Form F-00519 "Community Substance Abuse Service (Csas) Medically Managed Residential Detoxification Service Initial Certification Application" - Wisconsin

What Is Form F-00519?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2011;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-00519 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-00519 "Community Substance Abuse Service (Csas) Medically Managed Residential Detoxification Service Initial Certification Application" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter DHS 75.07, Wis. Admin. Code
F-00519 (11/11)
Page 1 of 2
COMMUNITY SUBSTANCE ABUSE SERVICE (CSAS)
MEDICALLY MANAGED RESIDENTIAL DETOXIFICATION SERVICE
INITIAL CERTIFICATION APPLICATION
Chapter DHS 75.07
Initial Certification
Initial certification must meet all requirements, including staffing requirements (hired and in place) before services begin.
This document paraphrases the rule language for application purposes.
Applicants for a medically managed inpatient detoxification service must demonstrate preparedness to comply with all
Chapter DHS 75.07 standards.
Applicants will have completed all required policies, including Chapter DHS 94 (Patient Rights). Use the check boxes (
) to affirm
readiness to meet standards.
ATTENTION: The clinic must contact the regional Health Services Specialist to arrange a site visit following the submission
of fee and this application.
Chapter DHS 75.01(1) Authority and Purpose
This application is promulgated under the authority of ss. 46.973(2)(c), 51.42(7)(b), and 51.45(8) and (9), Wis. Stats., to establish standards
for community substance abuse prevention and treatment services under ss. 51.42 and 51.45, Wis. Stats. Sections 51.42(1) and 51.45(1)
and (7) provide that a full continuum of substance abuse services be available to Wisconsin citizens from county departments of community
programs, either directly or through written agreements or contracts that document the availability of services. This application provides that
service recommendations for initial placement, continued stay, level of care transfer, and discharge of a patient be made through the use of
Wisconsin uniform placement criteria (WI-UPC), American Society of Addiction Medicine (ASAM) placement criteria, or similar placement
criteria that may be approved by the department.
Use of approved placement criteria services as a contributor to the process of obtaining prior authorization from the treatment services
funding source. It does not establish funding eligibility regardless of the funding source. The results yielded by application of these criteria
serve as a starting point for further consultations among the provider, patient, and payer as to an initial recommendation for the type and
amount of services that may be medically necessary and appropriate in the particular case. Use of WI-UPS or any other department-
approved placement criteria does not replace and need to do a complete assessment and diagnosis of a patient in accordance with DSM-
IV.
Chapter DHS 75.01(2) Applicability
This application applies to each substance abuse service that receives funds under Chapter DHS 51, Wis. Stats., is approved by the state
methadone authority, is funded through the department as the federally designated single state agency for substance abuse services,
receives substance abuse prevention and treatment funding or other funding specifically designated for providing services under ch. DHS
75.04 or 75.16, or is a service operated by a private agency that requests certification.
By completing and submitting this form, the clinic indicates that
it is in compliance with the program standards as required by state statutes.
Name – Facility
Address – Physical
City
State
Zip Code
County
Telephone Number
E-mail Address
May be published in Provider Directory
Fax Number
Internet Address
May be published in Provider Directory
Name – Contact Person
Telephone Number
E-mail Address
May be published in Provider Directory
Name – Person Who Completed this Form
Telephone Number
E-mail Address
May be published in Provider Directory
I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge and
that I will comply with all laws, rules, and regulations governing alcohol and other drug abuse intervention services.
FULL SIGNATURE – Director
Date Signed
Full Name – Director (Print or type.)
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Chapter DHS 75.07, Wis. Admin. Code
F-00519 (11/11)
Page 1 of 2
COMMUNITY SUBSTANCE ABUSE SERVICE (CSAS)
MEDICALLY MANAGED RESIDENTIAL DETOXIFICATION SERVICE
INITIAL CERTIFICATION APPLICATION
Chapter DHS 75.07
Initial Certification
Initial certification must meet all requirements, including staffing requirements (hired and in place) before services begin.
This document paraphrases the rule language for application purposes.
Applicants for a medically managed inpatient detoxification service must demonstrate preparedness to comply with all
Chapter DHS 75.07 standards.
Applicants will have completed all required policies, including Chapter DHS 94 (Patient Rights). Use the check boxes (
) to affirm
readiness to meet standards.
ATTENTION: The clinic must contact the regional Health Services Specialist to arrange a site visit following the submission
of fee and this application.
Chapter DHS 75.01(1) Authority and Purpose
This application is promulgated under the authority of ss. 46.973(2)(c), 51.42(7)(b), and 51.45(8) and (9), Wis. Stats., to establish standards
for community substance abuse prevention and treatment services under ss. 51.42 and 51.45, Wis. Stats. Sections 51.42(1) and 51.45(1)
and (7) provide that a full continuum of substance abuse services be available to Wisconsin citizens from county departments of community
programs, either directly or through written agreements or contracts that document the availability of services. This application provides that
service recommendations for initial placement, continued stay, level of care transfer, and discharge of a patient be made through the use of
Wisconsin uniform placement criteria (WI-UPC), American Society of Addiction Medicine (ASAM) placement criteria, or similar placement
criteria that may be approved by the department.
Use of approved placement criteria services as a contributor to the process of obtaining prior authorization from the treatment services
funding source. It does not establish funding eligibility regardless of the funding source. The results yielded by application of these criteria
serve as a starting point for further consultations among the provider, patient, and payer as to an initial recommendation for the type and
amount of services that may be medically necessary and appropriate in the particular case. Use of WI-UPS or any other department-
approved placement criteria does not replace and need to do a complete assessment and diagnosis of a patient in accordance with DSM-
IV.
Chapter DHS 75.01(2) Applicability
This application applies to each substance abuse service that receives funds under Chapter DHS 51, Wis. Stats., is approved by the state
methadone authority, is funded through the department as the federally designated single state agency for substance abuse services,
receives substance abuse prevention and treatment funding or other funding specifically designated for providing services under ch. DHS
75.04 or 75.16, or is a service operated by a private agency that requests certification.
By completing and submitting this form, the clinic indicates that
it is in compliance with the program standards as required by state statutes.
Name – Facility
Address – Physical
City
State
Zip Code
County
Telephone Number
E-mail Address
May be published in Provider Directory
Fax Number
Internet Address
May be published in Provider Directory
Name – Contact Person
Telephone Number
E-mail Address
May be published in Provider Directory
Name – Person Who Completed this Form
Telephone Number
E-mail Address
May be published in Provider Directory
I hereby attest that all statements made in this application and any attachments are correct to the best of my knowledge and
that I will comply with all laws, rules, and regulations governing alcohol and other drug abuse intervention services.
FULL SIGNATURE – Director
Date Signed
Full Name – Director (Print or type.)
F-00519 (11/11)
Page 2 of 2
Checkboxes indicate a required response. To avoid delays in certification, ensure that you respond to each checkbox.
Chapter DHS 75.07 (1) Service Description
Yes
No
This service is equivalent to the service description as listed below and in ch. DHS 75.07(1).
A medically managed residential detoxification service provides 24-hour per day service in a residential setting providing
detoxification service and monitoring. Care is provided by a multidisciplinary team of service personnel, including 24-
hour nursing care under the supervision of a physician. Included is the provision of an examination in accordance with
s. 51.45(11)(c), Wis. Stats., and transportation, if needed, to an emergency room of a general hospital for medical
treatment.
Chapter DHS 75.07 (2) Requirements
This medically monitored residential detoxification service complies with all requirements included in ch. DHS 75.03 that
Yes
No
apply to a medically monitored detoxification service, as shown in Table Chapter DHS 75.03 (See DQA form F-00523.)
and, in addition, a medically monitored residential detoxification service and complies with the requirements of this
section. If a requirement in this section conflicts with an applicable requirement in ch. DHS 75.03, the requirement in
this section shall be followed.
Chapter DHS 75.07 (3) Organizational Requirements
Yes
No
This facility is approved under ch. DHS 124 as a hospital or licensed under ch. DHS 83 as a community-based
residential facility.
ATTENTION: Facilities certified under ch. DHS 75.07, DHS 75.09, and DHS 75.11 may not need to be licensed under
ch. DHS 83, because they do not meet key components, which include: the facility must provide care, treatment, or
services above the level of room and board and persons must intend to remain in the CBRF permanently or continuously
for more than 28 consecutive days. However, these facilities do need an appropriate physical environment with safety
and structural protections. Therefore, these facilities must meet subchapters VIII, IX, X, or XI of ch. DHS 83. Facilities
certified under ch. DHS 75.14 must be licensed as a CBRF, because the length of stay exceeds 28 days.
If needed, please contact your individual surveyor for more information regarding these requirements.
Chapter DHS 75.07 (4) Required Personnel
Yes
No
(a)
This medically monitored residential detoxification service ensures that a patient receives consultation from a
substance abuse counselor before the patient is discharged from the service.
Yes
No
(b)
This service has a nursing director who is a registered nurse.
(c)
A registered nurse is available on site on a 24-hour basis.
Yes
No
(d)
A physician is available on site (on call) on a 24-hour basis.
Yes
No
Note: The department’s intent is that physicians will be on call rather than on site.
Chapter DHS 75.07 (5) Service Operations
Yes
No
(a)
A physician reviews and documents the medical status of a patient within 72 hours after admission.
Yes
No
(b)
This service has written policies and procedures for the management of belligerent and disturbed patients, which
includes transfer of a patient to another appropriate facility, if necessary.
Yes
No
(c)
This service has a written agreement with certified substance abuse service providers or systems to provide care
after the patient is discharged from the service.
(d)
This service has a written agreement with a hospital for the hospital to provide emergency medical services for
Yes
No
patients and provides escort and transportation to the hospital. If necessary, the service shall also provide escort
and transportation for return to the service.
(e)
This service develops with each patient a detoxification plan and a discharge plan for the patient that addresses
Yes
No
the patient’s follow-up service needs, determined from the application of approved patient placement criteria
administered by the service, and includes provision for referral, escort, and transportation to other treatment
services, as necessary, to ensure that continuity of care is provided.
Yes
No
(f)
This service has a treatment room that has in it at least the following:
1.
First aid supplies maintained and readily available to all personnel responsible for the care of patients.
2.
Separate locked cabinets exclusively for all pharmaceutical supplies.
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