DHS 75.16DHS 75.16 Applicability of treatment service general requirements. This subchapter establishes general requirements that apply to the 11 types of community substance use treatment services under ss. DHS 75.49 to 75.59. General requirements apply to all treatment services certified under this chapter, unless otherwise specified. DHS 75.16 HistoryHistory: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction made under s. 35.17, Stats., Register October 2021 No. 790. DHS 75.17DHS 75.17 Governing authority or entity owner requirements. DHS 75.17(1)(1) Governing authority or entity owner requirements. The governing authority or entity owner of a service shall do all of the following: DHS 75.17(1)(a)(a) Designate a member or representative of the governing body that is legally responsible for the operation of a service that has the authority to conduct the policy, actions, and affairs of the service, to complete the entity owner background check and to be the entity owner responsible for a service. DHS 75.17(1)(b)(b) Appoint a service director whose qualifications, authority, and duties are defined in writing. DHS 75.17(1)(c)(c) Establish written policies and procedures for the operation of the service and exercise general direction over the service, including the following: DHS 75.17(1)(c)3.3. Ensure that no person will be denied service or discriminated against on the basis of sex, race, color, creed, sexual orientation, disability, or age, in accordance with 45 CFR part 92 and Title VI of the Civil Rights Act of 1964, as amended, 42 USC 2000d, Title XI of the Education Amendments of 1972, 20 USC 1681-1686 and s. 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794, and the Americans with Disabilities Act of 1990, as amended, 42 USC 12101-12213. DHS 75.17 HistoryHistory: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (1) (c) 3. made under s. 35.17, Stats., Register October 2021 No. 790. DHS 75.18DHS 75.18 General requirements for service staff. DHS 75.18(1)(b)(b) The service director shall be responsible for all of the following: DHS 75.18(1)(b)2.2. Ensuring that appropriate policies and procedures for the service are developed and carried out in compliance with this chapter. DHS 75.18(1)(b)3.3. Administrative oversight of the job performance and actions of service staff members. DHS 75.18(1)(b)4.4. Compliance with regulations governing the care and treatment of patients and the standards of practice for behavioral health professions. DHS 75.18(1)(c)(c) Unless otherwise specified for a specific level of care, the service director, or staff member designated by the director to be responsible for the operation of the service, shall be readily available, at all times the service is in operation. That person may provide direct counseling or other duties consistent with their scope of practice, in addition to being responsible for the service operation. DHS 75.18(2)(a)(a) A service shall have a clinical supervisor, either on staff or through a contracted agreement, to provide clinical supervision or clinical consultation to clinical staff of a service, as required within this chapter, and consistent with applicable professional licensure and certification requirements. DHS 75.18(2)(b)(b) The clinical supervisor is responsible for professional development of clinical staff, and for ensuring delivery of appropriate clinical services to patients of a service. DHS 75.18(2)(c)(c) Any staff who provides clinical supervision shall be a clinical supervisor, as defined in s. DHS 75.03 (19). A clinical supervisor who is on staff of the service and meets the requirements of a substance abuse counselor or mental health professional may provide direct counseling services in addition to supervisory responsibilities. DHS 75.18(3)(3) Substance abuse counselors. A service shall have a substance abuse counselor, as defined in s. DHS 75.03 (85), available during the hours of operation of clinical services. DHS 75.18(4)(4) Prescribers. A service may have prescribers that provide medical services and clinical consultation services. The service shall ensure appropriate training and oversight of prescribers. DHS 75.18(5)(5) Nurses. A service may have nurses that provide nursing services to support mental health and substance use treatment. The service shall ensure appropriate training and oversight of nursing staff. DHS 75.18(6)(a)(a) A service may have mental health professionals or prescribers that deliver mental health treatment services. All staff who provide mental health treatment, except prescribers knowledgeable in psychiatry, shall meet the appropriate qualifications under ch. 455 or ch. 457, Stats. DHS 75.18(6)(b)(b) For service levels of care in ss. DHS 75.49 to 75.59 that require a mental health professional, the role of substance abuse counselor and mental health professional may be occupied by the same individual with appropriate credentialing, and providing they are operating within the scope of their practice. DHS 75.18 HistoryHistory: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (2) (c), (3), (6) (a) made under s. 35.17, Stats., Register October 2021 No. 790. DHS 75.19(1)(1) Caregiver background check. At the time of hire, employment, or contract, and every 4 years after, the service shall conduct and document a caregiver background check following the procedures in s. 50.065, Stats., and ch. DHS 12. A service shall not employ or contract the service if the person has been convicted of the crimes or offenses, or has a governmental finding of misconduct, found in s. 50.065, Stats., and ch. DHS 12, unless the person has been approved under the department’s rehabilitation process, as defined in ch. DHS 12. DHS 75.19(2)(2) Personnel records. Employee records shall be available upon request at the service for review by the department. A separate record for each employee shall be maintained, kept current, and at a minimum, include: DHS 75.19(2)(a)(a) A written job description including duties, responsibilities and qualifications required for the employee. DHS 75.19(2)(e)(e) A copy of a signed statement regarding confidentiality of client information. DHS 75.19(3)(3) Clinical supervision. A service shall have written policies and procedures for the provision of clinical supervision to unlicensed staff, qualified treatment trainees, and recovery support staff. Clinical supervision for substance abuse counselors, mental health professionals in-training, and qualified treatment trainees shall be in accordance with requirements in ch. SPS 162, chs. MPSW 4, 12, and 16, and ch. Psy 2. A record of clinical supervision shall be made available to the department upon request. DHS 75.19(4)(a)(a) A service shall have written policies and procedures for determining staff training needs, formulating individualized training plans, and documenting the progress and completion of staff development goals. DHS 75.19(4)(b)(b) The requirements in this subsection may be met through documentation on an employee’s annual performance evaluation that addresses professional development goals. DHS 75.19(4)(c)(c) Minimum training requirements for clinical staff include all of the following: DHS 75.19(4)(d)(d) Documentation of training shall be made available to the department upon request. DHS 75.19(4)(e)(e) Documented training for areas identified in par. (c) shall occur within 2 months of hire for new clinical staff, unless the service is able to provide documentation of the staff member’s previous training, professional education, or supervised experience addressing these areas. DHS 75.19(5)(5) Universal precautions. A service shall have written policies and procedures for infection control and prevention that adheres to federal occupational safety and health administration bloodborne pathogens standards in 29 CFR 1910.1030. DHS 75.19 HistoryHistory: CR 20-047: cr. Register October 2021 No. 790, eff. 10-1-22; correction in (3), (4) (e) made under s. 35.17, Stats., Register October 2021 No. 790. DHS 75.20(1)(a)(a) With respect to general treatment service case records, the service shall do all of the following: DHS 75.20(1)(a)2.2. The service director or another designated staff member shall be responsible for the maintenance and security of patient case records. DHS 75.20(1)(a)4.4. Maintain each case record in a format that provides for consistency and facilitates information retrieval. DHS 75.20(1)(a)5.5. Whenever an edit to a signed entry in a patient’s case record is made, the service shall document the date of the edit, the name of the individual making the edit, and a brief statement about the reason for the edit, if the prior version of the edited information is not retained by the service. DHS 75.20(1)(b)(b) A patient’s case record shall include all of the following: DHS 75.20(1)(b)1.1. The patient’s name, physical residence, address, and phone contact information. DHS 75.20(1)(b)2.2. The patient’s date of birth, self-identified gender, and self-identified race or ethnic origin. DHS 75.20(1)(b)3.3. Consent for treatment forms signed by the patient or the patient’s legal guardian, if applicable, that are maintained in accordance with s. DHS 94.03. DHS 75.20(1)(b)4.4. An acknowledgment by the patient or the patient’s legal guardian, if applicable, that the service policies and procedures were explained to the patient or the patient’s legal guardian. DHS 75.20(1)(b)5.5. A copy of the signed and dated patient notification that was reviewed with and provided to the patient or the patient’s legal guardian, if applicable, which identifies patient rights, and explains provisions for confidentiality and the patient’s recourse in the event that the patient’s rights have been abused. DHS 75.20(1)(b)6.6. Results of all screening, examinations, tests, and other assessment information. DHS 75.20(1)(b)7.7. A completed copy of the standardized placement criteria and level of care assessment at admission, and subsequent reviews of level of care placement criteria. DHS 75.20(1)(b)8.8. Treatment plans, including all reviews and updates to the treatment plan. DHS 75.20(1)(b)9.9. Records for any medications prescribed or administered by the service, including any medication consent records required by s. DHS 94.09. DHS 75.20(1)(b)10.10. Copies of any incident reports or documentation of medication errors applicable to the patient. DHS 75.20(1)(b)13.13. Records of any referrals by the service, including documentation that referral follow-up activities occurred. DHS 75.20(1)(b)14.14. Correspondence relevant to the patient’s care and treatment, including dated summaries of relevant telephone or electronic contacts and letters. DHS 75.20(1)(b)15.15. Consents authorizing disclosure of specific information about the patient. DHS 75.20(1)(b)19.19. Documentation of each transfer from one level of care to another. Documentation shall identify the applicable criteria from ASAM or other department-approved placement criteria, and shall include the dates the transfer was recommended and initiated. DHS 75.20(1)(c)(c) For patients that discharge from a service and are subsequently re-admitted, a new case record shall be established for each episode of care. DHS 75.20(1)(e)(e) If the service discontinues operations or is taken over by another service, records containing patient identifying information shall be turned over to the replacement service, as permitted by applicable state and federal confidentiality requirements. DHS 75.20(2)(2) Case records for persons receiving only screening and referral. A treatment service shall have a written policy and procedure regarding case records for individuals that receive only screening, consultation, or referral services. The policy and procedure shall include: DHS 75.20(2)(a)(a) Information to be obtained for phone and in-person screening, consultation, or referral. DHS 75.20(2)(b)(b) Assurance that screening includes an individual’s pregnancy status.
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Chs. DHS 30-100; Community Services
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