Chapter DHS 75

DHS 75.56(2)(a)5. 5. Techniques and procedures for providing non-violent crisis management for patients, including verbal de-escalation, methods for obtaining backup, and acceptable methods for self-protection and protection of the patient and others in emergency situations.

DHS 75.56(2)(b) (b) Unlicensed staff working in the clinical setting shall complete a minimum of 40 hours of documented orientation training within 3 months after beginning work with the program.

DHS 75.56(2)(c) (c) Staff of an adult residential integrated behavioral health stabilization service shall receive at least 8 hours per year of training on emergency behavioral health services, rules and procedures relevant to the operation of the program, compliance with state and federal regulations, cultural competency in behavioral health services, and current issues in client’s rights and services.

DHS 75.56(3) (3) Additional intake and admission requirements.

DHS 75.56(3)(a) (a) An adult residential integrated behavioral health stabilization service shall have written policies and procedures for the assessment of safety and consideration of safety risks to the patient and others prior to admitting a patient.

DHS 75.56(3)(b) (b) An individual with any of the following symptoms, behaviors, or concerns shall be excluded from admission to an adult residential integrated behavioral health stabilization service:

DHS 75.56(3)(b)1. 1. Assaultive ideation or assaultive behaviors combined with likelihood to act on those behaviors.

DHS 75.56(3)(b)2. 2. Exhibiting active self-injurious behavior.

DHS 75.56(3)(b)3. 3. A recent suicide attempt or ongoing suicidal ideation combined with a continued threat or plan to act on suicidal ideation.

DHS 75.56(3)(c) (c) The intake screening shall include documentation of the determination and plan for the level of observation needed to address the patient’s needs and any safety concerns.

DHS 75.56 History History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22.

DHS 75.57 DHS 75.57 Residential withdrawal management service.

DHS 75.57(1) (1) Service description for residential withdrawal management service. In this section, “residential withdrawal management service” means a residential substance use treatment service that provides withdrawal management and intoxication monitoring, and includes medically managed 24-hour on-site nursing care, under the supervision of a physician. Residential withdrawal management is appropriate for patients whose acute withdrawal signs and symptoms are sufficiently severe to require 24-hour care; however, the full resources of a hospital are not required. Services delivered in this setting may include screening, assessment, intake, evaluation and diagnosis, medical care, observation and monitoring, physical examination, medication management, nursing services, case management, drug testing, counseling, individual therapy, group therapy, family therapy, psychoeducation, peer support services, recovery coaching, and recovery support services, to ameliorate symptoms of acute intoxication and withdrawal and to stabilize functioning. Services provided in this setting may include community-based withdrawal management and intoxication monitoring services, subject to the requirements listed in this section.

DHS 75.57(2) (2) Service description for community-based withdrawal management. Community-based withdrawal management is a medically-managed withdrawal management service delivered on an outpatient basis by a physician, or other service personnel acting under the supervision of a physician.

DHS 75.57(3) (3) Additional requirements for community-based withdrawal management.

DHS 75.57(3)(a) (a) A service that provides community-based withdrawal management shall meet the requirements in this section, however, services may be provided on an outpatient basis, in the community, or in the patient’s home.

DHS 75.57(3)(b) (b) Community-based withdrawal management services are delivered by medical and nursing professionals under the supervision of physician.

DHS 75.57(3)(c) (c) A service that provides community-based withdrawal management services shall have written policies and procedures for the delivery of community-based withdrawal management services.

DHS 75.57(3)(d) (d) Residential living areas under this section shall be physically separated from service areas for community-based withdrawal management patients.

DHS 75.57 History History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (2) made under s. 35.17, Stats., Register October 2021 No. 790.

DHS 75.58 DHS 75.58 Residential intoxication monitoring service.

DHS 75.58(1) (1) Service description. In this section, “residential intoxication monitoring service” means a residential service that provides 24-hour observation to monitor the safe resolution of alcohol or sedative intoxication and to monitor for the development of alcohol withdrawal for intoxicated patients who are not in need of emergency medical or behavioral healthcare. Residential intoxication monitoring services may include screening, assessment, intake, evaluation and diagnosis, observation and monitoring, case management, drug testing, counseling, individual therapy, group therapy, family therapy, psychoeducation, peer support services, recovery coaching, and recovery support services.

DHS 75.58(2) (2) Observation and medication requirements.

DHS 75.58(2)(a) (a) Observation. Trained staff shall observe a patient and record the patient’s condition at intervals no greater than every 30 minutes during the first 12 hours following admission.

DHS 75.58(2)(b) (b) Medications.

DHS 75.58(2)(b)1. 1. A residential intoxication monitoring service shall not administer or dispense medications.

DHS 75.58(2)(b)2. 2. When a patient has been admitted with prescribed medication, staff shall consult with the patient’s physician or other person licensed to prescribe and administer medications to determine the appropriateness of the patient’s continued use of the medication while under the influence of alcohol or sedatives.

DHS 75.58(2)(b)3. 3. If approval for continued use of prescribed medication is received from a prescriber, the patient may self-administer the medication under the observation of service staff.

DHS 75.58(3) (3) Prohibited admissions. No person may be admitted if any of the following apply:

DHS 75.58(3)(a) (a) The person’s behavior is determined by the service to be dangerous to self or others.

DHS 75.58(3)(b) (b) The person requires professional nursing or medical care.

DHS 75.58(3)(c) (c) The person is incapacitated by alcohol and is placed in or is determined to be in need of protective custody by a law enforcement officer as required under s. 51.45 (11) (b), Stats.

DHS 75.58(3)(d) (d) The person is under the influence of any substance other than alcohol or a sedative.

DHS 75.58(3)(e) (e) The person requires restraints.

DHS 75.58(3)(f) (f) The person requires medication normally used for the detoxification process.

DHS 75.58 History History: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; (2) (a) (title) created under s. 13.92 (4) (b) 2., Stats., and correction in (2) (b) 3. made under s. 35.17, Stats., Register October 2021 No. 790.

subch. VII of ch. DHS 75 Subchapter VII — Opioid Treatment Programs and Office-Based Opioid Treatment

DHS 75.59 DHS 75.59 Opioid treatment program.

DHS 75.59(1) (1) Service description. In this section, “opioid treatment program,” or “OTP,” means a service that provides for the management and rehabilitation of persons with an opioid use disorder through the use of methadone and other FDA-approved medications for the treatment of persons with an opioid use disorder, and also provides a broad range of medical and psychological services, substance use counseling and social services. OTPs shall provide adequate medical, counseling, vocational, educational, and other assessment and treatment services. These services must be available at the primary facility, except where the program sponsor has entered into a formal, documented agreement with a private or public agency, organization, practitioner, or institution to provide these services to patients enrolled in the OTP. The program sponsor, in any event, must be able to document that these services are fully and reasonably available to patients. An OTP is subject to the oversight of the SOTA.

DHS 75.59(2) (2) Requirements. To receive certification from the department under this chapter, an OTP shall comply with all requirements included in subch. IV, as applicable, be certified under and follow all requirements included in s. DHS 75.50, and the requirements of this section. If a requirement in this section conflicts with an applicable requirement in subch. IV or s. DHS 75.50, the requirement in this section shall be followed.

DHS 75.59(3) (3) Definitions. In this section:

DHS 75.59(3)(a) (a) “Biochemical monitoring” means the collection and analysis of specimens of body fluids such as blood or urine to determine use of licit or illicit drugs.

DHS 75.59(3)(b) (b) “Central registry” means an organization that obtains patient identifying information from 2 or more OTPs about individuals applying for maintenance treatment or detoxification treatment for the purpose of preventing an individual’s concurrent enrollment in more than one program.

DHS 75.59(3)(c) (c) “Clinical probation” means the period of time determined by the treatment team that a patient is required to increase frequency of service attendance due to rule violations.

DHS 75.59(3)(d) (d) “Guest dose” means administration of a medication used for the treatment of opioid addiction to a person who is not a client of the program that is administering or dispensing the medication.

DHS 75.59(3)(e) (e) “Initial dosing” means the first administration of methadone or other FDA-approved medication for the treatment of opioid use disorder to relieve a degree of withdrawal and drug craving of the patient.

DHS 75.59(3)(f) (f) “Maintenance treatment” means the dispensing of a narcotic drug in the treatment of an individual for opioid dependence.

DHS 75.59(3)(g) (g) “Mandatory schedule” means the required dosing schedule for a patient and the established frequency that the patient must attend the service.

DHS 75.59(3)(h) (h) “Medically-supervised withdrawal” means dispensing, administering, or prescribing of an FDA-approved medication for the treatment of opioid use disorder in gradually decreasing doses to alleviate adverse physical or psychological effects incident to withdrawal from the continuous or sustained use of opioid drugs. The purpose of medically supervised withdrawal is to bring a patient maintained on maintenance medication to a medication-free state within a target period.

DHS 75.59(3)(i) (i) “Medication unit” means a facility established as part of a service but geographically separate from the service, from which licensed private practitioners and community pharmacists are:

DHS 75.59(3)(i)1. 1. Permitted to administer and dispense a narcotic drug.

DHS 75.59(3)(i)2. 2. Authorized to conduct biochemical monitoring for narcotic drugs.

DHS 75.59(3)(j) (j) “Objectively intoxicated person” means a person who is determined through a breathalyzer test to be under the influence of alcohol.

DHS 75.59(3)(k) (k) “Opioid addiction” means psychological and physiological dependence on an opiate substance, either natural or synthetic, that is beyond voluntary control.

DHS 75.59(3)(L) (L) “Patient identifying information” means the name, address, social security number, photograph or similar information by which the identity of a patient can be determined with reasonable accuracy and speed, either directly or by reference to other publicly available information.

DHS 75.59(3)(m) (m) “Phase” means a patient’s level of dosing frequency.

DHS 75.59(3)(n) (n) “Potentiation” means the increasing of potency and, in particular, the synergistic action of two or more drugs which produces an effect that is greater than the effect of each drug used alone.

DHS 75.59(3)(o) (o) “SAMHSA” means the Substance Abuse and Mental Health Services Administration.

DHS 75.59(3)(p) (p) “Service physician” means a physician licensed to practice medicine in the jurisdiction in which the service is located, and knowledgeable in addiction treatment, who assumes responsibility for the administration of all medical services performed by the OTP including ensuring that the service is in compliance with all federal, state and local laws relating to medical treatment of an opioid use disorder with an FDA approved medication for the treatment of an opioid use disorder.

DHS 75.59(3)(q) (q) “Program sponsor” means the person named in the application for certification described in 42 CFR 8.11 (b) who is responsible for the operation of the OTP and who assumes responsibility for all its employees, including any practitioners, agents, or other persons providing medical, rehabilitative, or counseling services at the program or any of its medication units. The program sponsor need not be a licensed physician but shall employ a licensed physician for the position of medical director. The program sponsor is responsible for ensuring the service is in continuous compliance with all federal, state, and local laws and regulations.

DHS 75.59(3)(r) (r) “State opioid treatment authority” (SOTA) means the subunit of the department designated by the governor to exercise the responsibility and authority in this state for governing the treatment of a narcotic addiction with a narcotic drug.

DHS 75.59(3)(s) (s) “Take-homes” means medications such as methadone that reduce the frequency of a patient’s service visits and with the approval of the service physician, are dispensed in an oral form and are in a container that at a minimum discloses the treatment service name, address and telephone number and the patient’s name, the dosage amount and the date on which the medication is to be ingested.

DHS 75.59(3)(t) (t) “Treatment contracting” means an agreement developed between the primary counselor or the clinic director and the patient in an effort to allow the patient to remain in treatment on condition that the patient adheres to service rules.

DHS 75.59(3)(u) (u) “Treatment team” means a team established to evaluate the progress of a patient and consisting of at least the primary counselor, the service staff nurse who administers doses and the clinic director.

DHS 75.59(4) (4) State Opioid Treatment Authority. The powers and duties of the SOTA include:

DHS 75.59(4)(a) (a) Facilitating the development and implementation of rules, regulations, standards, and evidence-based practices, emerging best practices, or promising practices, to ensure the quality of services delivered by OTPs.

DHS 75.59(4)(b) (b) Monitoring and evaluation of program outcomes for service recipients and the community. The SOTA may establish or follow already established performance indicators by accrediting bodies or SAMHSA including improvement in medical condition, recidivism rates, and such other measures as appropriate.

DHS 75.59(4)(c) (c) Acting as a liaison between relevant state and federal agencies.

DHS 75.59(4)(d) (d) Reviewing opioid treatment guidelines and regulations developed by the federal government.

DHS 75.59(4)(e) (e) Delivering technical assistance and informational materials to OTPs as needed.

DHS 75.59(4)(f) (f) Performing both scheduled and unscheduled site visits to OTPs in cooperation with department certification office or other oversight agencies, or as designated by the SOTA, when necessary and appropriate, and preparing reports as appropriate to assist the department’s certification office or to meet the requirements set forth in s. 51.4223, Stats.

DHS 75.59(4)(g) (g) Consulting with the federal government regarding approval or disapproval of requests for exceptions to federal regulations, where appropriate.

DHS 75.59(4)(h) (h) Reviewing and approving exceptions to federal and state dosage and take home policies and procedures.

DHS 75.59(4)(i) (i) Receiving and addressing service recipient appeals and grievances in partnership with the department’s client rights office.

DHS 75.59(4)(j) (j) Working cooperatively with other relevant state and local agencies to determine the service need in the location of a proposed program by reviewing data to include overdose deaths, ambulance runs, hospitalizations, etc.

DHS 75.59(4)(k) (k) Issuing a list of required evidence-based practices, emerging best practices, and promising practices to be delivered by OTPs, so long as the required practices are recognized by SAMHSA, Centers for Disease Control, or National Institute of Health. The SOTA may also provide a list of recommended evidence-based practices, emerging best practices, and promising practices. The SOTA may update the required practices list and the recommended practices list as needed to reflect advances in outcomes research and medical services for persons living with opioid use disorders. The SOTA shall take into consideration the adequacy of evidence to support the efficacy of the practice, the quality of workforce available, and the current availability of the practice in the state when updating the lists. At least 120 days before issuing the initial required practices list and any revisions to the required practices list, the SOTA shall provide stakeholders with an opportunity to comment and shall take those comments into consideration when updating the required practices list.

DHS 75.59(4)(L) (L) Monitoring the central registry to prevent dual enrollments in OTP’s and ensure that all required information is entered.

DHS 75.59(5) (5) Required personnel.

DHS 75.59(5)(a) (a) Clinic director. The service shall designate in writing a clinic director who is responsible for the day to day operation of the service and overall compliance with federal, state and local laws and regulations regarding the operation of OTPs, and for all employees including practitioners, agents, or other persons providing services at the facility. The service shall notify the SOTA in writing within 5 calendar days whenever there is a change in clinic director. If the clinic director is also licensed to provide counseling services they shall carry a caseload of patients that is reasonable to ensure prompt and adequate access to care of those patients while balancing their other business responsibilities to the clinic.

DHS 75.59(5)(b) (b) Medical director. The service shall designate a physician licensed under ch. 448, Stats., as its medical director. The medical director shall have at least one year of experience in addiction medicine or addiction psychiatry, be licensed to practice medicine or osteopathy, and meet all other requirements listed in s. DHS 75.03 (52). If a service is not able to secure a medical director who meets the one year of experience requirement, as documented through recruitment efforts, there shall be a specific plan for the person to acquire equivalent training and skills within 4 months after beginning employment. The medical director, service physician, or mid-level practitioner that has a federal exception approved by SAMHSA and the SOTA to 42 CFR 8.12 (b), (e), (h), and (i) shall be physically present at the OTP at least 40 percent of the time that the program administers or dispenses medication in order to comply with s. DHS 94.08, assure regulatory compliance, and carry out duties specifically assigned by regulation as required by SAMHSA under 42 CFR 8.12. OTPs in the first 60 days of operation may reduce the time requirement medical directors must be present on site to at least 20 percent of the time that the program administers or dispenses medication. On the 61st day of operation the service shall be subject to the requirements of this rule.

DHS 75.59(5)(c) (c) Nurses. The service shall have a registered nurse on staff to supervise the dosing process and perform other functions delegated by the physician. A registered nurse shall be physically on the premises any time dosing is occurring.

DHS 75.59(5)(d) (d) Nursing assistants. The service may employ nursing assistants and related medical ancillary personnel to perform functions permitted under state medical and nursing practice statutes and administrative rules.

DHS 75.59(5)(e) (e) Licensed counselors. The service shall employ at least one of the following: substance abuse counselors, substance abuse counselors-in training, licensed marriage and family therapists, licensed professional counselors, licensed clinical social workers or clinical substance abuse counselors who are under the supervision of a clinical supervisor. An OTP shall employ one of these identified clinicians for a minimum of one full-time equivalent of 40 hours per week for every 55 enrolled patients in the service. All counselors rostered to the service are subject to this ratio.

DHS 75.59(5)(f) (f) Supervision of counseling staff. The service shall provide for ongoing clinical supervision of the counseling staff in accordance with s. SPS 162.01. The service shall employ one full-time clinical supervisor at an equivalent of 40 hours per week for every 10 counselors employed. The clinical supervisor shall not carry a caseload greater than 30 patients to ensure access to prompt and adequate care of those patients while balancing their clinical supervision responsibilities.

DHS 75.59(5)(g) (g) Physician assistants. The service may employ physician assistants to practice in accordance with ch. Med 8 and carry out duties specifically allowed by regulation as required by SAMHSA under 42 CFR 8.11 (h).

DHS 75.59(6) (6) Admission.

DHS 75.59(6)(a) (a) Admission criteria. For admission to the service, a person shall meet all of the following criteria as determined by the service physician:

DHS 75.59(6)(a)1. 1. ‘Maintenance treatment for an adult.’ The service shall maintain current procedures determined by the service physician to ensure that patients are admitted to maintenance treatment by qualified personnel who have determined, using accepted medical criteria, such as those listed in the DSM, that the person is currently addicted to an opioid drug, and that the person became addicted at least one year before admission for treatment. In addition, a service physician shall ensure that each patient voluntarily chooses maintenance treatment and that all relevant facts concerning the use of the opioid drug are clearly and adequately explained to the patient, and that each patient provides informed written consent to treatment.

DHS 75.59(6)(a)2. 2. ‘Maintenance treatment for a minor.’ A minor shall be eligible for maintenance treatment only if the minor has had at least 2 documented unsuccessful attempts at short-term detoxification or drug-free treatment within a 12-month period. No minor may be admitted to maintenance treatment unless a parent, legal guardian, or responsible adult designated by the relevant state authority consents in writing to such treatment.