Program Certification Unit Information
PDF Version of BQA 99-056
(PDF, 21 KB)
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
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
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 clients 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
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
masters 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.
Masters 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)
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 masters 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
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 masters 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
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
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 masters 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
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
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.
Beginning November 1, 1999, the branch office fee is $200 regardless of the number of
days per week the branch is open.
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
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.
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.
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: www.dhfs.state.wi.us. 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 programs 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 complainants 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 States
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)
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