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 35.13DHS 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 NoteNote: 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: (608) 266-8481, Fax: (608) 267-0352.

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 35.14(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)(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).