Chapter DHS 40

DHS 40.07(2)(b)2. 2. A program shall inform the youth or legal representative of the proposed services and supports within the treatment plan and provide a written copy of the plan.

DHS 40.07(2)(b)3. 3. Transition services shall consider the needs and preferences of the youth or legal representative.

DHS 40.07(2)(c) (c) To ensure that the proposed services reflect a partnership between the youth or legal representative and program staff, a program shall do all of the following, as available and needed:

DHS 40.07(2)(c)1. 1. Employ, contract, or coordinate for the services of parent peer specialists who can help a youth or legal representative understand the operations of the program and support effective input in the planning and implementation of services.

DHS 40.07(2)(c)2. 2. Establish flexible schedules for meetings and activities so that legal representatives can participate without taking time off from work.

DHS 40.07(2)(c)3. 3. Make arrangements for transportation to the program if possible when legal representatives lack the ability to travel to the program using their own resources.

DHS 40.07(2)(c)4. 4. Adjust program services and activities to accommodate cultural and linguistic preferences and needs.

DHS 40.07(2)(c)5. 5. Use technological resources to encourage participation when in-person meetings are not possible, consistent with requirements to ensure confidentiality of treatment information.

DHS 40.07(3) (3) General requirements. In addition to services that are necessary to achieve the treatment objectives identified in each youth’s assessment and individual treatment plan, all of the following minimum requirements services shall be provided:

DHS 40.07(3)(a) (a) Community-based program. A community-based program shall offer all of the following:

DHS 40.07(3)(a)1. 1. Individual, group and family psychotherapy provided by trained mental health professionals.

DHS 40.07(3)(a)2. 2. A structured therapeutic milieu supervised by a clinical coordinator.

DHS 40.07(3)(a)3. 3. Care coordination.

DHS 40.07(3)(a)4. 4. Support services.

DHS 40.07(3)(a)5. 5. Crisis response services.

DHS 40.07(3)(a)6. 6. Implementation of transition services designed to support the reintegration of a youth who is completing the program into family, community and school activities and to prevent recurrence of the problems which led to the original placement in the program.

DHS 40.07(3)(b) (b) Intensive hospital-based programs. An intensive hospital-based program shall offer minimum required services under par. (a) and shall increase the hours of direct clinical services under s. DHS 40.10 (3) (b) and increase the hours of operation under s. DHS 40.10 (4) (b) to meet the needs of youth who have severe symptomology and need closer supervision.

DHS 40.07(4) (4) Support services. Each program shall provide support services that include all of the following:

DHS 40.07(4)(a) (a) Methods for documenting, measuring, and tracking progress on measurable objectives contained in a youth’s treatment plan.

DHS 40.07(4)(b) (b) Strategies for all of the following:

DHS 40.07(4)(b)1. 1. Reducing or eliminating the use of emergency safety interventions.

DHS 40.07(4)(b)2. 2. Teaching and increasing positive replacement behaviors, based on baseline measures at intake.

DHS 40.07(4)(b)3. 3. Building relationships between youth and staff members that promote trust and safety.

DHS 40.07(4)(b)4. 4. Empowering youth to take responsibility for their behavior and regulating their emotions.

DHS 40.07(4)(b)5. 5. Sensory interventions within the treatment milieu to enhance functioning and assist with behavioral challenges.

DHS 40.07(5) (5) Voluntary time out. Support services shall be provided to a youth prior to using a voluntary time out. Voluntary time out should be used as a least restrictive measure, prior to involuntary seclusion or physical restraint, unless there is imminent danger due to a youth’s aggression to self or others. Voluntary time out shall be encouraged for the shortest time possible and only for the length of time necessary for the youth to de-escalate or regulate his or her emotions. Programs shall encourage voluntary time out for youth who show signs of agitation or anxiety.

DHS 40.07 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (1) (g) made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: cr. (1) (fm) Register September 2023 No. 813, eff. 10-1-23; CR 23-046: am. (2) (a) 2. Register April 2024 No. 820, eff. 5-1-24.

DHS 40.08 DHS 40.08 Emergency safety interventions.

DHS 40.08(1) (1) Prohibited interventions. Mechanical restraints, with the exception of procedures in sub. (5) (e) and chemical restraints are prohibited.

DHS 40.08(2) (2) General requirements for seclusion and physical restraint. Seclusion and physical restraint shall comply with the requirements under s. 51.61 (1) (i), Stats., s. DHS 94.10, and this chapter.

DHS 40.08(3) (3) Staff requirements. Seclusion and physical restraint shall only be administered by program staff members who have completed orientation described in s. DHS 40.10 (6) (b).

DHS 40.08(4) (4) Administration requirements. Seclusion and physical restraint may only be administered when all of the following requirements are met in addition to the requirements under s. 51.61 (1) (i), Stats., and s. DHS 94.10:

DHS 40.08(4)(a) (a) When all other less restrictive methods have been exhausted.

DHS 40.08(4)(b) (b) For the shortest time possible and only until the youth is no longer a danger to self or others.

DHS 40.08(4)(c) (c) In a manner that is attentive to, and respectful of the trauma history, dignity, and civil rights of the youth.

DHS 40.08(4)(d) (d) To avoid or cause the least possible physical or emotional discomfort, harm, and pain to the youth.

DHS 40.08(4)(e) (e) Allowing adequate access to bathroom facilities, drinking water, and necessary medication.

DHS 40.08(5) (5) Specific requirements for seclusion.

DHS 40.08(5)(a) (a) Program staff members shall provide uninterrupted supervision and monitoring of the youth and entire seclusion area during seclusion by being in the room with the youth or by observation through a window into the room.

DHS 40.08(5)(b) (b) A program shall maintain an incident log to document the use of seclusion. The log shall include the time when the seclusion began, the youth’s behaviors and staff member’s response to those behaviors every 5 minutes, and the time seclusion ended.

DHS 40.08(5)(c) (c) Seclusion rooms shall be free of objects or fixtures with which the youth could inflict bodily harm.

DHS 40.08(5)(d) (d) Only a single youth may be placed in a seclusion room.

DHS 40.08(5)(e) (e) A youth may only be kept in the seclusion area by means of one of the following:

DHS 40.08(5)(e)1. 1. A staff member is in a position, such as in a doorway, to prevent a youth from leaving the seclusion area.

DHS 40.08(5)(e)2. 2. A staff member physically holds a door shut to a seclusion room.

DHS 40.08(5)(e)3. 3. A door to a seclusion room is latched by positive pressure applied by a staff member’s hand without which the latch would spring back allowing the door to open on its own accord, except that a hospital-based program may use a magnetic door lock or a lock which requires the turn of a knob to unlock a door. Other designs of door locks shall not be used, including padlock, key lock, or other locks of similar design.

DHS 40.08(6) (6) Specific requirements for physical restraint.

DHS 40.08(6)(a) (a) Physical restraint shall only be administered to a youth during an emergency, when there is a serious threat of violence to other youth or a staff member, personal injury, or attempted suicide.

DHS 40.08(6)(b) (b) At a minimum, two staff members trained in the use of emergency safety interventions shall be physically present during the administration of physical restraint, and shall continually monitor the condition of the youth and the safe use of physical restraint throughout the duration of the intervention.

DHS 40.08(6)(c) (c) Methods of physical restraint that are likely to cause bodily harm are prohibited, such as:

DHS 40.08(6)(c)1. 1. Pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, such as straddling or sitting on the torso.

DHS 40.08(6)(c)2. 2. Pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, such as choke holds or sleeper holds.

DHS 40.08(6)(c)3. 3. Wrestling holds or martial arts techniques.

DHS 40.08(6)(c)4. 4. Covering the face with any object, such as a pillow, towel, washcloth, blanket, or other fabric.

DHS 40.08(6)(c)5. 5. Pain or pressure points.

DHS 40.08(6)(c)6. 6. Hyperextension of limbs, fingers, or neck.

DHS 40.08(6)(c)7. 7. Forcible take downs from a standing position to the floor.

DHS 40.08(6)(c)8. 8. Restraint in a prone position.

DHS 40.08(6)(c)9. 9. Restraint in a supine position.

DHS 40.08(6)(c)10. 10. Restraint in a vertical position, with upper body pressed against a wall or hard surface.

DHS 40.08(6)(c)11. 11. Any other physical restraint that is not administered during an emergency, that is administered for longer than necessary to prevent immediate injury to a youth or others, or that is administered for a purpose other than to prevent immediate injury to a youth or others.

DHS 40.08(6)(d) (d) Immediately upon the termination of a physical restraint, a medical staff member, such as a physician, advanced practice nurse prescriber, physician assistant, advanced practice nurse, or registered nurse, shall conduct a follow-up assessment of the condition of the youth to ensure that the youth was not injured and shall document the finding of the assessment in the youth’s file. If a staff member who is a doctor or nurse is not present on site, a licensed treatment professional shall conduct the face-to-face assessment immediately upon termination of the physical restraint and notify a medical staff member.

DHS 40.08(6)(e) (e) If any injury is noted following a physical restraint, a staff member shall notify the youth’s legal representative, if any, and make a referral for medical care.

DHS 40.08(7) (7) Debriefing.

DHS 40.08(7)(a) (a) Following a seclusion or restraint, a staff member shall talk with the youth about each of the following:

DHS 40.08(7)(a)1. 1. The circumstances that contributed to the seclusion or physical restraint and what could have been handled differently by the staff member.

DHS 40.08(7)(a)2. 2. The youth’s psychological well-being and the emotional impact of the intervention.

DHS 40.08(7)(a)3. 3. What modifications can be made in the youth’s services or treatment plan to prevent future seclusion and physical restraint.

DHS 40.08(7)(b) (b) The debriefing should occur within 24 hours following a seclusion and restraint, with the following exceptions:

DHS 40.08(7)(b)1. 1. When clinically contraindicated.

DHS 40.08(7)(b)2. 2. When the 24 hour period falls during non-programming time such as on a weekend or holiday, then debriefing shall occur on the next programming day.

DHS 40.08(7)(b)3. 3. When a youth is suspended or discharged from programming following the incident and debriefing is contraindicated due to a serious risk of harm by the youth to others or to staff.

DHS 40.08(7)(c) (c) A program shall notify a youth’s legal representative, if any, of any seclusion or physical restraint on the same day that it was administered to the youth. The program shall document in the youth’s file any situation in which notification has been attempted and the program has been unable to contact the legal representative.

DHS 40.08(7)(d) (d) Each administration of seclusion or physical restraint shall be documented in the youth’s chart and shall specify all of the following:

DHS 40.08(7)(d)1. 1. Less restrictive interventions attempted prior to the seclusion or physical restraint.

DHS 40.08(7)(d)2. 2. Events precipitating the seclusion or physical restraint.

DHS 40.08(7)(d)3. 3. Length of time the seclusion or physical restraint was used.

DHS 40.08(7)(d)4. 4. Assessment of the appropriateness of the seclusion or physical restraint based on threat of harm to self or others.

DHS 40.08(7)(d)5. 5. Assessment of any physical injury to the youth, other clients, or to staff members.

DHS 40.08(7)(d)6. 6. The youth’s response to the emergency safety intervention.

DHS 40.08(7)(e) (e) A licensed treatment professional shall review all seclusion and physical restraint documentation prior to the end of the shift in which the intervention occurred and determine whether changes to the youth’s safety plan or treatment plan are necessary.

DHS 40.08(7)(f) (f) If seclusion or physical restraint is administered to a youth more than three times over a period of five days, or in a single instance for more than 30 minutes within 24 hours, the clinical coordinator, or designee, shall do all of the following:

DHS 40.08(7)(f)1. 1. Convene staff to discuss the emergency situation that required seclusion or physical restraint, including the precipitating factors that led up to the intervention and any alternative strategies that might have prevented the use of seclusion or physical restraint in those situations.

DHS 40.08(7)(f)2. 2. Convene staff to discuss the procedures, if any, to be implemented to prevent further administration of seclusion or physical restraint.

DHS 40.08(7)(f)3. 3. Convene staff to discuss the outcome of the seclusion or physical restraint including any injuries.

DHS 40.08(7)(f)4. 4. Convene the youth’s interdisciplinary treatment team to review the individualized treatment plan and make any necessary revisions to reduce the need for and likelihood of further use of seclusion or physical restraint, and document the discussion and any resulting changes to the plan in the youth’s chart.

DHS 40.08(7)(f)5. 5. Determine whether a higher level of care is required for the youth and if a referral for inpatient or residential placement is necessary.

DHS 40.08(8) (8) Reporting.

DHS 40.08(8)(a) (a) Programs shall report all incidences of seclusion, physical restraint, injury, and involvement of law enforcement to the department within 24 hours of the incident occurring. Reporting shall be completed through the department’s online reporting system.