Wyo. Code R. 048-0077-2
Mental Health and Substance Use Disorder Services
Chapter 2: Behavioral Health Service Provider Certification
Effective Date: 04/09/2020 to 09/18/2024
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0077.2.04092020
(a) This Chapter establishes the certification criteria and process for behavioral health service providers.
(b) This Chapter applies to all behavioral health service providers.
(a) Pursuant to Wyoming Statute 9-2-2701(c), the Department may not allocate to a provider state funds for substance use disorder treatment unless the provider is certified by the Department under these Rules.
(b) In order to be certified, the following types of providers must be nationally accredited, as follows:
(i) If a provider seeks to receive funds from the Department pursuant to the Community Human Services Act and Chapter 3 of these Rules, the provider must be nationally accredited for each core behavioral health service to be funded by the Department.
(ii) If a provider seeks to receive funds from the Department pursuant to the Court Supervised Treatment Act and Chapter 6 of these Rules, the provider must be nationally accredited for each core behavioral health service to be funded by the Department.
(iii) If a substance use disorder residential treatment services provider provides services to court ordered clients the provider must be nationally accredited for substance use disorder residential treatment services.
(c) In order to be certified, the following types of providers must either be nationally accredited or satisfy the relevant certification standards under Section 8 of this Chapter, as follows:
(i) If a substance use disorder outpatient treatment provider seeks to provide services to court ordered clients, and does not receive funds from the Department pursuant to the Community Human Services Act and Chapter 3 of these Rules or the Court Supervised Treatment Act and Chapter 6 of these Rules, the provider must either:
(A) Be nationally accredited for each substance use disorder service provided to court ordered clients; or
(B) Meet the certification standards, as relevant, under Section 8 of this Chapter.
(ii) If a substance use disorder treatment provider receives funds from the Department of Corrections, the provider must either:
(A) Be nationally accredited for each substance use disorder service provided to court ordered clients and in a manner approved by the Department of Corrections; or
(B) Meet the certification standards, as relevant, under Section 8 of this Chapter.
(a) In order to be certified by the Department, a provider shall submit a complete certification application in the form established by the Department through the Department's website: https://health.wyo.gov/behavioralhealth/mhsa/certification/.
(b) A certification application must provide documentation or other evidence that the provider is nationally accredited pursuant to Section 2 of this Chapter or satisfies the applicable certification requirements established under Section 8 of this Chapter. The certification requirements under Section 8 of this Chapter are deemed satisfied if the provider is nationally accredited pursuant to Section 2 of this Chapter.
(a) Upon receipt of a complete certification application, the Department shall review the application for compliance with these Rules.
(i) The Department's review may include an on-site inspection and independent verification of national accreditation with the accrediting body, if applicable.
(ii) The Department shall approve or deny a completed application within sixty (60) calendar days after receiving the application.
(b) If the Department finds the provider satisfies the eligibility criteria and certification standards of these Rules, the Department shall certify the provider for a period of up to three (3) years and shall notify the provider of the term of the certification.
(i) A certification begins upon receipt of the certification notification and expires as established by the notice of certification.
(ii) If a certified provider is nationally accredited pursuant to Section 2 of this Chapter, the provider shall adhere to national accreditation standards throughout the term of certification. A nationally accredited provider shall submit to the Department, within thirty calendar (30) days of submission to the national accrediting body, all survey reports, continuous quality improvement reports, annual conformance reports, reports of major unusual incidents, or any other reports required by the national accrediting body. The provider's submission to the Department must include documentation that the reports were accepted by the accrediting body.
(iii) If a certified provider is not nationally accredited pursuant to Section 2 of this Chapter, the provider shall maintain compliance with applicable certification standards according to Section 8 of this Chapter throughout the term of certification.
(a) A renewed certification grants the same rights and imposes the same duties as an initial certification under Section 4(b) of this Chapter.
(b) In order to renew certification, a certified provider shall submit to the Department a complete renewal application in the form established by the Department through the Department's website: https://health.wyo.gov/behavioralhealth/mhsa/certification/.
(i) A renewal application must:
(A) Be submitted no less than sixty (60) calendar days prior to the expiration date of a provider's certification; and
(B) Provide documentation or other evidence that the provider continues to satisfy the certification standards established under Section 8 of this Chapter or continues to maintain national accreditation.
(c) Upon receipt of a complete application to renew certification, the Department shall review the application for compliance with these Rules.
(i) The Department's review may include an on-site inspection and independent verification of national accreditation with the accrediting body, if applicable.
(ii) The Department shall approve or deny an application within sixty (60) calendar days after receiving the application.
(a) The Department may deny a certification application, including an application to renew certification, or revoke a certification on the following grounds:
(i) Failure to submit a complete application in the form and manner established by the Department;
(ii) Failure to comply with Section 8 of this Chapter if a provider is not nationally accredited;
(iii) Failure to maintain national accreditation if national accreditation is required under Section 2(b) of this Chapter;
(iv) Failure to provide services in accordance with the applicable standard of care for the profession involved;
(v) Existence of a condition creating serious detriment to the health, safety, or welfare of clients;
(vi) Failure to complete a resolution plan or failure to submit a resolution plan within required timelines under Chapter 4 of these Rules; or
(vii) Prior revocation of a certification by the Department within three (3) years previous to the date the renewal application is submitted.
(b) If the Department denies a certification application or revokes a certification, the Department shall notify the provider in writing of the action. The notice must:
(i) State the grounds for the action; and
(ii) Inform the provider of its right to a contested case proceeding pursuant to the Wyoming Administrative Procedure Act, located at W.S. 16-3-101 to -115, and these Rules.
(c) Prior to revoking a certification, the Department may offer a provider an opportunity to correct each deficiency that would serve as grounds for the prospective revocation, based on the following conditions:
(i) The Department may not offer a provider an opportunity to correct unless the Department finds that each deficiency:
(A) Does not include the existence of a condition creating serious detriment to the health, safety, or welfare of clients; and
(B) Can reasonably be corrected within sixty (60) calendar days of the Department’s offer.
(ii) The Department’s offer to correct must be in writing and state each deficiency that would serve as grounds for the prospective revocation of the provider’s certification.
(iii) The provider shall submit an acceptable resolution plan to the Department within ten (10) business days from the provider’s receipt of the Department’s offer to correct. A resolution plan must be in writing and provide:
(A) Who will be charged with the responsibility to correct each deficiency stated in the Department’s offer;
(B) What will be done to correct each deficiency;
(C) How the resolution plan will be incorporated into the provider's quality management program;
(D) Who will be charged with monitoring to ensure each deficiency does not occur or develop again; and
(E) The deadline by when the provider expects to correct each deficiency, which may not exceed sixty (60) calendar days after the Department's offer was issued.
(iv) The Department may reject a resolution plan if the plan fails to satisfy the criteria enumerated under subsection (c)(iii) of this Section.
(v) The Department's offer to correct is deemed to be rescinded if:
(A) The Department rejects the provider's resolution plan; or
(B) The provider fails to timely submit a resolution plan.
(vi) If the Department's offer to correct is rescinded, the provider is not entitled to challenge the rescission through a contested case proceeding pursuant to the Wyoming Administrative Procedure Act.
(vii) If the Department accepts the provider's corrective action plan and the provider fails to correct each deficiency by the established deadline, the provider's failure to correct may serve as independent grounds for revocation under this section.
(a) A certification is non-transferable.
(b) If there is a change or transfer in ownership of a certified provider:
(i) The provider's certification expires on the effective date of the change or transfer in ownership; and
(ii) The new owner(s) shall submit a new certification application to the Department in order to become a certified provider.
(c) If a certified provider intends to terminate operations or cease services the provider shall immediately notify the Department. The notification must:
(i) Include the anticipated effective date of the termination or cessation; and
(ii) Be provided to the Department seven (7) business days before the actual effective date of the termination or cessation.
(d) A provider's certification expires on the effective date of the provider's termination or cessation.
(a) To be certified or to renew certification, a provider of substance use disorder services, who is not nationally accredited pursuant to Section 2 of this Chapter, shall meet the following standards as applicable:
(a) If a provider is neither a hospital nor a governmental entity, the provider shall have documentation:
(b) A provider shall adopt, implement, and enforce written policies and procedures that address:
(ii) Client grievance procedure which must include review of grievances by the provider’s executive director and, if the provider receives funds from the Department according to Section 2(b) of this Chapter, review by the governing board;
(iii) Clinical oversight;
(iv) Client rights including consent to treatment;
(v) Continuing education of staff and cross-training;
(vi) Fiscal management in accordance with Generally Accepted Accounting Principles;
(vii) A fee schedule or written financial policy which includes a payment plan that considers the client’s income, financial resources and number of dependents for clients unable to pay the established fee;
(viii) Maintenance and contents of client case records in accordance with Section 11 of this Chapter;
(ix) Placement of clients in the appropriate level of care based on ASAM criteria;
(x) Quality of care reviews;
(xi) Relevant insurance maintenance; and
(xii) The treatment process and clinical protocols, including the type of infractions or conditions that must occur for a client to be terminated from a provider.
(a) Clinical services must be provided by qualified clinical staff capable of:
(i) Monitoring substance use disorders and stabilized mental health illnesses;
(ii) Recognizing any instability of clients with co-occurring mental health diagnoses;
(iii) Obtaining and interpreting information regarding the client’s bio-psychosocial and spiritual needs; and
(iv) Demonstrating competency in working with substance use disorder clients.
(b) A qualified clinical supervisor, as defined in W.S. 33-38-102(a)(xiii), shall provide clinical oversight.
(i) At a minimum, clinical oversight must consist of one (1) contact per month between a clinical supervisor and treatment staff or peer consultation if the provider is one person.
(ii) A clinical supervisor shall provide oversight and performance evaluation of clinical staff in core competencies based on evidence-based supervision standards of the field and may include those identified in the SAMHSA TAP 21-A.
(iii) Clinical oversight must be part of the provider’s staff development plan.
(iv) Clinical oversight or peer consultation must include, at a minimum, documentation of regular meetings showing that consultation took place. This documentation may be completed by either party.
(a) A provider shall maintain a client case record for each client admitted for services.
(b) A provider shall maintain all client case records in accordance with professional standards of practice, including storage of records in a secure and designated area.
(c) Client case records must include the following documentation and reflect the following applicable services utilizing ASAM criteria, according to the unique needs of each individual client:
(i) Consent to receive treatment signed by the client or legal guardian;
(ii) A statement signed by the client or legal guardian affirming that confidentiality was explained to them and that they understand what information is protected and under what circumstances information can or cannot be released;
(iii) A form signed by the client or legal guardian acknowledging receipt and affirming that they understand the procedures for filing a complaint;
(iv) A form signed within the last year by the client or legal guardian acknowledging receipt and affirming that they understand client rights;
(v) A form signed by the client or legal guardian acknowledging receipt, understanding, and acceptance of provider policies and procedures governing the treatment process;
(vi) Clinical assessments, based on the following criteria:
(A) A provider serving adults shall utilize an evidence-based assessment tool which includes comprehensive information regarding the client’s bio-psychosocial and spiritual needs;
(B) A provider serving adolescents shall utilize a bio-psychosocial assessment tool which, at a minimum, includes the following domains: medical, criminal, substance use, family, psychiatric, developmental and academic history; intellectual capacity; physical and sexual abuse history; spiritual needs; peer, environmental, and cultural history; and, assessment of suicidal and homicidal ideation;
(C) A provider shall utilize the ASAM criteria including the dimensional criteria for each domain in the assessment process;
(D) A provider shall adequately assess the client’s need for case management services according to subsection (ix) of this section; and
(E) When a client is transferred from another provider which completed the assessment, a receiving provider shall complete a transfer note showing that the assessment information was reviewed. Further, a provider shall determine if the client’s needs are congruent with this assessment, make needed adjustments to treatment recommendations, and note the adjustment in the client file;
(vii) Diagnosis and diagnostic summary utilizing diagnostic tools which are standard for the field and which are acknowledged by the Department and payer sources;
(viii) Treatment plans, which must:
(A) Be completed when treatment is initiated and updated at a minimum of every ninety (90) calendar days;
(B) Be developed utilizing the assessment information, including the diagnosis and ASAM criteria;
(C) Integrate mental health needs if included as part of the assessment and diagnosis, if identified as part of the assessment process, or at any point during the course of treatment; and
(D) Include:
(I) Evidence the client or guardian participated in the development of the treatment plan, signed the treatment plan, and received a copy of the treatment plan;
(II) Outcome driven goals and measurable objectives;
(III) Changes in the client’s symptoms and behaviors that are expected during the course of treatment in the current level of service, expressed in measurable and understandable terms;
(IV) The desired improved functioning level of the client utilizing the assessment; and
(V) Documentation of appropriate consequences of infractions that do not require immediate termination with appropriate timeframes for clients to address infractions prior to terminating the client;
(ix) A case management plan, based on the following criteria;
(A) A provider shall provide case management services directly or through memorandum of agreement among multiple agencies or providers;
(B) Case management services must include collaboration with other available agencies, providers, and services to meet individual client needs based on ongoing assessments when applicable; and
(C) Special emphasis must be placed on coordinating with other providers including, but not limited to, education institutions, vocational rehabilitation, recovery supports, and workforce development services to enhance the client’s skill base, chances for gainful employment, housing, community resource supports, and other options for independent functioning;
(x) Progress notes, which must:
(A) Document the symptoms and condition of the client, response to treatment, and progress or lack of progress toward specified treatment goals;
(B) Be detailed enough to allow a qualified person to follow the course of treatment;
(C) Be completed as they occur for individual, IOP, and group therapy sessions. The dates of services shall be documented as part of each individual or group therapy session progress note; and
(D) Be signed by the staff providing services to the client. If the staff is not a qualified clinical staff the progress notes shall also be signed by a qualified clinical staff;
(xi) Releases of client confidential information completed in full and signed by the client or legal guardian and the provider;
(xii) Referrals;
(xiii) Quality of care reviews;
(xiv) Correspondence relevant to the client’s treatment, including all letters and dated notations of telephone conversations conducted by provider staff;
(xv) Documentation of any prescribed medication, to include:
(A) The client was fully apprised about the medication;
(B) The assessment for the medication;
(C) Each prescribed medication;
(D) Medication monitoring; and
(E) If the client is receiving MAT from another provider, documentation of collaboration and attempts to collaborate with the qualified provider of MAT;
(xvi) Evidence the client was given information regarding communicable diseases, referred for screening, and provided linkages to appropriate counseling; and
(xvii) Documentation of continued stay, transition, and discharge planning, including the ASAM level of care recommendation. Discharge summaries must contain a summary of pertinent case record information and any plan for continuing care, referral, or admission to another level of care.
(a) A provider shall provide therapies and intervention services in an amount, frequency, and intensity appropriate to the client’s individualized treatment plan.
(i) A provider shall utilize family therapy when indicated by client needs and, with the consent of the client, shall involve family members, guardians, or significant other(s) in the assessment, treatment, and continuing care of the client.
(ii) If a provider provides group therapy, the group must be composed of two (2) or more unrelated clients for the purpose of implementing each person’s treatment plan. A provider shall provide group therapy consistent with evidence-based practice. 12-Step meetings are not considered group therapy.
(iii) For clients with mental health concerns, a provider shall address the issues of psychotropic medication and mental health treatment and their relationship to substance use disorders. A provider shall employ intervention strategies, as needed. Co-occurring treatment must include therapies to actively address, monitor, and manage psychotropic medication, mental health treatment, and the interaction with substance use related disorders.
(b) A provider of outpatient substance use disorder treatment to adults referred or ordered to receive services by the court shall follow best practice guidelines, including those contained in the SAMHSA TIP 44.
(c) The clinical staff person responsible for treatment shall review the client’s ASAM level of care a minimum of every ninety (90) days, or whenever the client’s condition changes significantly.
(a) IOP services must:
(i) Consist of nine (9) hours per week of structured clinical treatment programming for adults and six (6) hours per week of structured clinical treatment programming for adolescents, except while the client is being transitioned into a lower level of care;
(ii) Be provided three (3) times a week with no more than three (3) days between clinical services, excluding holidays;
(iii) Vary in intensity and duration based on ASAM Criteria and the SAMHSA TIP 47;
(iv) Be available within two (2) weeks of the initial clinical assessment unless the provider has no capacity to provide the service or the client is not able to begin the program. If the provider has no capacity to provide the service within two (2) weeks, engagement services or referral to another provider with the capacity shall be provided; and
(v) Address the client’s needs for psychiatric and medical services through consultation and referral arrangements.
(b) The clinical staff person responsible for treatment shall reassess the client’s level of care using ASAM criteria a minimum of one (1) time per month, or whenever the client’s condition changes significantly.
(a) A provider of DUI/MIP services shall:
(i) Provide a minimum of eight (8) hours of client face-to-face services, which may be delivered through telehealth, utilizing evidence based curricula that is appropriate to age and developmental levels;
(ii) Ensure services are provided by qualified clinical staff or health educators supervised by qualified clinical staff;
(iii) Maintain records documenting client attendance and curricula completion or failure to attend or complete;
(iv) Provide adult and adolescent services separately; and
(v) Assess each client according to Section 11(c)(vi) of this Chapter, subject to the following conditions:
(A) If an assessment was conducted by another provider within the three (3) months prior to receiving DUI/MIP services, the provider is not required to conduct another assessment, however, the provider shall obtain a copy of the recommendations resulting from the prior assessment.
(B) If the assessment results indicate a need for additional services, the provider shall make the appropriate referrals.
(C) An assessment must include documentation of a review of the blood alcohol level at time of arrest and driving record of the client.
(b) A provider shall require clients, as a condition of completion of the curricula, to develop a written personal action plan based on nationally accepted practices setting forth actions the client will take in the future to avoid violations. The provider shall maintain a copy of the written plan as part of the client file.
(c) Upon completion of the curricula, the provider shall provide a certificate of completion to the client. It is the client’s responsibility to notify the court of completion.
(d) A provider shall report the failure of a client to follow the court order or to meet the requirements of the Wyoming Department of Transportation, Driver Services, to successfully complete the curricula, to the court and any supervising or probation agent or the Department of Transportation within ten (10) business days of the end of the services.
(e) An authorization to release medical records, including substance use disorder treatment records to the court and the Wyoming Department of Transportation, Driver Services, must comply with state and federal law.
(a) A behavioral health service provider may be granted a waiver from the Department of any standard imposed under Sections 9 to 14 of this Chapter if the Administrator determines that requiring immediate compliance with a particular standard would create an undue hardship on a provider and that temporary noncompliance would not impair the quality of the services being provided.
(b) A request for a waiver must be made in writing and may be made to the Administrator at any time the provider deems a standard represents an undue hardship.
(c) Prior to or as a condition of granting a waiver, the Administrator may:
(i) Set a time limit on the effective duration of the waiver; and
(ii) Require the provider to submit a written plan to the Administrator setting forth proposed methods of achieving compliance with the standard within the time frame of the waiver.
(d) The Administrator reserves absolute discretion in considering and granting a request for a waiver.
(i) The Administrator shall communicate to the provider in writing the Administrator’s decision on a waiver request and if denied, the grounds for denial.
(ii) If the Administrator grants a waiver request, the requesting provider shall keep a copy of the Administrator’s decision as part of the provider’s records.
(iii) If the Administrator denies a waiver request, the Administrator’s denial is final and not subject to administrative review.
(a) A behavioral health service provider may request a variance from the Department of any standard imposed under Sections 9 to 14 of this Chapter.
“Variance” means a permanent change to a required standard. A variance may be requested at any time.
(ii) A request for variance must be made in writing and, if the provider receives funds from the Department under Section 2(b) of this Chapter, signed by the chair of the governing board.
(iii) A request for variance must establish how the variance will maintain or enhance the quality of a provider’s operations and client services.
(b) The Administrator reserves absolute discretion in considering and granting a request for variance.
(i) The Administrator shall communicate to the provider in writing the Administrator’s decision on a variance request and if denied, the grounds for denial.
(ii) If the Administrator grants a variance request, the requesting provider shall keep a copy of the Administrator’s decision as part of the provider’s records.
(iii) If the Administrator denies a variance request, the Administrator’s denial is final and not subject to administrative review.