Section DHS 40.04 - Certification(1) INITIAL CERTIFICATION REQUIREMENTS. (a)General. A program that provides mental health day treatment services may not be established without certification from the department(b)Application.1. Certification may be granted to establish any of the following: a. A community-based program.b. An intensive hospital-based program. Note: Application materials may be obtained from the Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969 or online at DHSDQAMentalHealthAODA@wisconsin.gov. Completed application materials may be submitted by mail to the Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969.
2. A program may apply for certification by submitting the following application materials to the department:a. A completed application form.c. A program description, containing all of the following information:1) The age range and characteristics of youth the program proposes to admit and if the program proposes to offer services based on age, the age range and client characteristics for each service.2) The maximum number of youth that the program proposes to serve at any given time.3) The hours and days of the year when the program will operate, and the proposed times during the day and week when youth will receive services from the program.4) The treatment, services and supports, including parent peer specialists when appropriate, that will be offered by the program, and a rationale for how they will help the youth population achieve and sustain positive outcomes. If the program proposes to incorporate specific evidence-based practices in its array of services, a description of those services, the training and certification that its staff members have received or will receive that qualifies them to offer those services, and how those services will be provided. A description of the therapeutic milieu the program proposes to create with the proposed treatment, services and supports, how it will be maintained, its intended therapeutic benefits, and the rationale supporting its use for the youth served by the program. If the program proposes to offer other services within the same facility or program, it shall indicate the process that the program will use in deciding when and how to offer these services, how it will obtain any necessary authorization for these services, and how these services will be funded and regulated.5) The program's proposal for meeting staffing level requirements in s. DHS 40.10(2), the qualifications and roles for each position, and an analysis showing that staffing is adequate to meet the needs of the youth that the program proposes to serve. A description is also required of any specialized training and certification that program staff members have received or will be receiving that will help them better identify and address the specific needs of the youth served by the program.6) A description of the physical settings indicating where services will be provided and whether these settings will be used for other purposes. Documentation of inspection or permit indicating the state building code requirements have been met, including chs. SPS 361 to 366, American with Disabilities Act, any applicable local ordinance or municipal building codes, and any additional information requested by the department.7) If a program is proposing to operate a community-based program in a school, an agreement that describes the school in which the program will be located, the area or areas in the school where program operations will occur, the interactions that the program will have with other school activities and classes, the relationship that the program staff will have with school staff, how program staff and school staff will maintain separate duties, and the activities that youth will be participating in while also receiving services through the program.8) How the program will participate in care coordination for youth within the community.9) Where client records will be maintained and how confidentiality requirements of those records will be safeguarded, as required under s. DHS 40.15.10) How the program will arrange for food service to any youth who is in the program for four or more hours during a day.(c)Initial on-site inspection. Upon receipt of all application materials described in sub. (2), the applicant shall do all of the following: 1. Permit the department to conduct an on-site inspection of the program's physical settings to determine compliance with this chapter.2. Make available for review by the department any documentation necessary to determine compliance with the standards in this chapter.(d)Certification determination.1. The department shall make a certification determination within 60 days of receiving all completed application materials.2. The department may grant certification if all the requirements of this chapter are met.3. If the department determines that a program applying for certification does not comply with the requirements of this chapter, has a major deficiency, or the program description is not approved, the department may deny certification. A denial of certification shall be in writing and shall contain the reason for the denial and notice of appeal rights.(e)Scope of certification. Certification granted by the department shall only be valid for the program described in the application materials.(2) Ongoing oversight provisions. (a)Notification of changes. A program that has received certification from the department shall notify the department of any change of administration, ownership, program name, required staff, or any other program change that may affect compliance with this chapter before the effective date of the change. A new application will be required if, upon notification, the department determines there is a substantial change in the program. Note: Program notifications should be made to: Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969 or by emailing DHSDQAMentalHealthAODA@wisconsin.gov.
(b)Duration of certification.1g. Certification is valid until suspended or terminated by the department under sub. (2) (f).1r. Certification may be suspended or terminated under sub. (2) (f).2. Any program that intends to close shall notify the department in writing at least 30 days before closing and comply with s. DHS 40.15(9).(c)Biennial report and fees. Every 24 months, by the date of renewal, the program shall submit a biennial report on the form provided by the department, and shall submit payment of certification continuation fees for the purpose of renewing certification of the program for two years.(d)Ongoing on-site inspections. The program shall permit unannounced, on-site inspections of the program by the department to conduct program reviews, to conduct complaint or death investigations involving any aspect of the program, or to determine a program's progress in correcting a deficiency or major deficiency cited by the department. All of the following conditions apply to an on-site inspection: 1. The department shall use a random selection process for reviewing client records during program reviews.2. The department shall conduct client interviews as part of the program review process.(e)Notice of deficiencies.1. If the department determines that a program has a deficiency, the department shall issue a notice of deficiency to the program. The notice of deficiency may place restrictions on the activities of the program, or suspend or terminate the program's certification.2. The program shall submit a plan of correction to the department as indicated in the notice of deficiency. The plan of correction shall identify the specific steps the program will take to correct the deficiency, the timelines within which the corrections will be made, and the staff members who will implement the plan and monitor for future compliance.3. If the department determines that the plan of correction submitted by the program does not adequately address deficiencies listed in the notice of deficiency, the department may impose a plan of correction.(f)Termination and suspension of certification.1. The department may terminate certification at any time for any major deficiency by issuing a notice of major deficiency to the program. The notice shall specify the reason for the department action and contain appeal information.2. The department may summarily suspend a program's certification if the department determines that immediate action is required to protect the health, safety, or welfare of youth. Notice of suspension may be written or verbal and shall specify the reason for the department action and the date the action becomes effective. Within 10 working days after the order is issued, the department shall either lift the suspension on the program's certification or proceed to terminate the program's certification.(g)Appeals. If the department denies or terminates certification, the program may request a hearing under ch. 227, Stats.(h)Reapplication. If an application for certification is denied, the program may not reapply for certification for one year following the date on which certification was denied.(i)Dissemination of results. Upon completing action on an application for certification, staff of the department shall provide a summary of the results of the process to the applicant, to the sub-unit within the department responsible for monitoring community mental health programs, and to the department of community programs under s. 51.42, Stats., in the county in which the program is located.Wis. Admin. Code Department of Health Services § DHS 40.04
Cr. Register, August, 1996, No. 488, eff. 9-1-96; correction in (2) (e) made under s. 13.93(2m) (b) 7, Stats., Register January 2004 No. 577; corrections in (2) (b) 2. and (e) made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.Adopted by, CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in numbering of (2) (b) 1g., 1r. made under s. 13.92(4) (b) 1., Stats., and correction in (1) (c) (intro.), (2) (a), (b) 2., (c), (d) made under s. 35.17, Stats., Register June 2020 No. 774, eff. 7/1/2020Amended by, correction in (2) (b) 1g., 1r. made under s. 13.92(4) (b) 7., Stats., Register December 2020 No. 780, eff. 1/1/2021