A CCF shall have written policies and procedures for all of the following:

1. (1) Communicating bed availability via the department-approved psychiatric bed locator in accordance with s. DHS 31.11 (7) and a dedicated 24/7 phone line for incoming external calls.

2. (2) Coordination requirements, including all of the following:

   1. (a) Procedures for coordinating crisis care for individuals in need of services but not admitted to a CCF.

   2. (b) Procedures for follow-up and care coordination with external providers, as appropriate, including any of the following:

      1. 1. County crisis providers
      2. 2. Inpatient psychiatric facilities
      3. 3. Any facility established or operated with funding received under s. 165.12, Stats., from settlement proceeds from the opiate litigation as defined in s. 165.12 (1), Stats.
      4. 4. A hub-and-spoke health home pilot program, or other transition facilities

3. (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:

   1. (a) The minimum age requirements for admission.

   2. (b) The arrangement of rooms and space, including all of the following, as applicable:

      1. 1. The number of client rooms in a secured setting and whether they are single or dual occupancy.
      2. 2. The number of client rooms in an unsecured setting and whether they are single or dual occupancy.
      3. 3. The size of any observation unit for client stays less than 24 hours and how this space is designed.
   3. (c) The total number of beds available, and how those beds are allocated across the spaces identified in par. (b) 1. to 3.
   4. (d) Eligibility requirements, including how a CCF will coordinate care for individuals in need of crisis services who do not meet eligibility requirements.
   5. (e) Procedures for the determination of referring an individual when a CCF is at capacity or holding on admissions consistent with s. DHS 31.11 (6).
   6. (f) Policies regarding involuntary admission of a client under s. 51.15, Stats., and s. DHS 31.11 (3).
   7. (g) Policies regarding voluntary admission of a client in accordance with s. 51.10 (5), Stats., and, if serving minors, s. 51.13, Stats.

   8. (h) Policies specific to admission and placement coordination with law enforcement and county crisis personnel which shall include the following:

      1. 1. Circumstances under which a voluntary person may be referred or transported for services and procedures for referral.
      2. 2. Placement determination for involuntary persons which includes detention and placement authorization confirmation prior to admission.
      3. 3. Circumstances under which medical clearance is and is not required prior to admission.
   9. (i) A method for obtaining informed consent for treatment consistent with s. DHS 94.03.

   10. (j) A method for obtaining the client’s signed acknowledgement of having been informed of the following:

       1. 1. The general nature and purpose of the service.
       2. 2. Client rights and the protection of privacy provided by confidentiality laws.
       3. 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. 4. Information about the cost of treatment, who will be billed, and the accepted methods of payment if the client is billed.
4. (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 responsibility.

5. (5) Policies for the assessment of physical health needs and personal care needs, and delivery of care for minor physical health conditions including policies on the following:

   1. (a) Managing common medical conditions.
   2. (b) Managing medical emergencies.
   3. (c) Identifying what personal care needs can be safely provided and how.
   4. (d) Performing necessary laboratory and diagnostic services and identification of which licensed laboratory or laboratories a CCF will use and copies of the laboratory’s license.
   5. (e) Treating an individual under the influence of alcohol or other drugs.
   6. (f) Administration of opioid reversal medication by staff.

6. (6) Policies for medication management, including all of the following:

   1. (a) Policies and procedures for prescribing and administering medications.

   2. (b) Prescriber checks and use of the PDMP database, including policies identifying when it is clinically necessary to check the PDMP database.

      Note: The Wisconsin Prescription Drug Monitoring Program database is available online at https://pdmp.wi.gov/.

   3. (c) Procedures for obtaining and updating client consents for medications received and acknowledgement of risks and benefits explained consistent with DHS 94.09.
   4. (d) Procedures for reporting and reviewing medication errors via facility incident reports or other documentation.
   5. (e) Prescriber access or consultation relationships to prescribe or consult on psychiatric medications.
   6. (f) Policies on medication storage, security, management, and administration, and which staff is responsible.
   7. (g) Policies identifying which licensed pharmacy or pharmacies a CCF will use and copies of the pharmacy’s license.
   8. (h) Policies on clients’ access to medications prescribed to them, post discharge.

7. (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:

   1. (a) Job positions and descriptions for each employee.
   2. (b) Employee qualifications including copies of licenses or certifications as applicable.
   3. (c) Onboarding, orientation, training, and continuing education for each employee.
   4. (d) Training exemption determination.
   5. (e) Clinical supervision of staff and performance reviews for each employee.
8. (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, Stats.

9. (9) Policies and procedures regarding guests and visitors, including all of the following:

   1. (a) Procedures to ensure confidentiality for clients, including information on ensuring recording devices are not utilized.
   2. (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. (10) Facility rules and how they are communicated with clients.
11. (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. (12) Policies on service notes, treatment documentation, and client records including information on the following:

    1. (a) Client information to be documented and by which staff.
    2. (b) Frequency of documentation.
    3. (c) Maintenance of client records.
    4. (d) Confidentiality requirements.

13. (13) Policies on safety concerns specific to clients, visitors, and staff including policies on the following:

    1. (a) Facility entrances and exits.
    2. (b) Facility design such as ligature and barricade risk prevention, tamper-resistant electrical outlets, control of sharps, impact resistant glass, and anchoring of weighted furniture.
    3. (c) Search of clients and property.
    4. (d) Levels of staff observation required to address client needs.
    5. (e) Emergency safety interventions in the event of client related emergencies, natural disasters, structural or environmental emergencies, and imminent internal or external threats.
    6. (f) Elopement and procedures for responding to client elopement.
    7. (g) Emergency safety interventions. This policy must be consistent with s. 51.61 (1) (i) 1., Stats., 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. (14) Policies on telehealth, artificial intelligence, and consultation via electronic communication, including all of the following:

    1. (a) When telehealth, artificial intelligence, or electronic communications can be used and by whom.
    2. (b) Client privacy and information security considerations.
    3. (c) A client’s right to decline services provided via telehealth, artificial intelligence, or electronic communication.

15. (15) Discharge and transfer policy criteria consistent with s. DHS 31.11 (5), and including all the following:

    1. (a) Transfers related to a client’s physical health care needs, including emergency medical health care.
    2. (b) Transfers when longer-term care beyond 5 days is required.
16. (16) A CCF that serves minors shall have written, specific policies and procedures for the care of minors consistent with this subchapter.
17. (17) Policies regarding mandated reporting requirements consistent with s. 48.081, Stats.

History

History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (3) (c), (9) (a), (15) (b) made under s. 35.17, Stats., Register February 2026 No. 842.