Chapter DHS 35

DHS 35.12(4) (4) 

DHS 35.12(4)(a) (a) Within 60 days of the receipt of a request for waiver, the department shall grant or deny the waiver in writing. If the department denies a request for a waiver or variance, or revokes a waiver or variance, the reason for the denial or revocation shall be included in the notice.

DHS 35.12(4)(b) (b) The department may revoke a waiver or variance if any of the following occurs:

DHS 35.12(4)(b)1. 1. The actions taken as a result of the waiver or variance have or will adversely affect the health, safety or welfare of a consumer.

DHS 35.12(4)(b)2. 2. The clinic has failed to comply with the variance as granted.

DHS 35.12(4)(b)3. 3. The clinic notifies the department that it wishes to relinquish the waiver or variance.

DHS 35.12(4)(b)4. 4. There is a change in applicable law.

DHS 35.12(4)(b)5. 5. For any other reason the department finds the revocation is necessary to protect the health, safety, or welfare of a consumer.

DHS 35.12 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

subch. III of ch. DHS 35 Subchapter III — Personnel

DHS 35.123 DHS 35.123 Staffing requirements for clinics.

DHS 35.123(1) (1) Each clinic shall have a clinic administrator who is responsible for clinic operations, including ensuring that the clinic is in compliance with this chapter and other applicable state and federal law. A clinic administrator may be a licensed treatment professional or mental health practitioner.

DHS 35.123(2) (2) In addition to the clinic administrator, the clinic shall have a sufficient number of qualified staff members available to provide outpatient mental health services to consumers admitted to care. Except as provided in s. DHS 35.12 (2m), the clinic shall implement any one of the following minimum staffing combinations to provide outpatient mental health services:

DHS 35.123(2)(a) (a) Two or more licensed treatment professionals who combined are available to provide outpatient mental health services at least 60 hours per week.

DHS 35.123(2)(b) (b) One or more licensed treatment professionals who combined are available to provide outpatient mental health services at least 30 hours per week and one or more mental health practitioners or recognized psychotherapy practitioners who combined are available to provide outpatient mental health services at least 30 hours per week.

DHS 35.123(2)(c) (c) One or more licensed treatment professionals who combined are available to provide outpatient mental health services at least 37.5 hours per week, and at least one psychiatrist or advanced practice nurse prescriber who provides outpatient mental health services to consumers of the clinic at least 4 hours per month.

DHS 35.123(2m) (2m) If a clinic has more than one office, both the clinic as a whole and its main office shall comply with the requirements of sub. (2).

DHS 35.123(3) (3) If a clinic provides services to persons 13 years old or younger, the clinic shall have staff qualified by training and experience to work with children and adolescents.

DHS 35.123(4) (4) A clinic that is certified before June 1, 2009 shall meet the requirements of subs. (1) and (3) upon June 1, 2009, but shall have until January 1, 2012 to meet the minimum staffing requirements under sub. (2).

DHS 35.123(5) (5) A person whose professional license is revoked, suspended, or voluntarily surrendered may not be employed or contracted with as a mental health professional, or a prescriber. A person whose professional license is limited or restricted, may not be employed or contracted with to practice in areas prohibited by the limitation or restriction.

DHS 35.123 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; correction to numbering of (4) and (5) made under s. 13.92 (4) (b) 1., Stats., Register May 2009 No. 641.

DHS 35.127 DHS 35.127 Persons who may provide psychotherapy services through an outpatient mental health clinic.

DHS 35.127(1) (1) Any mental health professional may provide psychotherapy to consumers through a clinic required to be certified under this chapter.

DHS 35.127(2) (2) A qualified treatment trainee may provide psychotherapy to consumers only under clinical supervision as defined under s. DHS 35.03 (5) (a).

DHS 35.127(3) (3) A clinic may choose to require clinical supervision of a mental health practitioner or recognized psychotherapy practitioner.

DHS 35.127(4) (4) A person who has a suspended, revoked, or voluntarily surrendered professional license may not provide psychotherapy to consumers. A person whose license or certificate is limited or restricted, may not provide psychotherapy under circumstances prohibited by the limitation or restriction.

DHS 35.127 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.13 DHS 35.13 Personnel policies. The clinic shall have and implement written personnel policies and procedures that ensure all of the following:

DHS 35.13(1) (1) Each staff member who provides psychotherapy or who prescribes medications is evaluated to determine if the staff member possesses current qualifications and demonstrated competence, training, experience and judgment for the privileges granted to provide psychotherapy or to prescribe medications for the clinic.

DHS 35.13(2) (2) Compliance with the caregiver background check and misconduct reporting requirements in s. 50.065, Stats., and ch. DHS 12, and the caregiver misconduct reporting and investigation requirements in ch. DHS 13.

DHS 35.13 Note Note: Forms for conducting a caregiver background check including the background information disclosure form may be obtained from the department’s website at http://dhs.wisconsin.gov/caregiver/index.htm or by writing the department at Office of Caregiver Quality, Division of Quality Assurance, P.O. Box 2969, Madison, WI 53701-2969. Phone: [phone], Fax: [phone].

DHS 35.13(3) (3) A record is maintained for each staff member and includes all of the following:

DHS 35.13(3)(a) (a) Confirmation of an applicant’s current training or professional license or certification, if a training or professional license or certification is necessary for the staff member’s prescribed duties or position. All limitations and restrictions on a staff member’s license shall be documented by the clinic.

DHS 35.13(3)(b) (b) The results of the caregiver background check including a completed background information disclosure form for every background check conducted, and the results of any subsequent investigation related to the information obtained from the background check.

DHS 35.13(3)(c) (c) A vita of training, work experience and qualifications for each prescriber and each person who provides psychotherapy.

DHS 35.13 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.14 DHS 35.14 Clinical supervision and clinical collaboration.

DHS 35.14(1) (1) 

DHS 35.14(1)(a) (a) The clinic administrator shall have responsibility for administrative oversight of the job performance and actions of each staff member and require each staff member to adhere to all laws and regulations governing the care and treatment of consumers and the standards of practice for their individual professions.

DHS 35.14(1)(b) (b) Each clinic shall implement a written policy for clinical supervision as defined under s. DHS 35.03 (5), and clinical collaboration as defined under s. DHS 35.03 (4). Each policy shall address all of the following:

DHS 35.14(1)(b)1. 1. A system to determine the status and achievement of consumer outcomes, which may include a quality improvement system or a peer review system to determine if the treatment provided is effective, and a system to identify any necessary corrective actions.

DHS 35.14(1)(b)2. 2. Identification of clinical issues, including incidents that pose a significant risk of an adverse outcome for one or more consumers of the outpatient mental health clinic that should warrant clinical collaboration, or clinical supervision that is in addition to the supervision specified under ch. MPSW 4, 12, or 16, or Psy 2, or for a recognized psychotherapy practitioner, in accordance with s. DHS 35.03 (5) (a), whichever is applicable.

DHS 35.14(2) (2) Except as provided under sub. (4) (b), the clinic’s policy on clinical supervision shall be in accordance with ch. MPSW 4, 12, or 16, or Psy 2, or for a recognized psychotherapy practitioner, whichever is applicable. The clinic’s policy on clinical collaboration shall require one or more of the following:

DHS 35.14(2)(a) (a) Individual sessions, with staff case review, to assess performance and provide feedback.

DHS 35.14(2)(b) (b) Individual side-by-side session while a staff member provides assessments, service planning meetings or outpatient mental health services and in which other staff member assesses, and gives advice regarding staff performance.

DHS 35.14(2)(c) (c) Group meetings to review and assess quality of services and provide staff members advice or direction regarding specific situations or strategies.

DHS 35.14(2)(d) (d) Any other form of professionally recognized method of clinical collaboration designed to provide sufficient guidance to assure the delivery of effective services to consumers by the staff member.

DHS 35.14(3) (3) Clinical supervision and clinical collaboration records shall be dated and documented with the signature of the person providing these functions in a supervision or collaboration record, or in the staff record of each staff member who attends the session or review. If clinical supervision or clinical collaboration results in a recommendation for a change to a consumer’s treatment plan, the recommendation shall be documented in the consumer file.

DHS 35.14(4) (4) 

DHS 35.14(4)(a) (a) A qualified treatment trainee who provides psychotherapy shall receive clinical supervision.

DHS 35.14(4)(b) (b) If any staff member, including a staff member who is a substance abuse counselor-in training, substance abuse counselor, or clinical abuse counselor, provides services to consumers who have a primary diagnosis of substance abuse, the staff member shall receive clinical supervision from a clinical supervisor as defined under s. SPS 160.02 (7).

DHS 35.14 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; correction in (4) (b) made under s. 13.92 (4) (b) 7., Stats., Register November 2011 No. 671.

DHS 35.15 DHS 35.15 Orientation and training.

DHS 35.15(1) (1) General requirement. The clinic administrator shall ensure each staff member receives initial and continuing training that enables the staff member to perform staff member’s duties effectively, efficiently, and competently. Documentation of training shall be made available to department staff upon request.

DHS 35.15(2) (2) Orientation.

DHS 35.15(2)(a) (a) The clinic shall maintain documentation that each staff member who is a mental health professional and who is new to the clinic has completed the training requirements specified under par. (b), either as part of orientation to the clinic or as part of prior education or training. The clinic administrator shall require all other staff members to complete only the orientation training requirements specified under par. (b) that are necessary, as determined by the clinic administrator, for the staff member to successfully perform the staff member’s assigned job responsibilities.

DHS 35.15(2)(b) (b) The orientation training requirements under this subsection are:

DHS 35.15(2)(b)1. 1. A review of the pertinent parts of this chapter and other applicable statutes and regulations.

DHS 35.15(2)(b)2. 2. A review of the clinic’s policies and procedures.

DHS 35.15(2)(b)3. 3. Cultural factors that need to be taken into consideration in providing outpatient mental health services for the clinic’s consumers.

DHS 35.15(2)(b)4. 4. The signs and symptoms of substance use disorders and reactions to psychotropic drugs most relevant to the treatment of mental illness and mental disorders served by the clinic.

DHS 35.15(2)(b)5. 5. Techniques for assessing and responding to the needs of consumers who appear to have problems related to trauma; abuse of alcohol, drug abuse or addiction; and other co-occurring illnesses and disabilities.

DHS 35.15(2)(b)6. 6. How to assess a consumer to detect suicidal tendencies and to manage persons at risk of attempting suicide or causing harm to self or others.

DHS 35.15(2)(b)7. 7. Recovery concepts and principles that ensure services, and supports connection to others and to the community.

DHS 35.15(2)(b)7m. 7m. Appropriate delivery of telehealth services, including issues ensuring privacy and confidentiality of recipient information and communications.

DHS 35.15(2)(b)8. 8. Any other subject that the clinic determines is necessary to enable the staff member to perform the staff member’s duties effectively, efficiently, and competently.

DHS 35.15(3) (3) Maintaining orientation and training policies. A clinic shall maintain in its central administrative records the most current copy of its orientation and training policies.

DHS 35.15 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; CR 23-053: am. (2) (b) 7m. Register September 2023 No. 813, eff. 10-1-23.

subch. IV of ch. DHS 35 Subchapter IV — Outpatient Mental Health Services

DHS 35.16 DHS 35.16 Admission.

DHS 35.16(1) (1) The clinic shall establish written selection criteria for use when screening a consumer for possible admission. The criteria may include any of the following limitations as applicable:

DHS 35.16(1)(a) (a) Sources from which referrals may be accepted by the clinic.

DHS 35.16(1)(b) (b) Restrictions on acceptable sources of payment for services, or the ability of a consumer or a consumer’s family to pay.

DHS 35.16(1)(c) (c) The age range of consumers whom the clinic will serve based on the expertise of the clinic staff members.

DHS 35.16(1)(d) (d) Diagnostic or behavioral requirements that the clinic will apply in deciding whether or not to admit a consumer for treatment.

DHS 35.16(1)(e) (e) Any consumer characteristics for which the clinic has been specifically designed, including the nature or severity of disorders that can be managed on an outpatient basis by the clinic, and the expected length of time that services may be necessary.

DHS 35.16(2) (2) A clinic shall refer any consumer not meeting the clinic’s selection criteria for admission to appropriate services.

DHS 35.16(3) (3) If a clinic establishes priorities for consumers to be served, a waiting list for consumers to be admitted, or a waiting list for consumers who have been admitted but resources to provide services to these consumers are not yet available, the priorities or the procedures for the operation of the waiting list shall be maintained in writing and applied fairly and uniformly.

DHS 35.16(4) (4) Only a licensed treatment professional, or a recognized psychotherapy practitioner, may diagnose a mental illness of a consumer on behalf of a clinic. The licensed treatment professional, or recognized psychotherapy practitioner shall document, in the consumer file, the recommendation for psychotherapy specifying the diagnosis; the date of the recommendation for psychotherapy; the length of time of the recommendation; the services that are expected to be needed; and the name and signature of the person issuing the recommendation for psychotherapy.

DHS 35.16(5) (5) If a clinic provides substance use services to a consumer, the clinic shall use a department approved placement criteria tool to determine if a consumer who has a co-occurring substance use disorder requires substance abuse treatment services. If the consumer is determined to need a level of substance use services that are above the level of substance use services that can be provided by the clinic, the consumer shall be referred to an appropriate department certified provider.

DHS 35.16 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09; CR 14-066: renum. (4) (a) to (4), r. (4) (b) Register August 2015 No. 716, eff. 9-1-15.

DHS 35.165 DHS 35.165 Emergency services.

DHS 35.165(1) (1) The clinic shall have and implement a written policy on how the clinic will provide or arrange for the provision of services to address a consumer’s mental health emergency or crisis during hours when its offices are closed, or when staff members are not available to provide outpatient mental health services.

DHS 35.165 Note Note: The phrase “available to provide outpatient mental health services” is defined under s. DHS 35.03 (2).

DHS 35.165(2) (2) The clinic shall include, in its written policies, the procedures for identifying risk of attempted suicide or risk of harm to self or others.

DHS 35.165 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.17 DHS 35.17 Assessment.

DHS 35.17(1) (1) 

DHS 35.17(1)(a) (a) A mental health professional, shall complete an initial assessment of a consumer before a second meeting with a staff member. The information collected during the initial assessment shall be sufficient to identify the consumer’s need for outpatient mental health services.