STATE OF WISCONSIN
Office of Legal Counsel
WISCONSIN DEPARTMENT OF HEALTH SERVICES
PROPOSED ORDER TO ADOPT EMERGENCY RULES
The Wisconsin Department of Health Services proposes an order to amend
DHS 13.03 (11) (Note); and create DHS 31, 105.529, and 107.13 (9), related to
crisis urgent care and observation facilities.
FINDING OF EMERGENCY
An emergency rule is necessary to protect the public peace, safety, and welfare.
Wisconsin currently has a behavioral health crisis. The suicide rate among
Wisconsin residents increased by 38% from 2000 to 2022 and the number of
unique individuals receiving crisis services has increased 71% from 2013 to
2021. Yet 44% of Wisconsin adults do not have access to a crisis stabilization
facility, 36% do not have access to 24/7 mobile crisis services, and 66% of
county crisis programs report staffing shortages. Specific to emergency
detentions, an analysis by the Department of Health Services’ Office of Policy
Initiatives and Budget found that while overall emergency detentions decreased
21% from 2013 to 2021, the number of emergency detentions at Winnebago
Mental Health Institute (WMHI) increased 133% over that same time. WMHI
estimates that in 2023, 38% of their admissions were hospitalized for 72
hours or less. Based on a 2019 Wisconsin Department of Justice survey, the
average officer time spent responding to a mental health incident—which,
notably, includes transporting the individual to WMHI—is nine hours. This data
suggests that there is a shortage of accessible, facility-based crisis services
and WMHI is serving as a default placement in lieu of more effective, efficient,
and less restrictive options. Creating crisis urgent care and observation facilities
through this administrative rule project will increase access to less restrictive
crisis intervention services and promote the best practice of integrated crisis
care to treat co-occurring mental health and substance use related needs. This
critical component of crisis services is a proactive step to attempt to reduce
unnecessary inpatient hospital admissions and decrease law enforcement
time spent on crisis response. Providing persons experiencing a crisis prompt,
accessible care, at the right time and in the right place is essential in improving
the overall health of the populace and reducing more restrictive, costly, and
time-consuming interventions.
If approved in accordance with Ch. 227, Stats., the proposed emergency rule
will be replaced by a corresponding permanent rule, and the rulemaking process
will be concurrent.
RULE SUMMARY
Statutes interpreted
Sections 51.01 (19), 51.036 (2) and 51.04, Stats.
Statutory authority
The department is authorized to promulgate the proposed rules under the
authority of ss. 49.45 (10), 51.036 (4) (intro.) and (a) to (m), and 227.11 (2)
(a), Stats.
Explanation of agency authority
Section 51.036 (4) authorizes the Department to promulgate rules to implement
s. 51.036, Stats. Broadly, s. 51.036, Stats., relates to crisis urgent care and
observation facilities (“CUCOFs”), which are a new type of treatment facility that
admits an individual to prevent, de-escalate, or treat an individual in crisis due to
behavioral health, mental health, or substance use issues.
Subsection (4) of the statutes specifically directs the Department to establish
rules regarding all of the following:
(1) A grant program in accordance with s. 51.036 (2), Stats.
(2) Requirements for a CUCOFs awarded a grant under 51.036 (2) to match
those funds with a non-state, federal, or third-party revenue source. See
also s. 51.036 (2) (c) 10., Stats.
(3) Requirements for admitting, holding, and discharging individuals held on
emergency detentions under s. 51.15, Stats.
(4) Minimum security requirements for CUCOFs.
(5) The range of beds allowed in a CUCOF.
(6) Policies and criteria that a CUCOF must have regarding emergency
detentions, including when law enforcement or a person authorized to
transport may drop an individual off at a CUCOF.
(7) Policies for interfacility transfers initiated at a CUCOF.
(8) Procedures for communicating bed availability at a CUCOF before an
individual is transported there.
(9) Policies for coordination between a CUCOF and a facility established
or operated with settlement funds from the national opiate litigation under
s. 165.12, Stats.
(10) Procedures for coordinating continuity of care between a CUCOF
and a hub-and-spoke home health pilot program or any other appropriate
transition facility for any patient treated at a CUCOF for 5 or fewer days.
(11) Policies and procedures for admitting adults and, if applicable, youth at
a CUCOF, including requirements that youth be treated in a separate part
of the facility from adults.
(12) Staffing level requirements at a CUCOF.
(13) Requirements to define the population served at a specific CUCOF,
including minimum age requirements.
When certified in accordance with s. 51.036, Stats., these facilities meet the
definition of a “crisis intervention service” under s. 49.45 (41) (a) 1., Stats.,
and certain services provided in a certified CUCOF are reimbursable under
Medical Assistance (“MA”). See s. 49.46 (2) (b) 15., Stats. As the single state
agency for administering MA in Wisconsin, the Department is authorized
under s. 49.45 (2) (a) 11. to create rules establishing criteria for certification
of MA providers, setting conditions of participation and reimbursement, and
promulgating rules “consistent with its duties in administering [MA].” Section
49.45 (10), Stats., further authorizes the Department to “promulgate such
rules as are consistent with its duties in administering [MA].
In accordance with the grants of authority under ss. 51.036 (4), 49.45 (2) (a)
11. and (10), Stats., the Department has determined that rules in addition
to the specific items listed under s. 51.036 (4) (a) to (m), Stats., rules are
necessary to implement s. 51.036, Stats., and “establish a certification process
for [CUCOFs],” under s. 51.036 (2) (a), Stats. Additionally, s. 51.04, Stats.,
provides that the Department “shall annually charge a certification fee for
each certification [of a treatment facility].” A CUCOF meets the definition of a
“treatment facility” under s. 51.01 (19), Stats.
Finally, s. 51.036 (2) (a), Stats., provides that the Department may limit the
number of CUCOFs certified and directs the Department to include statewide
geographic consideration[s] in its evaluation of applications for CUCOF
certifications. Section 51.036 (2) (c), Stats., includes specific items a CUCOF
application must contain. Rules are required to codify these directives from the
Legislature.
Related statute or rule
Sections 49.45 (41) (c) (intro.) and 51.15 (2) (d), Stats.
Plain language analysis
The proposed rules seek to create a mechanism for regulating CUCOFS in
accordance with s. 51.036, Stats. CUCOFs are a new facility type to serve
adults and may serve youth who are experiencing a crisis related to behavioral,
mental health, or substance use challenges. CUCOFs provide facility-based
crisis intervention services 24 hours a day, seven days a week for both
voluntary persons arriving as walk-ins and persons subject to emergency
detention under s. 51.15, Stats. Crisis services provided at a CUCOF can be
accessed by voluntarily with or without a referral. Services are delivered by a
multi-disciplinary team and are designed to identify and de-escalate the
presenting crisis and reduce associated symptoms. A stay at a CUCOF is
intended to be short term and not exceed five days. Crisis services available
are provided to persons to the extent and duration they need them. CUCOFs
collaborate with county emergency mental health programs, law enforcement,
outpatient and inpatient providers, and other related partners to coordinate care
for persons needing services. A CUCOF is not regulated as a hospital, except
to the extent the facility is otherwise required due to the facility’s licensure
or certification for other services or purposes. Section 51.036, Stats. does
not prohibit, limit, or otherwise interfere with services provided by a county
or a hospital or other facility consistent with the facility’s existing licensure or
certification, whether the facility is publicly or privately funded.
Section 51.036, Stats., was created by 2023 Wis. Act 249 to help address
a statewide lack of accessible and urgent facility-based care for persons
experiencing a crisis related to behavioral, mental health, or substance use. Due
to the shortage, many individuals in crisis either do not receive adequate care,
or they are transported to WMHI, where they may receive more restrictive care
than necessary. Adding CUCOFs as an available facility to accept involuntary
and voluntary admissions will help decrease time and resources spent by law
enforcement and other emergency personnel who coordinate placement and
care for persons in crisis. Act 249 was supported by mental health providers and
related community partners as an appropriate and additional option to address
gaps in the current crisis continuum.
As a newly created facility type, there are no existing rules for CUCOFs. The
proposed rules seek to create ch. DHS 31, will include all of the following in
relation to CUCOFs:
(1) general certification requirements.
(2) ongoing certification compliance requirements, including annual
treatment facility certification fees under s. 51.04, Stats.
(3) program requirements related to staffing, admissions, transfers,
services, and client rights
(4) physical building requirements
(5) grant program requirements.
In accordance with s. 51.036 (2) (a), Stats., the Department initially expects
to certify 1 or 2 CUCOFs across the state. The geographic location of initial
applicants will be considered as it relates to statewide need and resource
availability. Certifications will be prioritized for applicants located at least
100 miles from WMHI and those in the state defined western region.
Because services rendered at a certified CUCOF may be reimbursed under
MA, the proposed seek to create s. DHS 105.529 to require that a facility be
certified under ch. DHS 31 as a CUCOF in order to be reimbursed under MA.
Additionally, the proposed rules seek to create s. DHS 107.13 (9) to identify
covered services provided in a certified CUCOF.
Summary of, and comparison with, existing or proposed federal
regulations
There appear to be no existing or proposed federal regulations that address the
activities to be regulated by the proposed rule.
Comparison with rules in adjacent states
Illinois:
Illinois certifies triage centers and crisis stabilization units through
Ill. Admin. Code tit. 77 p. 380. Under section 380.300 of these rules, “triage
centers shall provide an immediate assessment of consumers who present
in psychiatric distress, as an alternative to emergency room treatment or
hospitalization, and shall connect the consumer with community-based
services and treatment when considered necessary”. Under section
380.310 of these rules, crisis stabilization units “shall provide safety,
structure and the support necessary, including peer support, to help a
consumer to stabilize a psychiatric episode”. Triage centers are similar in
that they are intended to provide immediate assessment of clients in crisis
as an alternative to an emergency room or hospitalization and provide
connections and referrals to other community-based treatment services.
Triage centers are different in that they do not accept law enforcement
referrals or involuntary admissions and have a maximum length of stay of
23 hours. Crisis stabilization units are similar to CUCOFS in that they are
intended to assist in stabilizing persons with acute psychiatric symptoms.
Crisis stabilization units are different from CUCOFs in that they do not
accept involuntary persons and have a maximum length of stay of 21 days.
Iowa:
Iowa certifies crisis stabilization residential services through Iowa Admin.
Code r. 441-24.39 (225C). Under these rules, crisis stabilization residential
services are short-term services provided in facility-based settings of no
more than 16 beds. The goal of these facilities is to stabilize and reintegrate
the individual back into the community. Crisis stabilization residential
services are similar in that the intended length of stay is less than five days.
Crisis stabilization residential services are different from CUCOFs because
that they do not admit involuntary individuals.
Michigan:
Michigan certifies crisis stabilization units under their mental health code,
specifically Mich. Admin. Code r. 330.1971. Under these rules, crisis
stabilization units are crisis receiving and stabilization facilities that provide
an alternative to emergency departments for individuals who can be
stabilized typically within several hours but in no longer than 72 hours. Crisis
stabilization units are similar to CUCOFs in that they accept all referrals and
do not require medical clearance prior to admission, having the capacity to
carry out limited medical evaluative functions. Crisis stabilization units are
different from CUCOFs in that services may be provided for a period of up
to 72 hours, after which the individual must be provided with the clinically
appropriate level of care.
Minnesota:
Minnesota licenses residential crisis stabilization facilities under Minn. Stat.
s. 245I.23. The statutes regulate “residential crisis stabilization that provides
structure and support to adult clients in a community living environment
when a client has experienced a mental health crisis and needs short-term
services to ensure that the client can safely return to the client’s home or
precrisis living environment with additional services and supports identified
in the client’s crisis assessment”. These facilities are similar to CUCOFs in
that facilities can choose to operate involuntary programs. These facilities
are different from CUCOFs because involuntary programs are not required,
and they can only accept adult clients.
Summary of factual data and analytical methodologies
Information about other states was found on each state’s certification board
website and through discussion with state authorities.
Analysis and supporting documents used to determine effect on small
business
According to the U.S. Small Business Administration, a small business is
defined as a for-profit business of any legal structure. Section 227.114 (1) of
the Wisconsin Statutes defines a small business as “a business entity, including
its affiliates, which is independently owned and operated and not dominant
in its field, and which employs 25 or fewer full-time employees or which has
gross annual sales of less than $5,000,000.” Based on discussions with mental
health providers and related community partners, the Department believes
most organizations conducting this work are not-for-profit or have more than
25 employees and would not meet the definition of a small business.227.114(1),
Wis. Stats.
Effect on small business
Based on the foregoing analysis, the proposed rules are anticipated to have little
or no economic impact on small businesses.
Agency contact person
Sarah Coyle, Dept. of Health Services, Division of Care and Treatment
Services, 1 W. Wilson St., Room 850, Madison, WI 53716.
Please direct any inquiries to: DHSCUCOF@dhs.wisconsin.gov.
Statement on quality of agency data
See summary of factual data and analytical methodologies.
Place where comments are to be submitted and deadline for submission
Comments may be submitted to the agency contact person that is listed above
until the deadline given in the upcoming notice of public hearing. The notice
of public hearing and deadline for submitting comments will be published in
the Wisconsin Administrative Register and to the department’s website, at
https://www.dhs.wisconsin.gov/rules/active-rulemaking-projects.htm.
Comments may also be submitted through the Wisconsin Administrative Rules
Website, at: https://docs.legis.wisconsin.gov/code/chr/active.
RULE TEXT
SECTION 1. DHS 13.03 (11) (Note) is amended to read:
DHS 13.03 (11) Note: Entities include those facilities, organizations or services
that are licensed or certified by, approved by or registered with the department
under the following chapters of the department’s administrative rules:
DHS 31 Crisis urgent care and observation facilities
DHS 34 Emergency mental health service programs
DHS 35 Outpatient mental health clinics
DHS 36 Comprehensive community services
DHS 40 Mental health day treatment services for children
DHS 50 Youth crisis stabilization facilities
DHS 61 Community mental health, alcoholism and other drug abuse
(AODA) program
DHS 63 Community support programs for chronically mentally ill persons
DHS 75 Community substance abuse standards
DHS 83 Community-based residential facilities
DHS 88 Licensed adult family homes
DHS 89 Residential care apartment complexes
DHS 105.17 Personal care agencies
DHS 110 Ambulance service providers
DHS 124 Hospitals
DHS 127 Rural medical centers
DHS 131 Hospices
DHS 132 Nursing homes
DHS 133 Home health agencies
DHS 134 Facilities serving people with developmental disabilities
SECTION 2. DHS 31 is created to read:
Chapter DHS 31
CRISIS URGENT CARE AND OBSERVATION CENTER CERTIFICATION
Subchapter I – General Provisions and Requirements
DHS 31.01
Authority and purpose.
DHS 31.02
Applicability.
DHS 31.03
Definitions.
DHS 31.04
Certification.
DHS 31.05
Variance and waiver.
DHS 31.06
Department action.
Subchapter II – Program Requirements
DHS 31.07
Required policies and procedures.
DHS 31.08
Personnel.
DHS 31.09
Staffing requirements.
DHS 31.10
Personnel development.
DHS 31.11
Admissions, transfers, discharges, and holds on admissions.
DHS 31.12
Services.
DHS 31.13
Treatment documentation.
DHS 31.14
Emergency safety interventions.
DHS 31.15
Investigation, notification, and reporting requirements.
DHS 31.16
Client rights and grievance procedures.
Subchapter III – Facilities
DHS 31.17
Applicability.
DHS 31.18
General facility requirements.
DHS 31.19
Physical environment.
DHS 31.20
Building design.
DHS 31.21
Infection control program.
DHS 31.22
Food service.
DHS 31.23
Fire safety requirements.
DHS 31.24
Fire protection systems.
DHS 31.25
Oxygen storage.
DHS 31.26
Records retention and posting.
Subchapter IV – Grant Program Requirements
DHS 31.27
Grant program overview.
DHS 31.28
Application.
DHS 31.29
Awards.
DHS 31.30
Restrictions.
DHS 31.31
Records and reports.
Subchapter I – General Provisions and Requirements
DHS 31.01 Authority and purpose. This chapter is promulgated under the
authority of ss. 51.036 (4), and 227.11 (2), Stats., for the purpose of certifying
and regulating crisis urgent care and observation facilities.
DHS 31.02 Applicability.
(1) This subchapter establishes general program requirements that apply to
crisis urgent care and observation facilities, including those facilities that are
also licensed as a hospital under ch. 50, Stats. The requirements under this
section shall not prohibit, limit, or otherwise interfere with services provided
by a county, hospital, or other facility that are provided under the facility’s
existing licensure or certification. This chapter shall apply to any of the
following:
(a) A publicly or privately operated facility providing crisis urgent care and
observation facility services, in accordance with s. 51.036, Stats.
(b) A publicly or privately operated hospital providing crisis urgent care
and observation facility services, in accordance with s. 51.036, Stats. This
applies to co-located and off-site facilities.
(2) The certification requirements of this chapter do not apply to any facility
meeting the criteria under s. 51.036 (2) (f), Stats.
DHS 31.03 Definitions. In this chapter:
(1) “Assessment” means the procedure by which staff of the program, operating
within their scope of practice, gathers relevant information to assess risk,
identifies client care needs, and determines intervention or treatment
options.
(2) “Bed” means a piece of furniture designed to accommodate a person
sleeping in an outstretched position. For purposes of this chapter, a bed may
include a reclining chair, convertible sofa, or recovery couch.
(3) “Behavioral health assessment” means the process of gathering relevant
information regarding a client’s behavioral and mental health status.
(4) “Care coordination” means the deliberate organization of a person’s care
across multiple care providers and support networks.
(5) “Certification” means the approval granted by the department that a CUCOF
meets the requirements of this chapter.
(6) “Certified peer specialist” means a person who has all of the following:
(a) Lived experience with mental illness or substance use disorders, or both.
(b) Completed a formal training and holds a department certification in the peer
specialist model of mental health or substance use disorders support, or
both.
(7) “Client” means a person receiving care at a CUCOF. Unless otherwise
indicated in this chapter, a person screened for services but not admitted
is not a client.
(8) “Clinical supervision” means a process of oversight of an employees’
professional development and practice to ensure that each client is receiving
quality care.
(9) “Cognitive assessment” means the process of gathering relevant information
regarding a client’s cognitive, developmental, or intellectual status.
(10) “County department” means a county department of human services under
s. 46.23, Stats., or a county department of community programs under s.
51.42 (1) (b), Stats.
(11) “Crisis” has the meaning provided in s. 51.036 (1) (a) Stats.
(12) “Crisis plan” means a plan prepared for an individual at high risk of
experiencing a mental health crisis so that, if a crisis occurs, staff
responding to the situation will have the information and resources they
need to meet the person’s individual service needs.
(13) “Crisis urgent care and observation facility” has the meaning provided in
s. 51.036 (1) (b), Stats.
(14) “CUCOF” means a crisis urgent care and observation facility.
(15) “Day” means calendar day, unless otherwise indicated.
(16) “De-escalation” means the use of interventions to stabilize, slow, or reduce
the intensity of a crisis.
(17) “Department” means the Wisconsin department of health services.
(18) “Elopement” means when a client leaves a CUCOF without authorization or
supervision and may be a threat to their health or safety.
(19) “Follow-up” means the process of assessing the well-being of a client,
including those who have been discharged.
(20) “Hub-and-spoke health home pilot program” means a network of treatment,
resources, and support for persons with substance use and health care
needs.
(21) “Ligature resistant” means an object designed to reduce the ability of
securing a ligature to it.
(22) “Medication management” means services that include prescribing,
transcribing, verifying, dispensing, delivering, administering, monitoring,
and reporting over the counter and prescription medication.
(23) “Nursing assessment” means the process of gathering relevant information
regarding a client’s physical and medical health status.
(24) “Observation unit” means a space for client care and observation for client
stays less than 24 hours where multiple clients may occupy a single room.
(25) “Opioid antagonist” means a medication approved by the federal drug
administration that blocks the effects of opioids.
(26) “Prescriber” means a physician, physicians assistant, or nurse prescriber,
who is operating within the scope of their license to deliver services under
this chapter.
(27) “Psychiatric Bed Locator” means a tool to assist in identifying potentially
available psychiatric beds.
(28) “Re-assessment” means the procedure by which staff of the program,
operating within their scope of practice, gather relevant information to
update a client’s initial assessment based on a change in symptoms,
status, needs, or risk.
(29) “Recovery coach” means an individual that works with and supports
individuals receiving substance use services to assist with engagement in
treatment services or recovery systems, or both.
(30) “Risk assessment” means the process of gathering relevant information
regarding a client’s risk of harm to self or others.
(31) “Safety plan” means a personalized set of written guidelines to be used as
a tool to assist someone prior to or during a crisis to identify coping skills
and access supports.
(32) “Secure” or “secured” means a locked area within a CUCOF.
(33) “Sight and sound separation” means the maintenance of physical
separation between minors and adults so that both sustained visual contact
and direct and sustained oral communication between them is not possible.
(34) “Screening” means a process of identification of needs and risk including
urgent medical, psychiatric, or substance use related.
(35) “Stabilization” means a service aimed at reducing or eliminating a client’s
symptoms to reduce the need for inpatient hospitalization.
(36) “Staffing plan” means a document to strategically identify and anticipate the
workforce required to effectively deliver client care.
(37) “Substance-use disorder assessment” means the process of gathering
relevant information regarding a client’s substance-use status.
(38)
(a) “Telehealth” means the use of telecommunications technology by a certified
provider to deliver services allowable under ss. 49.45 (61) and 49.46 (2) (b)
21. to 23., Stats., this chapter, and s. DHS 107.02 (5), including assessment,
diagnosis, consultation, treatment, or transfer of medically relevant data in a
functionally equivalent manner as that of an in-person contact.
(b) “Telehealth” may include real-time interactive audio-only communication.
(c) “Telehealth does not include communication between a certified provider
and a recipient that consists solely of an electronic mail, text, or facsimile
transmission.
(39) “Therapeutic counseling” means applying therapeutic services to assist a
client or group of clients to achieve behavioral health stability.
(40) “Transfer” means the movement of a client or individual in need of services
between approved treatment facilities, from an approved treatment facility
to the community, or from the community to an approved treatment facility.
(41) “Variance” means an alternate means of meeting a requirement in this
chapter.
(42) “Waiver” means an exemption from a requirement of this chapter.
(43) “Wisconsin Prescription Drug Monitoring Program database” or “PDMP
database” means an online tool used to provide information about
monitored prescription drugs that are dispensed in the state.
(44) “Withdrawal management” means a service, or component of a service,
which provides care and interventions to address an individual’s physical or
psychosocial needs related to acute intoxication or withdrawal. Withdrawal
management includes intoxication monitoring, management of acute
symptoms, interruption of habitual and compulsive use, and engagement
in ongoing services.
DHS 31.04 Certification.
(1) General.
(a) No person, agency, or facility may operate a CUCOF without a
certification from the department.
(b) Any facility licensed as a hospital under ch. 50 that provides services
consistent with those described in this chapter can apply for CUCOF
certification under this section.
(c) This chapter shall not prevent co-location of a CUCOF with other
facilities, including hospitals, or shared staffing arrangements.
(2) application. All of the following materials shall be submitted to the
department when applying for CUCOF certification:
(a) A completed application specifying the population to be served, and
which demonstrates the program’s ability to do all the following:
1. Accept referrals for crisis services for adults and, if specifically
identified in the application, for minors, including all the following:
a. Involuntary clients brought under s. 51.15, Stats.
b. Voluntary clients for services arriving as walk-ins or brought by
law enforcement, emergency medical responders, or county
crisis personnel.
2. Abstain from requiring medical clearance before admission
assessment.
3. Provide assessments for physical health, mental health, and
substance use.
4. Provide screening for suicide and violence risk.
5. Provide medication management and therapeutic counseling.
6. Provide coordination of services for basic needs.
7. Provide for the safety and security of staff and clients.
8. Provide voluntary and involuntary treatment of individuals in crisis
and allow for an effective conversion from involuntary to voluntary
treatment, or conversion from voluntary to involuntary treatment.
9. If serving minors, demonstrate how sight and sound separation
between services for minors and adults will be achieved.
10. Maintain adequate staffing 24 hours a day, 7 days a week, including
through the use of telehealth.
11. Contribute, from at least one nonstate, federal, or 3rd-party revenue
source, at minimum 5% of biennial operating costs, in addition to
any grant awarded by the department under this section.
Note: Application forms are available at:
https://www.dhs.wisconsin.gov/regulations/mentalhealth/
certification.htm.
(b) Payment for the application fee required under s. 51.04, Stats.
Note: Fee information is available at
https://www.dhs.wisconsin.gov/regulations/mentalhealth/
certification.htm
(c) A copy of the proposed CUCOF’s policies and procedures, as specified
under s. DHS 31.07.
(d) A floor plan of the proposed CUCOF which demonstrates all of the
following:
1. Dimensions, exits, and planned room usage.
2. The proposed number of single-occupancy client rooms, doubleoccupancy client rooms, observation units, seclusion rooms, and
private treatment spaces and the rationale for these numbers.
3. The floor plan, which shall demonstrate compliance with s. 51.61,
Stats. and include all the following:
a. An accessible and easily identified walk-in area for persons
seeking immediate services to be triaged.
b. A locked unit for service provision to accommodate clients under
s. 51.15 Stats., which may also serve voluntary clients.
c. Methods to ensure privacy for each client.
d. Measures to ensure the safety of clients, visitors, and staff.
(e) All inspection reports completed during the last 12 months, as
required under s. DHS 31.26 (2).
(f) Proof of building insurance, risk insurance, liability insurance, and
agency-owned vehicle insurance if providing transportation.
(g) Payment of any forfeitures, fees, or assessments related to any
licenses or certifications issued by the department to the applicant, or
a written statement signed by an authorized representative stating that
no fees, forfeitures, or assessments are owed.
(h) Any additional information requested by the department.
(3) compliance review. Upon receipt of all completed application materials
under sub. (2), the applicant shall permit the department to conduct
an on-site inspection of the facility and a review of any documentation
necessary to determine compliance with this chapter.
(4) certification Determination.
(a) The department shall make a certification determination in accordance with
s. 51.036 (2), Stats. The department shall consider all the following before
making certification determinations:
1. The region of the state to be served, and existing certified CUCOFs
in that region or close proximity.
2. Whether any hospital facilities granted certification as a CUCOF are
in the region or close proximity to the proposed CUCOF.
3. Whether the proposed CUCOF is in the region or close proximity to
a state treatment facility designated for emergency detentions under
s. 51.15 (2) Stats.
(b) In accordance with s. 51.036 (2) (a), Stats., the department may
limit the number of certifications issued.
Note: Additional information about CUCOF certifications is available at
https://www.dhs.wisconsin.gov/regulations/mentalhealth/certification.htm.
(c) As a condition of certification, a CUCOF shall agree to allow the
department to make unannounced inspections and complaint
investigations of a CUCOF as it deems necessary, at reasonable
times and in a reasonable manner.
(5) notification of chanGes. A CUCOF that has received certification from the
department shall notify the department of any change of administration,
ownership, program name, or any other change that may affect compliance
with this chapter before the effective date of the change. A certification is
non-transferable. A new application will be required if the department
determines there is a substantial change in a CUCOF.
(6) Duration of certification.
(a) A certification is valid until suspended or terminated by the department.
(b) A certification becomes invalid upon non-payment of biennial fees.
(7) Biennial report anD fees.
(a) Every 24 months, by the date determined by the department and specified
on the CUCOF certification, 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 2 years.
(b) The department will send the re-certification materials to the provider,
which the provider is expected to fill out and submit to the department
according to instructions provided.
(c) A certification may be suspended or terminated if biennial reports are not
submitted by the date required under par. (a).
DHS 31.05 Variance and waiver.
(1) exception to a requirement.
(a) A CUCOF certified under this chapter may apply for a discretionary waiver
or variance to a requirement under this chapter. A written request for a
waiver or variance shall be sent to the department on a form provided by
the department. The application shall address all of the criteria in par. (b).
A variance application shall include a description of the alternative means
planned to meet the intent of the requirement.
Note: More information about variances and waivers is available
on the department’s website at https://www.dhs.wisconsin.
gov/regulations/waiver-variance.htm. A variance or waiver
request form is available at https://www.dhs.wisconsin.gov/
library/f-60289.htm.
(b) The department may grant an application for a waiver or variance if the
department determines that all of the following criteria are met:
1. Strict enforcement of the requirement for which a waiver or variance
is sought would result in an unreasonable hardship for the CUCOF.
2. The proposed waiver or variance will not diminish the effectiveness of
the services provided at the CUCOF.
3. The proposed waiver or variance increases client access to care
and sufficiently supports the efficient and economic operation of the
service.
4. The proposed waiver or variance will not jeopardize the health,
safety, welfare, or rights of any client.
5. Any waiver or variance proposed in the application is consistent with
all state and federal laws.
(2) RescinDinG a waiver or variance.
(a) The department may rescind or limit a waiver or variance if any of the
following occurs:
1. The department determines the waiver or variance has adversely
affected the health, safety, or welfare of a client.
2. The service fails to comply with any of the conditions of the waiver
or variance as granted.
3. Rescinding the waiver or variance is required by federal or state law.
4. There is no longer sufficient justification that the waiver or variance
increases client access to care or sufficiently supports the efficient
and economic operation of a service
(b) The department shall notify a CUCOF in writing if it rescinds or limits a
waiver or variance in accordance with par. (a).
DHS 31.06 Department Action.
(1) inspections. The department shall make unannounced, on-site inspections
at a CUCOF to conduct program reviews complaint investigations, death
investigations, or to determine progress in correcting a deficiency cited by
the department. The department may use a random selection process for
reviewing client records during program reviews. Complaint-driven program
reviews shall include the records related to the complaint and may include
additional records and interviews.
(2) statement of Deficiencies.
(a) If the department determines that a CUCOF has a deficiency, the department
shall issue a statement of deficiency within 30 days of the on-site survey. The
statement of deficiency may place restrictions on a CUCOF or its activities,
or suspend or terminate the certification, pursuant to sub. (3).
(b) A CUCOF shall submit a plan of correction to the department within 30
days of receipt of as the statement of deficiency under par (a). The plan
of correction shall propose the specific steps the CUCOF will take to
correct the deficiency, the timelines within which the corrections will be
made, and the personnel who will implement the plan and monitor for
future compliance.
(c) If the department determines that the plan of correction submitted
by the CUCOF does not adequately address the deficiencies listed
in the statement of deficiency, the department may request a new
plan of correction or may impose a plan of correction created by the
department.
(3) termination anD suspension of certification.
(a) The department may terminate certification at any time for a major deficiency
by issuing a notice of termination to a CUCOF. The notice shall specify the
reason for the department action and include the appeal information under
sub. (4).
(b) The department may suspend a CUCOF’s certification if the
department determines that immediate action is required to protect the
health, safety, and welfare of individuals utilizing the program. Written
notice of suspension shall specify the reason for the department action
and the date the action becomes effective. Within 14 calendar days
after the order is issued, the department shall either lift or impose
conditions on the suspension of a CUCOF certification or proceed to
terminate the program’s certification.
(4) appeals. If the department denies, suspends, or terminates certification,
or imposes conditions on a certification, a CUCOF may request a
hearing under ch. 227, Stats.
Subchapter II – Program Requirements
DHS 31.07 Required policies and procedures. A CUCOF shall have written
policies and procedures for all of the following:
(1) Communicating bed availability via the department-approved psychiatric
bed tracker in accordance with s. DHS 31.11 (1) (f).
(2) Coordination requirements, including all of the following:
(a) Procedures for coordinating crisis care for individuals in need of services
but not admitted to a CUCOF.
(b) Procedures for follow-up and care coordination with external providers,
as appropriate, including any of the following:
1. County crisis providers.
2. Inpatient psychiatric facilities
3. Any facility established or operated with funding received under s.
165.12 from settlement proceeds from the opiate litigation as defined
in s. 165.12(1)
4. A hub-and-spoke health home pilot program, or other transition
facilities
(3) Admission, screening and assessment policies and procedures meeting the
requirements of ss. DHS 31.11 and 31.12. At minimum, these policies should
include all of the following:
(a) The minimum age requirements for admission.
(b) The arrangement of rooms and space, including all of the following,
as applicable:
1. The number of client rooms in a secured setting and whether they are
single or dual occupancy.
2. The number of client rooms in an unsecured setting and whether they
are single or dual occupancy.
3. The size of any observation unit for client stays less than 24 hours
and how this space is designed.
(c) The total number of beds available, and how those beds are
allocated across the spaces identified in par. (b) 1. to 3.
(d) Eligibility requirements, including how a CUCOF will coordinate care
for individuals in need of crisis services who do not meet eligibility
requirements.
(e) Procedures for the determination of referring an individual when a
CUCOF is at capacity or holding on admissions consistent with s. DHS
31.11 (6).
(f) Policies regarding involuntary admission of a client under s. 51.15, Stats.
and s. DHS 31.11 (3).
(g) Policies regarding voluntary admission of a client in accordance with s.
51.10 (5), Stats., and, if serving minors, s. 51.13, Stats.
(h) Policies specific to admission and placement coordination with law
enforcement and county
crisis personnel which shall
include the following:
1. Circumstances under which a voluntary person may be referred or
transported for services and procedures for referral.
2. Placement determination for involuntary persons which includes
detention and placement authorization confirmation prior to
admission.
3. Not requiring medical clearance prior to admission.
(i) A method for obtaining written consent for treatment.
(j) A method for obtaining the client’s signed acknowledgement of having
been informed of the following:
1. The general nature and purpose of the service.
2. Client rights and the protection of privacy provided by confidentiality
laws.
3. Service regulations governing client conduct, the types of infractions
that result in corrective action or discharge from the service, and the
process for review or appeal.
4. Information about the cost of treatment, who will be billed, and the
accepted methods of payment if the client is billed.
(4) Involuntary hold policies and procedures consistent with s. 51.15, Stats.,
and s. DHS 31.11 (3) that include procedures on coordination of admissions,
transfers, and discharges with the county of detention or responsibility.
(5) Assessment of physical health needs and delivery of care for minor physical
health conditions including policies on the following:
(a) Managing common medical conditions.
(b) Managing medical emergencies.
(c) Treating an individual under the influence of alcohol or other drugs.
(d) Administration of an opioid antagonist by staff.
(6) Policies for medication management, including all of the following:
(a) Policies and procedures for prescribing and administering medications.
(b) Prescriber checks and use of the Wisconsin PDMP
Note: The Wisconsin Prescription Drug Monitoring Program database is
available online at https://pdmp.wi.gov/.
(c) Procedures for obtaining and updating client consents for
medications received and acknowledgement of risks and benefits
explained.
(d) Procedures for reporting and reviewing medication errors via facility
incident reports or other documentation.
(e) Prescriber access or consultation relationships to prescribe or consult
on psychiatric medications.
(f) Policies on medication storage, security, management, and
administration, and which staff is responsible.
(g) Policies identifying which licensed pharmacy or pharmacies a CUCOF
will use and copies of the pharmacy’s license.
(h) Policies on clients’ access to medications prescribed to them, post
discharge.
(7) Personnel policies and documentation, which shall be made available upon
request for review by the department. Personnel policies and documentation
shall include all of the following:
(a) Job positions and descriptions for each employee.
(b) Employee qualifications including copies of licenses or certifications as
applicable.
(c) Onboarding, orientation, training, and continuing education for each
employee.
(d) Training exemption determination.
(e) Clinical supervision of staff and performance reviews for each employee.
(8) Policies for clients’ personal possessions, phone or other communication
device usage, electronics usage, room searches, or other applicable policies
in accordance with s. 51.61.
(9) Policies and procedures regarding guests and visitors, including all of the
following:
(a) Procedures to ensure confidentiality for clients, including information on
ensuring recording devices aren’t utilized.
(b) Methods to mitigate risks, such as the delivery of drugs or alcohol
by guests or visitors, the possession or delivery of weapons or other
contraband by guests and visitors, or potential violent behavior by
guests or visitors.
(10) Facility rules and how they are communicated with clients.
(11) Policies and procedures for assessing the cultural and linguistic needs of
the population to be served, and to ensure that services are responsive
and appropriate to the cultural and linguistic needs of the community to
be served.
(12) Policy on service notes, treatment documentation, and client records
including information on the following:
(a) Client information to be documented and by which staff.
(b) Frequency of documentation.
(c) Maintenance of client records.
(d) Confidentiality requirements.
(13) Policies on safety concerns specific to clients, visitors, and staff including
policies on the following:
(a) Facility entrances and exits.
(b) Facility design such as ligature and barricade risk prevention, tamperresistant electrical outlets, control of sharps, impact resistant glass, and
anchoring of weighted furniture.
(c) Search of clients and property.
(d) Levels of staff observation required to address client needs.
(e) Emergency safety interventions in the event of client related
emergencies, natural disasters, structural or environmental
emergencies, and imminent internal or external threats.
(f) Elopement and procedures for responding to client elopement.
(g) Emergency safety interventions. This policy must be consistent with s.
51.61(1)(i)(1) and comply with s. DHS 31.14. It must specify alternative
interventions, best practices, and a description of how restraint will be
administered and where seclusion will occur.
(14) Policies on telehealth, artificial intelligence, and consultation via
electronic communication, including all of the following:
(a) When telehealth, artificial intelligence, or electronic communications can
be used and by whom.
(b) Client privacy and information security considerations.
(c) A client’s right to decline services provided via telehealth, artificial
intelligence, or electronic communication.
(15) Discharge and transfer policy criteria consistent with s. DHS 31.11 (5),
and including all the following:
(a) Transfers related to a client’s physical health care needs, including
emergency medical health care.
(b) Transfers when longer-term care beyond five days is required.
(16) A CUCOF that serves minors shall have written, specific policies and
procedures for care of minors consistent with this subchapter.
(17) Policies regarding mandated reporting requirements consistent with s.
48.081, Stats.
DHS 31.08 Personnel.
(1) General staff qualifications.
(a) Program staff retained to provide services at a CUCOF shall be qualified
as follows:
1. Psychiatrists shall be licensed to practice medicine in Wisconsin
under ch. 448, Stats, and be certified by the medical examining board
to practice as a psychiatrist.
2. Psychologists shall be licensed to practice medicine in Wisconsin
under ch. 455, Stats.
3. Psychology residents shall hold a doctoral degree in psychology
meeting the requirements of s. 455.04(1)(c), Stats.
4. Psychiatric residents shall hold a doctoral degree in medicine and be
in training to become a psychiatrist.
5. Physicians shall be licensed and board certified to practice medicine
or osteopathy under ch. 448, Stats.
6. Physician assistants shall be certified and registered pursuant to ss.
448.05 and 448.07, Stats.
7. Nurses shall meet the qualifications established in ch. 441, Stats.,
and be certified by the board of nursing.
8. Social workers shall meet the qualifications established in ch. 457,
Stats., and be certified by the examining board of social workers,
marriage and family therapists and professional counselors.
9. Professional counselors and marriage and family therapists shall
meet the qualifications established in ch. 457, Stats., and be certified
by the examining board of social workers, marriage and family
therapists and professional counselors.
10. Substance abuse counselors, clinical supervisors, and prevention
specialists shall meet the qualifications established in ch. 440.88,
Stats.
11. Certified peer specialists and certified parent peer specialists shall
be certified in the state of Wisconsin and have experience providing
peer services.
12. Recovery coaches shall meet the training and experience
requirements in subch. II of ch. DHS 72.
13. Other qualified mental health professionals shall have at least a
bachelor’s degree in a relevant area of education or human services
and a minimum of six months of combined experience providing
mental health services, or work experience and training equivalent
to a bachelor’s degree including a minimum of 4 years of work
experience providing mental health services.
14. Specialists in specific areas of therapeutic assistance, such as
recreational, art, and music therapies, shall have complied with
the appropriate certification or registration procedures for their
profession as required by state statute or administrative rule or the
governing body regulating their profession.
15. Occupational therapists and assistants shall meet the requirements
of ch. 448 Stats, subch. VII.
16. Behavioral health technicians or similarly titled staff providing
direct client care and serving in a clinically supportive role shall
be paraprofessionals who are employed based on personal
aptitude and life experience which demonstrates their ability to
provide effective emergency behavioral health services and have
professional health care experience.
(2) RequireD personnel. A CUCOF shall have all of the following minimum staff
positions at staffing levels identified in their staffing plan:
(a) Treatment or medical director. A CUCOF shall have a treatment
or medical director who is qualified under sub. (1) (a) 1. or 2. and
responsible for all of the following:
1. Assuming clinical responsibility and direction for the provision of care.
2. Providing clinical psychiatric services consistent with their scope of
practice.
3. Assuming responsibilities afforded a treatment director which are
consistent with ch. 51, Stats.
(b) Nursing administrator. A CUCOF shall have a nursing administrator
who is qualified under sub. (1) (a) 7. and responsible for the medical
health services provided by the program. The nursing administrator
shall also be responsible for ensuring that all staff members providing
medical health services have the qualifications required for their role in
the program and comply with all requirements relating to medical and
physical health assessment, treatment planning, service delivery, and
documentation.
(c) Clinical director. A CUCOF shall have a clinical director who has at
minimum a master’s degree and a professional, clinical license who is
responsible for all of the following:
1. The day to day behavioral, mental health and substance use services
provided by the program.
2. Ensuring that staff providing these services have the qualifications
required for their role in a CUCOF and comply with all requirements
relating to mental and behavioral health, and substance
use assessment, treatment planning, service delivery, and
documentation.
(d) Program administrator. A CUCOF shall have a program
administrator who is responsible for all of the following:
1. Administration and overall operation of a CUCOF.
2. Ensuring that appropriate policies and procedures for services are
developed and carried out in compliance with this chapter.
3. Administrative oversight of the job performance and action of service
staff.
4. Compliance with regulations governing the care and treatment
of clients and the standards of practice for behavioral health
professionals.
(3) permissiBle Dual roles.
(a) The treatment director under sub. (2) (a) may also serve as the clinical
director under sub. (2) (c).
(b) The treatment director, nursing administrator, or clinical director under
sub. (2) (a), (b), or (c) may also serve as the program administrator
under sub. (2) (d).
(4) BackGrounD checks. A CUCOF shall comply with the criminal history and
patient abuse record search requirements in s. 50.065, Stats.
DHS 31.09 Staffing requirements.
(1) StaffinG requirements.
(a) In this subsection, “24/7” means 24 hours per day, 7 days per week.
(b) On-site staffing levels shall be adequate to allow for all of the following:
1. Persons to receive services on a 24/7 basis, including through
telehealth.
2. Safety and security of clients, staff, and visitors.
3. Staff who are trained to safely engage in seclusion and restraint, if
needed, and available 24/7.
(c) A CUCOF shall maintain the following minimum staffing requirements:
1. The treatment director or their designee shall be available on-site or
by electronic communication 24/7.
2. The nursing administrator or their designee shall be available onsite 24/7.
3. The clinical director or their designee shall be available on-site or by
electronic communication 24/7.
4. A prescriber shall be available on-site or by electronic communication
24/7.
5. A nurse or physician qualified under DHS 31.08 (1) (a) 5., 6., or 7.
shall be on-site 24/7. This may include the nursing administrator
under s. DHS 31.08 (2) (b) or their designee.
6. Clinical staff qualified to provide required behavioral and mental
health, and substance use services to clients shall be on-site 8 hours
a day, 7 days a week. This may include the clinical director under s.
DHS 31.08 (2) (c) or their designee.
7. A minimum of 4 staff, which may include those identified in s. DHS
31.08 (2) (a) to (d) shall be on-site 24/7 and capable of providing all
services identified in this chapter.
8. A minimum of 2 staff identified in this paragraph shall be trained in
each of the following and on-site 24/7:
a. Basic cardiac life support and use of an automated external
defibrillator equipment.
b. Administration of an opioid antagonist.
(d) A CUCOF shall ensure staffing is adequate to maintain compliance with
requirements in s. 51.15, Stats.
(2) StaffinG plan anD scheDules.
(a) A CUCOF shall make available to the department a staffing plan which
shall include all the following:
1. Staffing levels for required personnel under DHS 31.08 (2) and sub.
(1), to include both the number of positions needed and the actual
number hired.
2. Staff availability, including staff available on-site, on-call, via
telehealth, and via electronic communication.
3. A plan for responding to fluctuations in acuity, serving clients with high
needs, staffing shortages, and surges in referrals and admissions.
(b) A CUCOF shall make available to the department, as requested, a
daily staff schedule which
identifies shifts, work hours, and
scheduled positions.
(c) A CUCOF shall consider the acuity levels and clinical and safety needs
of clients being served and adjust staffing levels based on those needs
while meeting staffing requirements as outlined in sub. (1).
(d) A staffing plan must demonstrate adequate staffing is available for the
provision of care if minors are being served.
(e) A staffing plan shall be updated when needed to meet the needs of
a CUCOF.
DHS 31.10 Personnel development.
(1) Orientation anD traininG
(a) Orientation program. A CUCOF shall develop and implement an
orientation for all new staff to ensure that staff know and understand
all of the following:
1. Pertinent parts of this chapter.
2. The program’s policies and procedures.
3. Job responsibilities for staff and volunteers of the program.
4. Applicable parts of chs. 51 and 55, Stats., ch. DHS 34, and any
administrative rules related to the provision of emergency mental
health services and care for voluntary and involuntary clients.
5. The provisions of s. 51.30 and s. 51.61 Stats., related to client rights
and confidentiality of treatment records.
(b) All employee training. A CUCOF shall provide, obtain, or otherwise
ensure adequate training for all employees in all of the following:
1. Standard precautions.
2. Fire Safety.
3. First aid and choking.
4. Abuse, neglect, and misappropriation prevention.
5. Basic mental health and psychopharmacology concepts applicable
to crisis situations.
6. Techniques and procedures for non-violent crisis intervention with
clients, including verbal de-escalation, positional de-escalation,
methods for obtaining backup, and acceptable methods for
self-protection and protection of the client and others.
7. Emergency safety interventions consistent with s. 51.61 (1) (i) (1),
Stats., and industry best practices for seclusion and restraint training
that emphasize prevention, safety, and least restrictive interventions.
8. Crisis intervention considerations for all of the following populations:
a. Clients with intellectual or developmental disabilities.
b. Clients with dementia.