Wisconsin Legislature: DHS 75.19(4)(c)

2. Ensuring that appropriate policies and procedures for the service are developed and carried out in compliance with this chapter.

3. Administrative oversight of the job performance and actions of service staff members.

4. Compliance with regulations governing the care and treatment of patients and the standards of practice for behavioral health professions.

(c) Unless otherwise specified for a specific level of care, the service director, or staff member designated by the director to be responsible for the operation of the service, shall be readily available, at all times the service is in operation. That person may provide direct counseling or other duties consistent with their scope of practice, in addition to being responsible for the service operation.

(2) Clinical supervisor.

(a) A service shall have a clinical supervisor, either on staff or through a contracted agreement, to provide clinical supervision or clinical consultation to clinical staff of a service, as required within this chapter, and consistent with applicable professional licensure and certification requirements.

(b) The clinical supervisor is responsible for professional development of clinical staff, and for ensuring delivery of appropriate clinical services to patients of a service.

(c) Any staff who provides clinical supervision shall be a clinical supervisor, as defined in s. DHS 75.03 (19). A clinical supervisor who is on staff of the service and meets the requirements of a substance abuse counselor or mental health professional may provide direct counseling services in addition to supervisory responsibilities.

(3) Substance abuse counselors. A service shall have a substance abuse counselor, as defined in s. DHS 75.03 (85), available during the hours of operation of clinical services.

(4) Prescribers. A service may have prescribers that provide medical services and clinical consultation services. The service shall ensure appropriate training and oversight of prescribers.

(5) Nurses. A service may have nurses that provide nursing services to support mental health and substance use treatment. The service shall ensure appropriate training and oversight of nursing staff.

(6) Mental health professionals.

(a) A service may have mental health professionals or prescribers that deliver mental health treatment services. All staff who provide mental health treatment, except prescribers knowledgeable in psychiatry, shall meet the appropriate qualifications under ch. 455 or ch. 457, Stats.

(b) For service levels of care in ss. DHS 75.49 to 75.59 that require a mental health professional, the role of substance abuse counselor and mental health professional may be occupied by the same individual with appropriate credentialing, and providing they are operating within the scope of their practice.

History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (2) (c), (3), (6) (a) made under s. 35.17, Stats., Register October 2021 No. 790.

DHS 75.19 Personnel requirements.

(1) 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 the service if the person has been convicted of the crimes or offenses, or has a governmental finding of misconduct, found in s. 50.065, Stats., and ch. DHS 12, unless the person has been approved under the department’s rehabilitation process, as defined in ch. DHS 12.

(2) Personnel records. 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) A written job description including duties, responsibilities and qualifications required for the employee.

(b) Beginning date of employment.

(d) A completed caregiver background check following procedures under s. 50.065, Stats., and ch. DHS 12.

(e) A copy of a signed statement regarding confidentiality of client information.

(f) Documentation of any required training.

(g) A copy of any required licenses or certifications.

(3) Clinical supervision. A service shall have written policies and procedures for the provision of clinical supervision to unlicensed staff, qualified treatment trainees, and recovery support staff. Clinical supervision for substance abuse counselors, mental health professionals in-training, and qualified treatment trainees shall be in accordance with requirements in ch. SPS 162, chs. MPSW 4, 12, and 16, and ch. Psy 2. A record of clinical supervision shall be made available to the department upon request.

(4) Staff development.

(a) A service shall have written policies and procedures for determining staff training needs, formulating individualized training plans, and documenting the progress and completion of staff development goals.

(b) The requirements in this subsection may be met through documentation on an employee’s annual performance evaluation that addresses professional development goals.

1. Assessment and management of suicidal individuals.

2. Safety planning for behavioral health emergencies.

3. Assessment and treatment planning for co-occurring disorders.

(d) Documentation of training shall be made available to the department upon request.

(e) Documented training for areas identified in par. (c) shall occur within 2 months of hire for new clinical staff, unless the service is able to provide documentation of the staff member’s previous training, professional education, or supervised experience addressing these areas.

(5) Universal precautions. A service shall have written policies and procedures for infection control and prevention that adheres to federal occupational safety and health administration bloodborne pathogens standards in 29 CFR 1910.1030.

History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (3), (4) (e) made under s. 35.17, Stats., Register October 2021 No. 790.

DHS 75.20 Patient case records.

(1) General treatment service case records.

(a) With respect to general treatment service case records, the service shall do all of the following:

1. Maintain a case record for each patient.

2. The service director or another designated staff member shall be responsible for the maintenance and security of patient case records.

3. Safeguard and maintain patient case records in accordance with applicable state and federal security requirements, including all applicable security requirements specified in ch. DHS 92, 42 CFR part 2, 45 CFR parts 164 and 170, and ss. 146.816 and 146.82, Stats.

4. Maintain each case record in a format that provides for consistency and facilitates information retrieval.

5. Whenever an edit to a signed entry in a patient’s case record is made, the service shall document the date of the edit, the name of the individual making the edit, and a brief statement about the reason for the edit, if the prior version of the edited information is not retained by the service.

(b) A patient’s case record shall include all of the following:

1. The patient’s name, physical residence, address, and phone contact information.

2. The patient’s date of birth, self-identified gender, and self-identified race or ethnic origin.

3. Consent for treatment forms signed by the patient or the patient’s legal guardian, if applicable, that are maintained in accordance with s. DHS 94.03.

4. An acknowledgment by the patient or the patient’s legal guardian, if applicable, that the service policies and procedures were explained to the patient or the patient’s legal guardian.

5. A copy of the signed and dated patient notification that was reviewed with and provided to the patient or the patient’s legal guardian, if applicable, which identifies patient rights, and explains provisions for confidentiality and the patient’s recourse in the event that the patient’s rights have been abused.

6. Results of all screening, examinations, tests, and other assessment information.

7. A completed copy of the standardized placement criteria and level of care assessment at admission, and subsequent reviews of level of care placement criteria.

8. Treatment plans, including all reviews and updates to the treatment plan.

9. Records for any medications prescribed or administered by the service, including any medication consent records required by s. DHS 94.09.

10. Copies of any incident reports or documentation of medication errors applicable to the patient.

11. Records for any medical services provided by the service.

12. Reports from referring sources, as applicable.

13. Records of any referrals by the service, including documentation that referral follow-up activities occurred.

14. Correspondence relevant to the patient’s care and treatment, including dated summaries of relevant telephone or electronic contacts and letters.

15. Consents authorizing disclosure of specific information about the patient.

16. Progress notes that include documentation of all services provided.

17. Clinical consultation and staffing notes, as applicable.

18. Any safety plans developed during the patient’s treatment.

19. Documentation of each transfer from one level of care to another. Documentation shall identify the applicable criteria from ASAM or other department-approved placement criteria, and shall include the dates the transfer was recommended and initiated.

20. Discharge documentation.

(c) For patients that discharge from a service and are subsequently re-admitted, a new case record shall be established for each episode of care.

(d) A patient’s case record shall be maintained in accordance with ch. DHS 92.

(e) If the service discontinues operations or is taken over by another service, records containing patient identifying information shall be turned over to the replacement service, as permitted by applicable state and federal confidentiality requirements.

(2) Case records for persons receiving only screening and referral. A treatment service shall have a written policy and procedure regarding case records for individuals that receive only screening, consultation, or referral services. The policy and procedure shall include:

(a) Information to be obtained for phone and in-person screening, consultation, or referral.

(b) Assurance that screening includes an individual’s pregnancy status.

History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (1) (a) 3., (b) 3., 9. made under s. 35.17, Stats., Register October 2021 No. 790.

DHS 75.21 Confidentiality. A service shall have written policies, procedures and staff training to ensure compliance with applicable confidentiality provisions of 42 CFR part 2, 45 CFR parts 164 and 170, ss. 51.30, 146.816 and 146.82, Stats., and ch. DHS 92. Each staff member shall sign a statement acknowledging responsibility to maintain confidentiality of personal information about persons served.

History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction made under s. 35.17, Stats., Register October 2021 No. 790.

DHS 75.22 Services for minors.

(1) Application. A service under this chapter that delivers treatment services to minors shall identify within their application to the department each level of care that will provide treatment services for minors.

(2) Statutory requirements. A service that delivers treatment services to minors shall adhere to all applicable requirements outlined in ss. 51.13, 51.138, 51.14, 51.47 and 51.48, Stats.

(3) Family involvement. Services for minors shall include the involvement of a parent, guardian, or other family members whenever possible.

(4) Staff qualifications. Staff delivering services to minors shall have training, experience, or education specific to the treatment of substance use and mental health for minors and shall practice within their scope. A record of relevant training, experience, or education shall be documented in the personnel record.

(5) Staff training. A service that delivers treatment services to minors shall provide training to clinical staff in the areas of adolescent development, family systems, child abuse and neglect, and involuntary treatment laws for minors, unless the service is able to provide documentation of the staff member’s previous training, professional education, or supervised experience addressing these areas. A record of required training shall be documented in the personnel record.

(6) Separation of services. Services for minors shall be separate from adult services, with the exception of specialized groups addressing the needs of transitional-age youth. Services for transitional-age youth shall be separate from other services for minors or adults.

(7) Policies and procedures. A service that delivers treatment services to minors shall have written policies and procedures to address specific safety needs of minors, including consideration of vulnerability related to adult populations served within the facility, adequacy of supervision for service delivery, and services addressing specific needs of youth.

History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22.

DHS 75.23 Service levels of care.

(1) Service levels of care.

(a) Services delivered under this chapter shall adhere to standardized levels of care as defined in this chapter. A service shall apply the ASAM criteria or other department-approved placement criteria to determine the appropriate level of care, and services shall be delivered consistent with that level of care.

(b) A service shall not deliver or purport to deliver a service for which they do not possess certification by the department under this chapter.