(b) The department will send the re-certification materials to the provider, which the provider is expected to fill out and submit to the department according to instructions provided.
(c) A certification will be suspended or terminated if biennial reports are not submitted prior to the end of the biennial cycle.
(8) YCSF INSPECTIONS. The YCSF shall permit unannounced, on-site inspections of the site by the department to conduct program reviews, complaint or death investigations involving any aspect of the YCSF, or to determine a YCSF’s progress in correcting a deficiency cited by the department. The department may use a random selection process for reviewing client records during program reviews. Complaint-driven program reviews shall include the records related to the complaint and may include additional records.
(9) NOTICE OF DEFICIENCIES.
(a) If the department determines that a YCSF has a deficiency, the department shall issue a notice of deficiency to the YCSF within 10 business days. The notice of deficiency may place restrictions on the YCSF or its activities, or suspend or terminate the YCSF’s certification, pursuant to s. DHS 50.03 (10). (b) The YCSF shall submit a plan of correction to the department within 10 business days as indicated in the notice of deficiency. The plan of correction shall propose the specific steps the YCSF will take to correct the deficiency, the timelines within which the corrections will be made, and the licensed professional staff members who will implement the plan and monitor for future compliance.
(c) If the department determines that the plan of correction submitted by the YCSF does not adequately address deficiencies listed in the notice of deficiency, the department may request a new plan of correction from the YCSF or may impose a plan of correction.
(10) TERMINATION AND SUSPENSION OF CERTIFICATION.
(a) The department may terminate certification at any time for major deficiency by issuing a notice of termination to the YCSF. The notice shall specify the reason for the department action and the appeal information under s. DHS 50.03(11). (b) The department may suspend a YCSF’s certification if the department determines that immediate action is required to protect the health, safety, and welfare of youth. Written notice of suspension shall specify the reason for the department action and the date the action becomes effective. Within 10 business days after the order is issued, the department shall either lift or impose conditions on the suspension of the YCSF’s certification or proceed to terminate the YCSF’s certification.
(11) APPEALS. If the department denies, suspends, or terminates certification, or imposes conditions on a certification, the YCSF may request a hearing under ch. 227, Stats.
DHS 50.04 Variance and waiver.
DHS 83.03(1)(a)(a) “Variance" means an alternate means of meeting a requirement in this chapter. DHS 83.03(1)(b)(b) “Waiver" means an exemption from a requirement of this chapter. DHS 83.03(2)(2) The department may grant a waiver or variance if the department determines that the proposed waiver or variance will not diminish the effectiveness of the services provided and will not jeopardize the health, safety, welfare, or rights of any youth. The department may specify a timeframe for the waiver. A request for a variance or waiver must be submitted on a form provided by the department. (3) The department may rescind or limit a waiver or variance at any time by notifying the YCSF, if any of the following occurs:
DHS 83.03(3)(a)(a) The department determines the waiver or variance has adversely affected or likely may adversely affect the health, safety or welfare of the youths. DHS 83.03(3)(b)(b) The YCSF fails to comply with any of the conditions of the waiver or variance as granted.
(4) The department shall inform a YCSF in writing if it rescinds or limits a waiver or variance.
DHS 50.05 Program Statement. A program statement shall contain all of the following:
(1) A description of how the YCSF fits into a continuum of care for youth crisis stabilization and treatment services.
(2)
A description of services the program intends to provide, including all of the following: (a) Referral and screening procedures.
(b) Intake procedures, including medication review.
(c) Assessment and treatment planning, including assessment of risk factors and safety planning for youth.
(d) Treatment services, including crisis prevention and emotional regulation, including, if applicable, a description of any services that will be delivered in a group setting.
(e) Care coordination.
(f) Discharge planning, including any linkages and follow-up.
(3) A description of the therapeutic milieu the program proposes to create, its intended therapeutic benefits, and the rationale supporting its use for the youth served by the YCSF.
(a) Describe use of any evidence-based practices and non-traditional services. The description should include a rationale for how the services will help the youth population achieve and sustain positive outcomes.
(b) A plan for coordination of any services in s. DHS 50.05 (2) that will be provided through outside providers, including with any of a youth’s current providers.
(4) A description of how the YCSF and its services are trauma-informed, strengths-based, and culturally responsive.
(5) A description of how the YCSF encourages involvement of families and caregivers in treatment planning and services, and involves individuals authorized to participate in the treatment planning and services.
(6) A description of the YCSF’s process for communicating with a youth’s school or educational setting and the measures it will take to facilitate a youth’s ability to stay up to date in educational expectations.
(7) The proposed schedule of the program, including any times allocated for treatment, recreation, study time, and meals.
(8) The YCSF’s proposal for meeting staffing level requirements in s. DHS 50.07, the qualifications and roles for each position, and an analysis showing that staffing is adequate to meet the needs of the youth that the program proposes to serve.
(9) A description of food service and how it will be provided, including at least three meals a day and snacks.
(10) A description of how the program will offer appropriate indoor and outdoor recreation activities.
(11) A description of methods to evaluate services.
Subchapter II - Program Requirements
DHS 50.06 Required Policies. A YCSF must have written policies and procedures for the following:
(1) Admission policy and criteria, including ages and gender of youth served, and how bedrooms will be allocated.
(2) Utilization review policy addressing determination of need and length of stay, frequency of review, and other utilization policy as needed. The YCSF is meant to be a short-term crisis stabilization facility. If utilization reviews show that a youth requires stabilization longer than a 30-day period, approval from the department must be obtained.
(Note) Approval may be requested at: https://www.dhs.wisconsin.gov/mh/ycsf.htm.
(3) Policy on prescriber consulting relationships and processes to access consultation with a physician, psychiatrist, physician’s assistant, or advanced practice nurse prescriber, to prescribe or consult on psychiatric medications of youths. This can include a youth’s own provider.
(4) Policy on how medications will be stored, managed, and administered, and which staff is responsible. A description of how medical conditions, if any, will be managed.
(5) Policy on medical emergencies.
(6) Policy on clinical supervision, per s. DHS 50.09.
(7) Policies for youths’ personal possessions, communication devices including phones, electronics usage, room searches, or other applicable policies.
(8) Facility rules, provided to youth and staff.
(9) Where client records will be maintained and how confidentiality requirements of those records will be safeguarded, as required under s. DHS 50.14.
(10) Policy on how the YCSF will address safety concerns specific to the youth being served.
(11) Policy on emergency safety interventions. This policy must comply with s. DHS 50.12. It must specify alternative interventions, best practices, and how the YCSF plans to implement emergency safety interventions. If seclusion or restraint will be used, it must provide a description of where the intervention will occur and how it will be handled procedurally. DHS 50.07 Personnel.
(1) POLICIES.
(a) A YCSF shall have written personnel policies.
(b) A YCSF shall maintain written documentation of employee qualifications and shall make that information available upon request for review by youths and their representatives or parents, and by the department.
(2) GENERAL QUALIFICATIONS.
(a) Qualified staff shall comply with s. DHS 34.21 (3) (b) 1. to 19. and must follow current department of safety and professional services standards for licensure and scope of practice. (b) Peer specialists or parent peer specialists must be trained in accordance with s. DHS 34.21 (8) (a) to (d). (c) Each staff member shall have the professional certification, training, experience, and ability to carry out his or her assigned duties as documented through the following steps:
1. Each applicant must pass a state background check as provided in s. 50.065, Stats. and ch. DHS 12, before being allowed to work for the YCSF. If the applicant lived in another state, a background check shall be obtained from that state. 2. Programs shall comply with caregiver misconduct reporting and investigation requirements in ch. DHS 13. 3. Each staff responsible for transporting youth shall have a valid Wisconsin driver’s license and a driving record free of any one of the violations specified in ss. 346.62 or 346.63, Stats, in the past 12 months. (Note) For a state of Wisconsin background check, obtain the name, sex, race, and date of birth of the person about whom you are requesting the check. Information on the process and fees for a background check can be found online at https://www.dhs.wisconsin.gov/caregiver/cbcprocess.htm.
(3) REQUIRED PERSONNEL.
(a) Program administrator. Each YCSF shall have a program administrator who is responsible for the overall YCSF operations and ensuring that the YCSF is in compliance with this chapter and other applicable state and federal laws.
(b) Clinical coordinator. Each YCSF shall have a clinical coordinator who is responsible for the mental health services provided by the program and 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. The clinical coordinator shall be qualified under s. DHS 34.21 (3) (b) 1. to 8. The program administrator may also serve as the clinical coordinator. (c) Required designee. The program administrator shall identify one or more staff members to whom authority may be delegated in the absence of the clinical coordinator. The designee must be qualified under s. DHS 34.21 (3) (b) 1. to 8. (d) Staffing requirements.
1. The program administrator, clinical coordinator, or designee must be available for consultation 24/7 either on site, by phone, or by other means.
2. At all times that youth are present at a YCSF, the program shall have a minimum of two staff members present that are qualified under s. DHS 50.07 (2). At least one of the two staff members present must meet one of the requirements from s. DHS 34.21 (3) (b) 1. to 14. DHS 50.08 Orientation and Training.
(1) Initial and ongoing orientation and training requirements must comply with s. DHS 34.21 (8) (a) to (d).
(2) Training must include review of ch. DHS 50, including review and training on all policy and procedures, program statement, and other pertinent information.
(3) Training must include content specific to youth in crisis and their treatment needs.
(4) Training for standard precautions, fire safety, first aid and choking, and medication administration and management is required and must comply with ss. DHS 83.20 (1) and (2).
(5) Training must include emergency safety interventions per s. DHS 50.12 and include de-escalation techniques, redirection, and other preventative techniques.
(6) Staff must be trained on mandated reporting requirements. YCSF staff are considered mandated reporters under ss. 48.981 (2) (a) to (c), Stats.
