Variance for Requirements for Certified Outpatient
PDF Version of BQA 05-007 (PDF,
Date: June 2, 2005 -- DDES-BQA 05-007
FROM: John Easterday, Associate Director, Division of
Disability and Elder Services; Cris Ros-Dukler, Director, Bureau of Quality Assurance
Administrative Code HFS 61 (exit DHFS)
governs Wisconsin certified outpatient mental health clinics. HFS
61.91-61.98, the Outpatient Psychotherapy Clinic Standards was last
revised in 1996. The Department last initiated an update to this rule by
drafting HFS 35 in 2000 which was not promulgated due to lack of staff
resources to complete the rule-making process. Given the changes in the
last few years, particularly with professional licensure and the emphasis
on evidenced-based programs, rules incorporating these and other concepts
need to be drafted.
In advance of rewriting HFS 61, the Department is issuing a
"bundle" of variances to provide immediate regulatory relief for
certified outpatient mental health clinics. The Department collaborated
with the Wisconsin Coalition, a group of seven professional associations
representing providers who work in these clinics.
For each of the six variances below, a provider may choose to comply
with either the existing requirement in HFS 61 or the variance
requirement. If a variance requirement is chosen, a provider must
demonstrate to the BQA surveyor at regular site visits, evidence that
these variances are reflected in clinic policies. Surveyors may monitor
the implementation of the clinic policies during any site visit.
The Department has the authority to revoke any variance if, for
example, it determines that the needs of the patients are not being met
with continued approval of this variance, or if the health, safety, or
welfare of any patient is jeopardized.
Current Rule: HFS 61.96 (1) (b) "Required Personnel. A social
worker with a masters degree from a graduate school of social work
accredited by the council on social work education, or a registered nurse
with a master's degree in psychiatric-mental health nursing, or community
mental health nursing from a graduate school of nursing accredited by the
national league of nursing."
Variance: Each clinic shall have sufficient staff with
appropriate training, experience and supervision to meet the needs of
clients as identified in the treatment plan. The certified clinic shall
employ or contract with a multidisciplinary team of qualified staff
readily available to meet the consumer needs.
Current Rule: HFS 61.97 (2) "The clinic shall provide a minimum of
2 hours each of clinical treatment by a psychiatrist or psychologist and a
social worker for each 40 hours of psychotherapy provided by the
Variance: Each clinic shall have a qualified psychiatrist or
psychologist available for consultation, supervision or collaboration with
clinical staff. Staff of a certified clinic shall include at least one
qualified licensed mental health professional as identified below. If a
clinic serves clients who are dually diagnosed with mental health needs
and needs related to alcohol or drug use or developmental disabilities,
the clinic shall demonstrate that the multiple needs of those clients are
Qualifications of Professional Staff. (a) 1. Professional staff of a
certified clinic shall include mental health professionals qualified under
par. (b) 1. to 7.
2. Professional staff identified in par. (b) shall provide clinical
services within the discipline's scope of practice as defined through
state licensure or certification.
(b) A person employed or retained by contract to fill any of the
following professional positions shall meet the minimum qualifications
listed for that position:
1. Psychiatrists shall be physicians licensed under ch. 448, Stats., to
practice medicine and surgery, shall have completed 3 years of residency
training in psychiatry in a program approved by the accreditation council
for graduate medical education, and be either certified or eligible for
certification by the American board of psychiatry and neurology.
2. Psychiatric residents shall hold a doctoral degree in medicine and
shall have successfully completed 1500 hours of supervised clinical
experience, the acceptable completion of which has been documented by the
program director of a psychiatric residency program accredited by the
accreditation council for graduate medical education.
3. Psychologists shall be licensed under ch. 455, Stats., and shall be
listed with the national register of health service providers in
psychology, meet the requirements for listing with the national register
of health services providers in psychology or have a minimum of one year
of supervised post-doctoral clinical experience related directly to the
assessment and treatment of clients with mental disorders.
4. Psychology residents shall hold a doctoral degree in psychology
meeting the requirements of s. 455.04 (1) (c), Stats., and shall have
successfully completed 1500 hours of supervised clinical experience as
documented by the Wisconsin psychology examining board.
5. Registered nurses, including advanced practice nurse prescribers (APNPs)
shall be licensed under ch. 441, Stats., as a registered nurse and shall
have had training in psychiatric nursing and at least one year of
experience providing psychotherapy in a supervised clinical setting.
6. Marriage and Family Therapists (LMFT), Professional Counselors (LPC)
or Clinical Social Workers (LCSW) shall be licensed under 2001 Wisconsin
Act 80 or meet the requirements of par. (b) 7.
7. Non-licensed master's level clinicians shall be persons with a
master's degree and course work in areas directly related to providing
mental health services, including but not limited to: clinical psychology,
psychology, school or educational psychology, rehabilitation psychology,
counseling and guidance, clinical social work, psychiatric nursing,
professional counselors, marriage and family therapy, or counseling
psychology. Such professionals may be in training, have a temporary
certificate, or working toward their 3,000 hours of supervised experience
in conjunction with their respective licensing credential.
Each clinic that employs non-licensed master's level practitioners as
identified under Variance #2 par. (b) (7) shall develop and implement a
written policy for clinical supervision. At minimum the policy shall
- Non-licensed master's level practitioners providing therapy shall
receive a minimum of one hour of direct, individual supervision for
every 30-clock hours of face-to-face psychotherapy services provided.
Supervision of non-licensed practitioners shall be documented by
notation in her/his appointment book or supervisory log.
- Providers of supervision. Supervision of individual, non-licensed
master's level practitioners shall be provided by mental health
professionals qualified under variance # 2 par. (b) 1. to 6, or (b)
(7) who have Individual Provider Status approval.
- Review of patient care for non-licensed masters' level
practitioners. The supervised review of patient progress shall occur
at intake and at least 30 day intervals for patients receiving at
least 2 therapy sessions per week and once every 90 days for patients
receiving one therapy session per week or less frequently. Staff that
provide supervision must document the review by signature and date in
the patient record.
(c) If a clinic does not employ or retain by contract a professional
under Variance #2 par. (b) to provide clinical treatment services specific
to the special needs of a client, the clinic shall have a written referral
agreement with an appropriate professional or entity to collaborate on
patient treatment needs to ensure continuity of clinical care.
Current Rule: HFS 61.97 (3) "Personnel employed by a clinic as
defined in s. HFS 61.96 (1) (b) and 2 shall be under the supervision of a
physician or licensed psychologist who meets the requirements of s. HFS
(a) There shall be a minimum of 30 minutes of supervision which shall be
documented by notation in the master appointment book for each 40 hours of
therapy rendered by each professional staff person.
(b) Supervision and review of patient progress shall occur at intake and
at least at 30 day intervals for patients receiving 2 or more therapy
sessions per week and once every 90 days for patients receiving one or
less therapy sessions per week."
Variance: Each clinic shall develop and implement a written
policy for clinical consultation and require all personnel to adhere to
all laws and regulations governing the care and treatment of patients and
the standards of practice for their individual professions. At minimum the
written policy will address the following:
- A system to determine the status or achievement of client outcomes,
which may include a quality improvement system or a peer review system
to determine if the treatment provided was effective, and if the
recorded information is necessary and sufficient. This system should
result in identification of necessary corrective actions, such as
staff training needs.
- Criteria that identify clinical issues that warrant consultation,
supervision, or collaboration, including critical incidents that
involves one or more clients of the outpatient mental health clinic.
- Documentation of peer review, clinical consultation, supervision, or
collaboration sought by all staff providing psychotherapy and any
recommended changes or improvement of the treatment plan.
Current Rule: HFS 61.97 (5) "A physician must make written
referrals of patients for psychotherapy when therapy is not provided by or
under the clinical supervision of a physician. The referral shall include
a written order for psychotherapy and include the date, name of the
physician and patient, the diagnosis and signature of the physician."
Variance: A physician, licensed clinical psychologist, licensed
marriage and family therapist, licensed professional counselor, licensed
clinical social worker or APNP Board Certified in Psychiatric-Mental
Health Nursing may issue the order for psychotherapy. The order for
psychotherapy shall include the diagnosis, date, name and signature of the
prescriber, and be documented in the clinical record.
Note: This variance does not constitute granting a variance of s.
49.46 (2) (b) 6. f., Stats., or the Medical Assistance (Title XIX)
requirements. BQA does not have the authority to grant waivers or
variances for Medical Assistance rules. Please contact Christine Wolf at
(608) 266-9195 for further information about requirements for Medical
Current Rule: HFS 61.97(9) Group therapy sessions should not exceed 10
patients and 2 therapists."
Variance: A ratio of 8 patients per therapist or up to 16
patients per group with two therapists is permitted. This group ratio is
consistent with Community Substance Abuse Standards, HFS 75.02 (3). (Note:
3rd party payers may have specific requirements/limitations for group
size. The payer requirements may potentially affect clinic group size and
reimbursement for group services.)
Current Rule: HFS 61.97(15) f "Upon written request of the patient
the clinic shall transfer the clinical information required for further
treatment as determined by the supervising physician or
Variance: The supervising physician, psychologist, treatment
director or "designated qualified staff" shall transfer or
release the clinical information required for further treatment. Qualified
staff shall either be licensed mental health professionals or other clinic
staff with experience/knowledge in record maintenance protocol. Note:
Staff that transfer or release clinical information must comply with the
confidentiality requirements identified in HFS 92, s.51.30 and the Health
Insurance Portability and Accountability Act of 1966 (HIPAA).
Note: Granting of any of these variances does not constitute
granting a variance s. 49.45 (2) (b) 6. f., Stats., of the Medical
Assistance (Title XIX) requirements. The Bureau of Quality Assurance does
not have the authority to grant waivers or variances for Medical
Assistance rules. Please contact Christine Wolf at (608) 266-9195 for
further information about requirements for Medical Assistance.
If you have questions about these variances, please contact your
Program Certification Specialist. Contact phone numbers are attached.
cc: Jeff Hinz, Section Chief, Bureau of Mental Health and Substance
Abuse Services; Mark Hale, Supervisor, Program Certification Unit, Bureau
of Quality Assurance; Dan Zimmerman, Contract Administrator, Bureau of
Mental Health and Substance Abuse Services
Last Updated: March 23, 2011