(c)10. 10. Restraint in a vertical position, with upper body pressed against a wall or hard surface.

DHS 40.08(6)(c)11. 11. Any other physical restraint that is not administered during an emergency, that is administered for longer than necessary to prevent immediate injury to a youth or others, or that is administered for a purpose other than to prevent immediate injury to a youth or others.

DHS 40.08(6)(d) (d) Immediately upon the termination of a physical restraint, a medical staff member, such as a physician, advanced practice nurse prescriber, physician assistant, advanced practice nurse, or registered nurse, shall conduct a follow-up assessment of the condition of the youth to ensure that the youth was not injured and shall document the finding of the assessment in the youth’s file. If a staff member who is a doctor or nurse is not present on site, a licensed treatment professional shall conduct the face-to-face assessment immediately upon termination of the physical restraint and notify a medical staff member.

DHS 40.08(6)(e) (e) If any injury is noted following a physical restraint, a staff member shall notify the youth’s legal representative, if any, and make a referral for medical care.

DHS 40.08(7) (7) Debriefing.

DHS 40.08(7)(a) (a) Following a seclusion or restraint, a staff member shall talk with the youth about each of the following:

DHS 40.08(7)(a)1. 1. The circumstances that contributed to the seclusion or physical restraint and what could have been handled differently by the staff member.

DHS 40.08(7)(a)2. 2. The youth’s psychological well-being and the emotional impact of the intervention.

DHS 40.08(7)(a)3. 3. What modifications can be made in the youth’s services or treatment plan to prevent future seclusion and physical restraint.

DHS 40.08(7)(b) (b) The debriefing should occur within 24 hours following a seclusion and restraint, with the following exceptions:

DHS 40.08(7)(b)1. 1. When clinically contraindicated.

DHS 40.08(7)(b)2. 2. When the 24 hour period falls during non-programming time such as on a weekend or holiday, then debriefing shall occur on the next programming day.

DHS 40.08(7)(b)3. 3. When a youth is suspended or discharged from programming following the incident and debriefing is contraindicated due to a serious risk of harm by the youth to others or to staff.

DHS 40.08(7)(c) (c) A program shall notify a youth’s legal representative, if any, of any seclusion or physical restraint on the same day that it was administered to the youth. The program shall document in the youth’s file any situation in which notification has been attempted and the program has been unable to contact the legal representative.

DHS 40.08(7)(d) (d) Each administration of seclusion or physical restraint shall be documented in the youth’s chart and shall specify all of the following:

DHS 40.08(7)(d)1. 1. Less restrictive interventions attempted prior to the seclusion or physical restraint.

DHS 40.08(7)(d)2. 2. Events precipitating the seclusion or physical restraint.

DHS 40.08(7)(d)3. 3. Length of time the seclusion or physical restraint was used.

DHS 40.08(7)(d)4. 4. Assessment of the appropriateness of the seclusion or physical restraint based on threat of harm to self or others.

DHS 40.08(7)(d)5. 5. Assessment of any physical injury to the youth, other clients, or to staff members.

DHS 40.08(7)(d)6. 6. The youth’s response to the emergency safety intervention.

DHS 40.08(7)(e) (e) A licensed treatment professional shall review all seclusion and physical restraint documentation prior to the end of the shift in which the intervention occurred and determine whether changes to the youth’s safety plan or treatment plan are necessary.

DHS 40.08(7)(f) (f) If seclusion or physical restraint is administered to a youth more than three times over a period of five days, or in a single instance for more than 30 minutes within 24 hours, the clinical coordinator, or designee, shall do all of the following:

DHS 40.08(7)(f)1. 1. Convene staff to discuss the emergency situation that required seclusion or physical restraint, including the precipitating factors that led up to the intervention and any alternative strategies that might have prevented the use of seclusion or physical restraint in those situations.

DHS 40.08(7)(f)2. 2. Convene staff to discuss the procedures, if any, to be implemented to prevent further administration of seclusion or physical restraint.

DHS 40.08(7)(f)3. 3. Convene staff to discuss the outcome of the seclusion or physical restraint including any injuries.

DHS 40.08(7)(f)4. 4. Convene the youth’s interdisciplinary treatment team to review the individualized treatment plan and make any necessary revisions to reduce the need for and likelihood of further use of seclusion or physical restraint, and document the discussion and any resulting changes to the plan in the youth’s chart.

DHS 40.08(7)(f)5. 5. Determine whether a higher level of care is required for the youth and if a referral for inpatient or residential placement is necessary.

DHS 40.08(8) (8) Reporting.

DHS 40.08(8)(a) (a) Programs shall report all incidences of seclusion, physical restraint, injury, and involvement of law enforcement to the department within 24 hours of the incident occurring. Reporting shall be completed through the department’s online reporting system.

DHS 40.08(8)(b) (b) The department will evaluate the circumstances of each incident, conduct any appropriate follow-up, and identify programs in need of technical assistance, training, policy development, or other quality improvement.

DHS 40.08 Note Note: The department reporting link is: https://www.dhs.wisconsin.gov/mh/cadaytreatmentproviders.htm. Questions and information about reporting may be directed to the Division of Care and Treatment Services at 608-266-2717.

DHS 40.08 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (4) (intro.), (5) (e) 3., (6) (d), (7) (e) made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: am. (7) (a) (intro.) Register September 2023 No. 813, eff. 10-1-23.

DHS 40.09 DHS 40.09 Personnel qualifications.

DHS 40.09(1) (1) Minimum requirements.

DHS 40.09(1)(a) (a) Each staff member shall have the professional certification, training, experience, and ability to carry out his or her assigned duties.

DHS 40.09(1)(b) (b) Each staff member shall pass a criminal history and patient abuse record search as provided in s. 50.065, Stats., and a caregiver background check under ch. DHS 12, before working for the program.

DHS 40.09(1)(c) (c) Programs shall comply with caregiver misconduct reporting and investigation requirements in ch. DHS 13.

DHS 40.09 Note Note: For a state of Wisconsin background check, information on the process and fees can be found on-line at: http://www.doj.state.wi.us/dles/cib/Fees.asp, or contact the Crime Information Bureau, Wisconsin Department of Justice, P.O. Box 2718, Madison, WI 53701-2718.

DHS 40.09(2) (2) Qualifications of program director. The program director shall meet all of the following requirements:

DHS 40.09(2)(a) (a) Meet the qualifications for any of the program staff listed in sub. (3) (a) to (j).

DHS 40.09(2)(b) (b) Have at least one year of experience in a mental health setting working with youth.

DHS 40.09(2)(c) (c) Have at least 2 years of experience as an administrator of a program that provides mental health services to youth and families.

DHS 40.09(3) (3) Qualifications of program staff.

DHS 40.09(3)(a) (a) The clinical coordinator shall meet all of the following qualifications:

DHS 40.09(3)(a)1. 1. Be a licensed mental health professional.

DHS 40.09(3)(a)2. 2. Have at least 1,500 hours of clinical experience in a practice with youth who have mental illness or severe emotional disturbance.

DHS 40.09(3)(b) (b) A psychiatrist shall be a physician licensed to practice medicine and surgery and meet the requirements for certification in child psychiatry by the American board of psychiatry and neurology. If a program can demonstrate that no board-certified or eligible child psychiatrist is available, the program may employ a psychiatrist who has a minimum of 1 year of clinical experience working with youth.

DHS 40.09(3)(c) (c) Advanced practice nurse prescribers shall be certified in mental health treatment by an appropriate board and shall have had either training in providing psychiatric services, including work with youth with mental illness or severe emotional disturbance, or one year of experience working in a clinical setting with youth. An advanced practice nurse prescriber shall issue only those prescription orders appropriate to the advanced practice nurse prescriber’s areas of competence, as established by his or her education, training, or experience. Advanced practice nurse prescribers shall facilitate collaboration with other health care professionals, at least one of whom shall be a physician. Advanced practice nurse prescribers shall have completed 3,000 hours of supervised clinical psychotherapy experience in order to also provide psychotherapy.

DHS 40.09(3)(d) (d) Licensed mental health professionals shall have a minimum of one year of experience working in a clinical setting serving youth with mental illness or severe emotional disturbance.

DHS 40.09(3)(e) (e) Physician assistants, advanced practice nurses, registered nurses, and occupational therapists shall have either training in providing services to youth with mental illness or severe emotional disturbance, or one year of experience working in a clinical setting with youth.

DHS 40.09(3)(f) (f) Qualified treatment trainees shall have one year of a graduate level education program specific to serving youth with mental illness or severe emotional disturbance and shall provide psychotherapy to clients only under clinical supervision.

DHS 40.09(3)(g) (g) Occupational therapy assistants shall be certified and receiving supervision under chs. OT 1 to 5.

DHS 40.09(3)(h) (h) Therapeutic specialists shall have one year of experience working with, or one year of a formal educational program specific to serving youth with mental illness or severe emotional disturbance.

DHS 40.09(3)(i) (i) Mental health support workers shall have a minimum of one year of experience or formal education related to working with youth who have severe emotion disturbance or mental illness.

DHS 40.09(3)(j) (j) Mental health technicians and parent peer specialists shall be at least 18 years old and have a minimum of 30 hours pre-service training on their role in the program.

DHS 40.09(4) (4) Volunteers. A program may use volunteers to support the activities of staff. Volunteers shall receive a minimum of 10 hours pre-service training under the requirements of s. DHS 40.10 (6) (b) and shall be supervised by a licensed treatment professional employed by the program. Each volunteer shall pass a criminal history and patient abuse record search state background check as provided in s. 50.065, Stats., and a caregiver background check under ch. DHS 12, before being allowed to working for the program.

DHS 40.09 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (2) (a) made under s. 13.92 (4) (b) 7., Stats., Register June 2020 No. 774.

DHS 40.10 DHS 40.10 Required personnel and services.

DHS 40.10(1) (1) Operational responsibilities. A program shall include all of the following administrators:

DHS 40.10(1)(a) (a) A program director who is responsible for program operations and ensuring that the program is in compliance with this chapter and other applicable state and federal laws.

DHS 40.10(1)(b) (b) A clinical coordinator who is responsible for ensuring that all staff members providing mental health services have the qualifications required for their roles in the program and comply with all requirements relating to assessment, treatment planning, service delivery, and service documentation.

DHS 40.10(1)(b)1. 1. The program director may also serve as the clinical coordinator, if the program director is qualified under s. DHS 40.09 (3) (a).

DHS 40.10(1)(b)2. 2. The program director shall identify one or more staff members qualified under s. DHS 40.09 (3) (a) to (e) to whom authority may be delegated in the absence of the clinical coordinator. The clinical coordinator or designee shall be on the premises at all times that youth are present at a program.

DHS 40.10(2) (2) Staffing requirements. At all times that youth are present at a program, the program shall have a minimum of two staff members qualified under s. DHS 40.09 (3) on site, at least one of whom shall be a mental health professional. The number of staff available shall be based on meeting the treatment needs of youth based on individualized treatment plans, with additional staff present when higher levels of clinical needs are indicated. Calculation of the staff-to-client ratios for the program shall not include volunteers. Programs shall meet all of the following staffing requirements:

DHS 40.10(2)(a) (a) If more than 10 youth are present at a community-based program, an additional staff member qualified under s. DHS 40.09 (3) shall be present for every 10 additional youth.

DHS 40.10(2)(b) (b) If more than 10 youth are present at a hospital-based program, an additional staff member qualified under s. DHS 40.09 (3) shall be present for every 5 additional youth.

DHS 40.10(3) (3) Service requirements. A program shall make available at least the following hours of direct clinical services, provided either by program staff members or professionals under contract to the program:

DHS 40.10(3)(a) (a) A community-based day treatment program shall comply with all of the following:

DHS 40.10(3)(a)1. 1. One hour per week of consultation shall be provided by a psychiatrist or advanced practice nurse prescriber. If a program is unable to utilize a psychiatrist or advanced practice nurse prescriber, they may utilize a psychologist as long as there is a written plan in place assuring that consultation with a psychiatrist or advanced practice nurse prescriber occurs for medication related concerns at least monthly or more frequently based on the individual needs of the youth.

DHS 40.10(3)(a)2. 2. One hour per week of health-related services shall be provided by a physician, physician assistant, advanced practice nurse, or registered nurse for every 4 full-time youth in the program.

DHS 40.10(3)(a)3. 3. Six hours per week of group sessions shall be provided in the program. Only a master’s-level mental health professional may provide psychotherapy group sessions. A mental health support worker may provide non-psychotherapy group sessions. Group sessions shall include no more than 10 youth with one staff or a maximum of 12 youth if 2 staff are present with the group.

DHS 40.10(3)(a)4. 4. One hour per week of care coordination services shall be provided by a mental health support worker or a mental health professional for every 2 full-time youth in the program.

DHS 40.10(3)(a)5. 5. Two hours per week of individual or family psychotherapy shall be provided by a mental health professional for each full-time youth in the program. One of the two required hours may be provided by a mental health support worker if they are under the supervision of the mental health professional implementing a piece of the individualized treatment plan.

DHS 40.10(3)(a)6. 6. At least 2 hours per week of support services shall be provided by mental health professionals, mental health support workers, mental health technicians, occupational therapists, or therapeutic specialists in the program.

DHS 40.10(3)(b) (b) Intensive hospital-based day treatment programs shall comply with all of the following:

DHS 40.10(3)(b)1. 1. One hour per week of consultation shall be provided by a psychiatrist or advanced practice nurse prescriber.

DHS 40.10(3)(b)2. 2. One hour per week of health-related services shall be provided by a physician, physician assistant, advanced practice nurse, or registered nurse for every 4 full-time youth in the program.

DHS 40.10(3)(b)3. 3. Crisis response, medical, and nursing services shall be readily available at all times youth are present in the program.

DHS 40.10(3)(b)4. 4. A physician, physician assistant, registered nurse, or advanced practice nurse shall be on duty and on-site in the program at all times that youth are present.

DHS 40.10(3)(b)5. 5. Eight hours per week of group sessions shall be provided in the program. Only a master’s-level mental health professional may provide psychotherapy group sessions. A mental health support worker may provide non-psychotherapy group sessions. Group sessions shall include no more than 10 youth with one staff or a maximum of 12 youth if 2 staff are present with the group.

DHS 40.10(3)(b)6. 6. One hour per week of care coordination services shall be provided by a mental health support worker or mental health professional for every full-time youth in the program.

DHS 40.10(3)(b)7. 7. Four hours per week of individual or family psychotherapy shall be provided by a mental health professional for each full-time youth in the program. Two of the four required hours may be provided by a mental health support worker if they are under the supervision of the mental health professional implementing a piece of the individualized treatment plan.

DHS 40.10(3)(b)8. 8. At least 4 hours per week of support services shall be provided by mental health professionals, mental health support workers, mental health technicians, occupational therapists, or therapeutic specialists in the program.

DHS 40.10(4) (4) Hours of operation. The amount of time a youth spends at a program shall be established by the individual treatment plan developed under s. DHS 40.14 for each youth, but a program shall be in operation and able to provide services for the following period:

DHS 40.10(4)(a) (a) A community-based program shall be in operation and available to provide services to youth for a minimum of 4 hours a day, 5 days a week, and may suspend operations for no more than 4 weeks each year.