Wisconsin Legislature: DHS 75.59(12)(d)6.

(e) Sufficient dosing. The FDA-approved medication dose that a service provides to a patient shall be sufficient to produce the desired response in the patient for the desired duration of time.

(f) Initial methadone dose. A patient’s initial dose shall be based on the service physician’s evaluation of the history and present condition of the patient. The initial dose of methadone may not exceed 30 milligrams except that the total dose for the first day may not exceed 40 milligrams.

(g) Withdrawal planning. A service shall incorporate withdrawal planning as a goal in a patient’s initial treatment plan and all subsequent treatment plans. A service physician shall determine the rate of withdrawal to prevent relapse or withdrawal symptoms.

(12) Involuntary termination from an OTP.

(a) Emergency termination.

1. The service may terminate a patient immediately, prior to a fair hearing and without provision for medically supervised withdrawal, when either of the following occurs:

a. The clinic director reasonably determines and documents that the patient’s continuance in the service presents an immediate and substantial threat of physical harm to other clients, service personnel or property.

b. The program’s medical director reasonably determines that continued treatment of a client presents a serious documented medical risk.

2. Upon termination under this paragraph, the service shall:

a. Immediately notify the patient of the decision and the reasons for the decision.

b. Schedule a hearing, to be held on the next business day and in accordance with par. (d), on the decision to terminate and provide notice of the hearing to the patient.

c. After a hearing is held in accordance with par. (d), notify the patient of the hearing officer’s decision within one business day of the hearing.

d. Provide referrals to ensure a continuum of care for the client, including continued counseling, medication, withdrawal management, and other services, including risk reduction and outreach.

3. Facilities that are in the process of termination are not required to provide medically supervised withdrawal services to clients who are discharged involuntarily on an emergency basis, but referrals for assistance elsewhere must be provided in such circumstances.

(b) Non-emergency termination. In a non-emergency situation, the service must afford the client the following procedural rights in addition to the rights listed in s. 51.61, Stats., and ch. DHS 94:

1. Prior to initiating medically supervised withdrawal, the service shall provide the client with prompt written notice which shall contain:

a. A statement of the reasons for the proposed termination, such as violations of a specific rule or rules, non-compliance with treatment contract, and the particulars of the infraction including the date, time, and place.

b. Notification that the client has the right, within 2 business days following receipt of written notice, to submit a written request for a fair hearing on the proposed termination; if a fair hearing is requested the medically supervised withdrawal is stopped until the hearing occurs and a decision is rendered.

c. A copy of the service’s hearing procedures.

2. If a timely request for a hearing is made, arrange with the patient or patient’s advocate for a mutually convenient date and time for a hearing within 10 business days of receipt of the notice. Additional time to secure appropriate representation may be granted to the client under exceptional circumstances.

3. Afford the client the opportunity of medically supervised withdrawal. If the client chooses medically supervised withdrawal, the service shall provide medically supervised withdrawal, or make arrangements for appropriate medically supervised withdrawal in another OTP. The rate of dosage reduction shall be determined by the services medical director in accordance with the patient’s medical condition and the dosage level at which the client was medicated before the decision was made to terminate or suspend. In determining an appropriate course of withdrawal, the medical director shall review the record, consider the patient’s physical and mental health status, and, upon request of the client, may take into account the opinions of the patients other physicians and medical providers. If a hearing is requested by the patient, the medically supervised withdrawal shall cease until the hearing occurs and a decision is rendered.

4. If a patient is terminated for non-payment of fees, medically supervised withdrawal may begin immediately upon providing written notice of termination, and continue concurrent with client’s appeal, if any.

(c) Documentation of receipt of notice. The service shall document provision of notice to the patient by obtaining the signature of the staff person providing notice and by obtaining a signed, dated receipt from the patient. If the patient refuses to sign a receipt, the service shall document that refusal on its record of notice.

(d) Hearing procedures. The service shall ensure that hearings are conducted in accordance with the following procedures:

1. An impartial hearing officer shall preside over the hearing. The hearing officer may be any staff or other person not directly involved in the facts of the incident giving rise to the disciplinary proceedings or in the decision to commence the proceedings, provided that the persons involved in either the facts of the incident or in the decision to commence the proceedings shall not have authority over the hearing officer.

2. The patient may be represented at the hearing by any responsible adult of the client’s choosing. If the patient chooses to be represented by legal counsel, the patient must give the service at least 72 hours’ notice in advance of the hearing, so that the service may consult its own legal counsel prior to the hearing.

3. At a hearing, the service bears the burden of proving, by a preponderance of the evidence, that the alleged violation occurred.

4. The patient shall be entitled, upon request, to examine any documentary evidence in the possession of the service that pertains to the subject matter of the hearing.

5. The patient shall be entitled to call his or her own witnesses and to question any adverse witnesses.

6. The service shall make an audio recording of the hearing. The patient may also make an audio recording of the hearing at the patient’s expense.

7. The hearing officer shall make a decision within 7 business days after the hearing and will base the decision solely upon the information presented at the hearing. The decision shall be based upon the services policy and procedures in effect and posted at the time of the violation.

8. The hearing officer shall issue the decision in writing, and shall provide the patient or and patient’s representative, or both, with a copy of the decision. The decision shall include an explanation of the reasons for the decision, and instructions explaining how to file an appeal of an adverse decision to the department. The instructions shall inform the client that the client’s written request for an appeal constitutes the client’s consent to release information to the department.

(e) Department review of program decisions to terminate.

1. A patient has the right to appeal an adverse decision of a hearing officer to the department’s client rights office. The patient must request this appeal in writing to the department within 3 business days following the receipt of the adverse decision. This request must be postmarked within the 3 business day time frame. The patient’s written appeal shall contain the patient’s argument in support of the appeal. The department will either affirm or reverse the hearing officer’s decision, or remand the decision to a new hearing officer for a new hearing. The decision of the department shall be made as follows in writing:

a. In the case of an emergency termination, the department shall decide within one business day of receipt of the complete hearing record and written materials submitted by both parties.

b. In the case of a non-emergency termination, the department shall decide within 10 business days of the department’s receipt of the complete hearing record and written materials submitted by both parties. A service’s failure to submit the complete hearing record will result in a finding for the patient. The department shall deliver a written decision, outlining the reason(s) for the decision, to the patient, the patient’s advocate, and the service. The decision of the department is final.

2. In the case of a non-emergency termination, if the patient timely appeals the hearing decision, the service may not terminate the client or begin medically supervised withdrawal without first receiving, and ensuring that the client also receives, the department’s decision on appeal.

(f) Humane taper. The process of withdrawal from medication for administrative reasons shall be conducted in a humane manner as determined by the service physician, and referral shall be made to other treatment services.

(13) Take-home medication practices.

(a) Granting take-home privileges. During treatment, a patient may benefit from less frequent required visits for dosing. This shall be based on an assessment by the treatment staff. Time in treatment is not the sole consideration for granting take-home privileges. After consideration of treatment progress, the service physician shall determine if take-home doses are appropriate or if approval to take-home doses should be rescinded. Federal and State requirements that shall be adhered to by the SOTA and the service are as follows:

1. Take-home doses are not allowed during the first 30 days of treatment. Patients are expected to attend the service daily. Exception requests may be submitted for review when extenuating circumstances (i.e. pandemic) arise and will be reviewed and a determination made by the SOTA.

2. Take-home doses shall not be granted if the patient continues to use illicit drugs and if the primary counselor and the treatment team determine that the patient is not making progress in treatment and has continued drug use or legal problems.

3. Take-home doses shall only be provided when the patient is clearly adhering to the requirements of the service. The patient shall be expected to show responsibility for security and handling of take-home doses.

4. Service staff shall go over the requirements for take-home privileges with a patient before the take-home practice for self-dosing is implemented. Clinical staff shall require the patient to provide written acknowledgment that all the rules for self-dosing have been provided and understood at the time the review occurs.

5. Service staff may not use the level of the daily dose to determine whether a patient receives take-home medication.

(b) Treatment team recommendation. A treatment team of appropriate staff in consultation with a patient shall collect and evaluate the necessary information regarding a decision about take-home medication for the patient and make the recommendation to grant take-home privileges to the service physician.

(c) Service physician review. The rationale for approving, denying or rescinding take-home privileges shall be recorded in the patient’s case record and the documentation shall be reviewed, signed and dated by the service physician. Physician orders for take-home medication for substance use disorders shall expire every 90 days. The physician shall document how a patient meets all criteria in par. (d) 1. to 8. within the order for take-home medication and what phase level the patient is at for which medication.

(d) Service physician determination. The service physician shall determine whether, in the service physician’s reasonable clinical judgment, the patient has made substantial progress in rehabilitation and can responsibly handle narcotic drugs. In order to make this determination in the affirmative and grant take home privileges, the service physician must consider and attest to all of the following:

1. The patient is not abusing substances, including alcohol.

2. The patient keeps scheduled service appointments.

3. The patient exhibits no serious behavioral problems at the service.

4. The patient is not involved in criminal activity, such as drug dealing and selling take-home doses.

5. The patient has a stable home environment and social relationships.

6. The patient has met the applicable criteria for length of time in treatment provided in pars. (e) and (h).

7. The patient provides assurance that take-home medication will be safely stored in a locked metal box within the home.

8. The rehabilitative benefit to the patient in decreasing the frequency of service attendance outweighs the potential risks of diversion.

(e) Time in treatment criteria and exceptions. The time in treatment criteria under par. (h) shall be the minimum time before take-home medications will be considered unless there are exceptional circumstances and the service applies for and receives approval from the designated federal agency and the SOTA for a particular patient.

(f) Individual consideration of request. A request for take-home privileges shall be considered on an individual basis. No request for take-home privileges may be granted automatically to any patient.

(g) Additional criteria for 6-day take-home privilege. When a patient is considered for 6-day take-homes, the patient shall meet the following additional criteria:

1. The patient is employed, attends school, is a homemaker, or is disabled.

2. The patient is not known to have used or abused substances, including alcohol, in the previous year.

3. The patient is not known to have engaged in criminal activity in the previous year.

(h) Phases.

1. Methadone shall be provided on a take-home basis as follows:

a. For patient time in treatment starting day 31 through day 90, the patient shall be allowed no more than one take-home dose of medication per week.

b. For patient time in treatment starting day 91 through 180, the patient shall be allowed no more than 2 take-home doses of medication per week.

c. For patient time in treatment starting day 181 through day 270, the patient shall be allowed no more than 3 take-home doses of medication per week.

d. For patient time in treatment starting day 271 through day 365, the patient shall be allowed no more than 4 take-home doses of medication per week.

e. For patient time in treatment starting day 366 through day 730, the patient shall be allowed no more than 6 take-home doses of medication per week.

f. For patient time in treatment starting day 731 through completion of treatment, the patient shall be allowed no more than 13 take-home doses every 2 weeks.

2. Buprenorphine Oral Products shall be provided on a take-home basis as follows:

a. For patient time in treatment starting day 31 through day 60, the patient shall be allowed no more than 1 take-home dose of medication per week.

b. For patient time in treatment starting day 61 through day 90, the patient shall be allowed no more than 2 take-home doses of medication per week.

c. For patient time in treatment starting day 91 through day 120, the patient shall be allowed no more than 3 take-home doses of medication per week.

d. For patient time in treatment starting day 121 through day 240, the patient shall be allowed no more than 4 take-home doses of medication per week.

e. For patient time in treatment starting day 241 through day 365, the patient shall be allowed no more than 6 take-home doses of medication per week.

f. For patient time in treatment starting day 366 through completion of treatment, the patient shall be allowed no more than 13 take-home doses every 2 weeks.

(i) Denial or rescinding of approval. A service shall deny or rescind approval for take-home privileges for any of the following reasons:

1. Signs or symptoms of withdrawal.

2. Continued illicit substance use.

3. The absence of laboratory evidence of FDA-approved narcotic treatment in test samples, including serum levels.

4. Potential complications from concurrent disorders.

5. Ongoing or renewed criminal behavior.

6. An unstable home environment.

(j) Review.

1. The service physician shall review the status of every patient provided with take-home medication at least every 90 days and more frequently if clinically indicated.

2. The service treatment team shall review the merits and detriments of continuing a patient’s take-home privilege and shall make appropriate recommendations to the service physician as part of the service physician’s 90-day review.

3. Service staff shall use biochemical monitoring to ensure that a patient with take-home privileges is not using illicit substances and is consuming the FDA-approved narcotic provided.

4. Service staff may not recommend denial or rescinding of a patient’s take-home privilege to punish the patient for an action not related to meeting requirements for take-home privileges.