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)(4) Staff development.

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)(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)(1) General treatment service case records.

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)3.3. Safeguard and maintain patient case records in accordance with applicable state and federal security requirements, including all applicable security requirements specified in ch. DHS 92, 42 CFR part 2, 45 CFR parts 164 and 170, and ss. 146.816 and 146.82, Stats.

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)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)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.