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Program Certification Unit Information

Date: October 5, 1999 -- DSL-BQA-99-056

From: Susan Schroeder, Director, Bureau of Quality Assurance

To:    All Certified Mental Health and AODA Facilities - CMHA 08

New Staff

The Division of Supportive Living has appointed me, Susan Schroeder, as the Director of the Bureau of Quality Assurance. I was formerly the Deputy Director of the Rock County Human Services Department prior to my most recent position as the Administrator of CrossRoads Counseling Center in Janesville, Wisconsin.

The Bureau of Quality Assurance has appointed Jason Kay to the vacant Licensing/Certification Specialist assigned to the following counties: Jefferson, Kenosha, Ozaukee, Racine, Walworth, Washington, and Waukesha. Mr. Kay can be reached at:

Jason Kay, Licensing/Certification Specialist
Southeast Regional Office
819 North 6th Street, Room 875
Milwaukee, WI 53203
(414) 227-4855

Attached is an updated listing of names, mailing addresses, telephone numbers and e-mail addresses [sorry, E-mail addresses not included]  of the Program Certification Unit (PCU) staff and their assigned counties. If you are unable to reach your certification specialist, contact Otis Woods, Supervisor of the PCU [replaced by Mark Hale, (608) 243-2087].

Frequently Asked Questions

The following is a list of frequently asked questions posed by certified programs and responses given by the PCU:

1.  Who can serve as the Client Rights Specialist (CRS)?

Answer: Section HFS 94.40 (3) (b) of the Wisconsin Administrative Code states: "The client rights specialist may be an employe of the program in a coalition or may be a person under contract to a program or to a coalition of programs." Furthermore, s. HFS 94.40 (3)(c) states, "The client rights specialist assigned to conduct a program level review under s. HFS 94.41 shall not have any involvement in the conditions or activities forming the basis of the client’s grievance, or have any other substantial interest in those matters arising from his or her relationship to the program or the client, other than employment." A question was raised on whether a therapist can serve as the CRS for a patient who is the client of another therapist employed by the same certified entity. This scenario is permitted by this rule, so long as the therapist is not involved in the issues surrounding the grievance; it would be recommended that the certified entity select a CRS that has no affiliation with patient services, and one that receives appropriate training to function as the CRS, under s. HFS 94.40 (2) (d), WI Administrative Code.

It is ultimately the responsibility of the certified program to ensure that there is not a conflict of interest in selecting a CRS that has no affiliation with the matter that resulted in the grievance. For this reason, we recommend that an independent party, outside of the clinic, be identified as the CRS.

Questions concerning the CRS can be directed to Mike Peters at (608) 266-6989.

2.  What is the criteria used to determine if an individual meets the educational requirements for approved provider status, under s. HFS 61.96 (2) and (3), and the Community Support Program Coordinator requirements under s. HFS 63.06 (2) (c)?

Answer: Section HFS 61.96 (3) and s. HFS 63.06 (2) (c) both require the attainment of a master’s degree (plus 3,000 clinical practice hours) before meeting the qualifications of a mental health technician, under the clinic standards for outpatient mental health services (s. HFS 61.91, WI Administrative Code) and under the community support program (CSP) requirements of Chapter HFS 63, WI Administrative Code. Master’s degrees approved in meeting this requirement include social work (clinical rather than administrative emphasis), clinical psychology, and psychiatric mental health nursing or equivalency requirements. Equivalency requirements include concentration in the behavioral sciences or a related field with at least 60% (or a minimum of 28 degree credits) taken in these behavioral sciences or related areas. If there are courses that you feel qualify under the equivalency considerations, please contact Otis Woods at (608) 266-0120.

Note: The 3,000 hours of clinical practice experience required under s. HFS 61.96 (3), WI Administrative Code, must be gained providing psychotherapy to patients that are DSM-IV diagnosed mentally ill. The 3,000 hours of clinical practice experience required of a CSP clinical coordinator, under s. HFS 63.06 (2) (c), must be obtained treating patients that are chronically mentally ill. Additionally, the CSP clinical coordinator may also qualify if there is a master’s degree similar to what was outlined above and 1,500 hours of supervised clinical experience in a CSP.

3.  Is there a difference between the 3,000 hours required for certification as an independent clinical social worker (CICSW) - who qualifies to practice psychotherapeutic social work, under chapter SFC 7 of the Wisconsin Administrative Code - and the 3,000 hours clinical practice requirements under s. HFS 61.96 (3), WI Administrative Code?

Answer: The requirements are essentially the same; however, individual therapists are not prevented from providing psychotherapy under s. HFS 61.96, WI Administrative Code. Certified clinics must meet these standards to qualify for reimbursement for services provided under s. 632.89, Stats.

Under s. SFC 7.01 (1)(a), WI Administrative Code, "… a certified independent clinical social worker may not engage in psychotherapeutic social work unless he or she has completed 3,000 hours of supervised clinical practice in accordance with sub. (2) after receiving a master’s degree, consisting of a minimum of one hour per week of face-to-face supervision during the 3,000 hour period by a person qualified under par. (a), if he or she is listed in the national registry of health care providers in clinical social work…"

Section SFC 7.01 (3) states, "A certified independent clinical social worker may engage in the independent unsupervised practice of psychotherapeutic social work when he or she has completed the 3,000 hour supervised clinical practice period, or is listed in the national registry of …"

Similarly, the qualifications for provider status, outlined in s. HFS 61.96 (3) state: "Mental health professionals designated in subs (1)(b)" (the social worker requirement) "and (2) shall have 3,000 hours of supervised experience in clinical practice, which means a minimum of one hour per week of face-to-face supervision during the 3,000 hour period by another mental health professional meeting the minimum qualifications…"

The Program Certification Unit verifies clinical practice by requiring a "Supervisor Affidavit" attesting to the completion of the 3,000 hours. This is required not only of those who have attained the CICSW approval from the Wisconsin Department of Regulation and Licensing, but other professionals with varying behavioral sciences or related master’s degrees. The practice of psychotherapy conducted at certified clinics is required to be supervised by either a physician who has completed a residency in psychiatry or by a licensed clinical psychologist that is listed or eligible to be listed in the national registry of health services providers in psychology, pursuant to s. HFS 61.96 (1) (a) and 61.97 (3) of the Wisconsin Administrative Code.

Note: the Department of Regulation and Licensing (DRL) enforces the requirements for credentialing under chapter SFC 7, WI Administrative Code. The Department of Health and Family Services has no authority in enforcing these rules. Questions concerning these requirements should be directed to DRL at (608) 266-0145.

New Office Procedures

  1. The Bureau has developed a new database for record and information retention for the Program Certification Unit. We will soon re-locate information that is contained in the current Dbase III system to the new data system. Effective November 1, 1999, renewal notices will contain an additional attachment outlining the exact fees required for re-certification.

  2. When submitting payment of certification fees by check from a non-certified central location, please attach a note or provide additional information indicating the provider name and location that will be listed on the certificate. This will prevent having to re-issue the certificate causing delays in reimbursement for rendered services.

  3. Beginning November 1, 1999, the branch office fee is $200 regardless of the number of days per week the branch is open.

  4. If there are currently multiple certificates for a certified location, the new system will combine all services on the same certificate. Exceptions to this may be the identification of a program certified under ch. HFS 63, WI Administrative Code, Community Support Program.

  5. Under the former data system, many certified programs have experienced delays in receiving a revised certificate; we apologize for these delays and thank you for your patience. We anticipate these delays to be corrected in the new system. If there are concerns regarding the new certificates, please contact M. Bid Webb at (608) 266-9480.

  6. Periodically, certified programs experience changes such as moving to a new location, undergoing a change in owner, or adding/replacing treatment staff. When this occurs, the program should immediately notify the licensing/certification specialist assigned to the program. Attached is an updated listing of Program Certification Unit staff. Please identify your home county, and thus, your assigned reviewer. This will ensure that you continue to receive all correspondence sent out by the Department, including Bureau memos.

Caregiver Law

The Caregiver Law went into effect October 1, 1998. Several changes to the Caregiver Law have occurred and further changes are proposed to the State biennial budget. Current information about caregiver background checks, caregiver misconduct, reporting requirements, HFS 12 and 13, including the crimes list, forms, and other information can be found at: Click on "Background Checks" to locate all the current information.

Certification of Waivers and Variances

Periodically, certified programs request exceptions to meeting program standards. A waiver, if granted, allows the provider to not meet the requested regulation. A "variance" indicates that the certified program will meet the regulation in a manner different than what the regulation requires. For example, most commonly requested is a waiver of s. HFS 61.97 (5), WI Administrative Code, for physician referrals for certified outpatient mental health programs. To meet this requirement, certified entities request using the services of a licensed clinical psychologist in place of a physician. This is actually a variance permitting them to meet the rule in a different manner. For future requests, please indicate whether you want a rule waived entirely or you would like to meet the rule in a manner other than what is required, thereby requesting a variance of a rule.

Client Rights Complaints

The PCU receives allegations of patient rights violations and determines the validity of the complaint. The rules do not require that upon receiving an allegation, the PCU make contact with the certified program’s client rights specialist. We often recommend that complainants, in addition to sharing their concerns with the PCU, also contact the CRS to try and work out their issues/grievances informally. Chapter HFS 94, WI Administrative Code, does not require that the complainant first contact the CRS. The PCU is often the first to discuss the complainant’s concerns as the complainant does not feel comfortable with contacting program staff. As a result, the PCU determines if an investigation of the allegation is warranted following discussion with the State’s Grievance Examiner, Mike Peters.

Reportable Death Investigations

The Division of Supportive Living has developed new procedures for reporting and investigating deaths that are the result of suicides, use of psychotropic medication or the use of a physical restraint. The guidelines will be issued in the coming months.

Please direct additional questions and concerns to Otis L. Woods, Supervisor, Program Certification Unit [replaced by Mark Hale, (608) 243-2087].

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