In the heart of ensuring quality and compliance within community substance abuse service (CSAS) programs, the F-00027 form emerges as a critical tool for recertification under the Wisconsin Department of Health Services' Division of Quality Assurance. With its comprehensive scope, the form facilitates a thorough review aligned with DHS 75.03 general requirements while simultaneously accompanying specific service applications ranging from DHS 75.04 to 75.16. Its design is thoughtfully aimed at enhancing compliance rates, refining on-site survey processes, and minimizing instances of non-compliance citations. The meticulous instructions embedded within the form guide providers through a preparation process that not only strengthens their application for recertification but also positions them for a successful on-site survey, courtesy of the Behavioral Health Certification staff's verification efforts. By requiring a detailed account of program policies, personnel credentials, patient rights, and quality assurance practices, among other essential elements, the form encourages a proactive stance towards maintaining high standards in substance abuse intervention services. Additionally, the structure of the form—inclusive of providing space for addenda and encouraging clear articulation of program modifications or growth—demonstrates a recognition of the dynamism inherent within CSAS programs. Consequently, the F-00027 form stands as more than a mere administrative requirement; it is a catalyst for continuous improvement and accountability in the realm of community substance abuse services.
Question | Answer |
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Form Name | F 00027 Form |
Form Length | 7 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 45 sec |
Other names | f csas fill online, csas compliance describe, csas staff 3, wi dhs 7503 |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
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Page 1 of 7 |
CSAS STANDARDS RECERTIFICATION APPLICATION
DHS 75.03 General Requirements
The goal of this application form is to assure that Community Substance Abuse Service (CSAS) Programs review compliance with DHS 75.03 general requirements, concurrent with applications for CSAS programs. It is anticipated that completion of this form will increase the likelihood of compliance, improve the
INSTRUCTIONS
The DHS 75.03 general requirements section must be completed at each recertification application and must accompany the specific service applications DHS 75.04 through 75.16, regardless of the number of certifications being sought. Chapter DHS 75, Wisconsin Administrative Code, is available
•Complete only those sections of 75.03 which pertain to the services requested. (See table on page 6.)
•Complete CSAS Staff Roster(s) for each program type. (See page 7.)
•Providers must remain in compliance with applicable subsections.
•Keep a copy of this application as a baseline from which future developments may be evaluated.
•Applicants are encouraged to use available space or attach addenda to provide information, provide relevant commentary, or to identify questions that will assist you and the surveyor in the review process.
Behavioral Health Certification staff will verify compliance through test and review
STEPS TO PREPARE FOR
Submit completed applications and fees to the appropriate DQA Regional Office, following the instructions provided. Contact information for DQA Regional Offices can be obtained by calling
•This application captures an overview of community substance abuse services in a format intended to encourage providers to evaluate and maintain compliance and to initiate plans of correction when needed, prior to Behavioral Health Certification Section (BHCS) surveyor findings or in lieu of citations and Statements of Deficiency.
•Questions are structured to identify program growth or other change from previous certification(s).
•Addenda or other attachments are welcomed where space is insufficient for a full reply.
•A survey will not be scheduled until a DHS 75 CSAS Staff Listing is completed.
•Applications must provide enough information to assure that a meaningful
All fees are required in advance of
1.Assure that relevant program documentation (including policies, personnel credential files, training records, supervision or collaboration documentation, evaluation reports, and complaint files) are ready for review.
Specific elements of review are identified in DQA publication
2.Treatments and patient rights will be evaluated
A sample of discharged or closed client records and other materials will be reviewed. The practice of regular quality assurance reviews of client treatment and case records ensures excellent results. The surveyor may also interview staff or clients to determine program compliance.
3.Applicants must contact the regional health services specialist (surveyor) to schedule an appointment well in advance of the certification end date.
Page 2 of 7 |
CSAS STANDARDS RECERTIFICATION APPLICATION
DHS 75.03 General Requirements
The goal of this application form is to assure that Community Substance Abuse Service Programs review compliance with DHS 75.03, General requirements, concurrent with applications for CSAS programs. It is anticipated that completion of this form will increase the likelihood of compliance, improve the
ENTITY INFORMATION
Name – Facility
Address – Physical
Certification No.
City |
State |
Zip Code |
County |
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Mailing Address (if different from above) |
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Zip Code |
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Telephone No. |
Email Address |
Do not publish in Provider Directory. |
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Fax No.
Internet Address
Do not publish in Provider Directory.
Name - Contact Person
Telephone No.
Email Address
Do not publish in Provider Directory.
ATTESTATION
I hereby attest that all statements made in this application and in any attachments are true and 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.
Name – Director (Print or type.)
Date Application Completed
SIGNATURE – Director (Full Signature)
Date Signed
Page 3 of 7 |
A. Governing Authority
Section
All CSAS Services
This section establishes the requirements for written policies and procedures.
1. Has the program reviewed or
Yes Enter date of last review:
No
Briefly describe changes in program policies during the past year. (Attach additional pages, as needed.)
B. Personnel
DHS
All CSAS Services
(4) |
Personnel; requirements for all staff |
(6) |
Written Verification of Training Assessment and Management of Suicidal Individuals |
(5) |
Staff development; training needs, plans, and progress |
(7) |
Confidentiality; policies and affirmations |
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2.Has the program reviewed its staffing policies and personnel requirements, e.g., credentials, staff training plans, confidentiality statements, and DHS 12 caregiver background checks?
Yes Assurance of these requirements will be confirmed
No However, this agency will review all credentials and completed all caregiver backgrounds before
3.Is a DHS 75 CSAS Staff Listing attached to this application?
Yes The recertification survey will not be scheduled without the staff listing.
C. Record Requirements
Sections
Applicable Services
By Program Types |
(See table on page 6.) |
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(8) |
Patient Case Records |
75.06 – 75.15 |
(9) |
Case Records for Emergency Services |
75.07 – 75.08 |
(15) |
Progress Notes |
76.06 – 75.15 |
DHS 92 and 94: Patient Rights and Protections |
All CSAS services |
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Initiation / Treatment (See question 6.) |
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(10) |
Screening |
75.05 – 75.15 |
(11) |
Intake |
75.06 – 75.15 |
(12) |
Assessment Process |
75.10 – 75.15 |
(13) |
Treatment Planning |
75.10 – 75.15 |
(14) |
Staffing Cases |
75.06 – 75.15 |
(15) |
Progress Notes |
75.06 – 75.15 |
Discharge and Service Conclusion |
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(16) |
Transfer Process |
75.06 – 75.15 |
(17) |
Discharge or Termination |
75.06 – 75.15 |
(18) |
Referral Process |
75.04 – 75.16 |
(19) |
75.06 – 75.15 |
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(20) |
Service Evaluations |
75.04 – 75.15 |
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4. Are case or treatment record reviews a regular part of the agency’s quality assurance practices? |
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Yes Describe the schedule, participants, and any changes in the process of QA. |
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No |
Treatment records are not applicable for 75.04, 75.05, and 75.16 services. |
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Page 4 of 7 |
5.Has the clinic remained in compliance with patient rights, informed consent, confidentiality, and grievance resolution standards (DHS 92 and 94), including documentation?
Yes Describe how the clinic assures compliance with DHS 92 and 94.
No Describe the clinic’s plans for corrective action.
6.Do current practices assure that all elements of client services initiation, assessment, treatment, staffing, and notes, including documentation, are in compliance with administrative code?
Yes Describe how the clinic assures compliance with initiation and treatment documentation.
No
7.Do current practices assure that all elements of client discharge and service conclusion, including documentation, are in compliance with administrative code?
Yes Describe how the clinic assures compliance by documenting discharges and service conclusions. No Describe the clinic’s plans for corrective action.
D. Evaluation
Section 75.03(20)
Services 75.06 – 75.15
8. Programs are required to complete an annual service evaluation which will be reviewed and assured
Applicable Briefly abstract the latest report on the progress toward meeting goals, objectives, and patient outcomes.
Not applicable
E. Communicable Disease Screening
Section 75.03(21)
Services 75.06 – 75.15
9.Is communicable disease screening conducted and documented in the client case record?
Yes Briefly describe current process and any plans for improvement below.
No
Not applicable
Diseases Screened (Check all that apply.)
Hepatitis B |
Hepatitis C |
HIV (human immunodeficiency) |
STDs (sexually transmitted diseases)
TB (tuberculosis)
Optional: How often is staff screened for communicable disease? Screening records will be confirmed in patient treatment and staff records.
Page 5 of 7
Never
F. Unlawful Alcohol or Psychoactive Substance Use
Section 75.03(22)
All services
10. How is staff made aware of this prohibition policy requirement?
Condition of employment
Policy manual review
Other
G. Emergency Shelter and Care
Section 75.03(23)
Services 75.06, 75.07, 75.09 – 75.12, 75.14
11. If this is a residential care program, do you have an emergency plan?
Yes
No Prepare an emergency plan prior to the
Not applicable
H. Reportable Deaths
Section 75.03(24)
Services 75.05 – 75.15
12. Does the program have policies for training staff on reporting certain client deaths?
Yes
No Prepare a policy, as required in Wis. Stat. § 51.64, with staff and record it in their training file.
Not applicable
I. Outpatient Treatment Service
Section 75.13
OPTIONAL
13.Describe innovations the agency has created or employed related to the program or its services. (Attach additional pages, as needed)
14.Describe program needs – problems, supports, or enhancement needs – which your agency has identified, including hiring qualified staff, training availability, or other technical assistance. (Attach additional pages, as needed)
15. Describe special burdens or challenges that the agency faces.
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Page 6 of 7 |
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DHS 75.03 GENERAL REQUIREMENTS |
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75.04 |
75.05 |
75.06 |
75.07 |
75.08 |
75.09 |
75.10 |
75.11 |
75.12 |
75.13 |
75.14 |
75.15 |
75.16 |
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(2) |
Certification |
X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
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(3) |
Governing Authority |
X |
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X |
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(4) |
Personnel |
X |
X |
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X |
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(5) |
Staff Development |
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X |
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(6) |
Training in Mgmt of Suicidal Individuals |
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(7) |
Confidentiality DHS 92 |
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(8) |
Patient Case Records |
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X |
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(9) |
Case Records for Emergency Services |
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X |
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(10) |
Screening |
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X |
X |
X |
X |
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X |
X |
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(11) |
Intake |
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X |
X |
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(12) |
Assessments |
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(13) |
Treatment Plan |
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X |
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X |
X |
X |
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(14) |
Staffing |
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X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
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(15) |
Progress Notes |
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X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
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(16) |
Transfer |
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X |
X |
X |
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X |
X |
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X |
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(17) |
Discharge or Termination |
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X |
X |
X |
X |
X |
X |
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X |
X |
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(18) |
Referral |
X |
X |
X |
X |
X |
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X |
X |
X |
X |
X |
X |
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(19) |
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X |
X |
X |
X |
X |
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X |
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X |
X |
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(20) |
Service Evaluation |
X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
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(21) |
Communicable Disease Screening |
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X |
X |
X |
X |
X |
X |
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X |
X |
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(22) |
Unlawful Substance Use |
X |
X |
X |
X |
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X |
X |
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X |
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(23) |
Emergency Shelter and Care |
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X |
X |
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X |
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X |
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(24) |
Death Reporting |
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X |
X |
X |
X |
X |
X |
X |
X |
X |
X |
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DHS 75 COMMUNITY SUBSTANCE ABUSE SERVICES (CSAS) STAFF LISTING
Name - Provider |
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Certification No. |
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1. |
Director |
4. |
7. Intermediate/Independent Clinical Supervisor (ICS) |
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2. Clinical Substance Abuse Counselor (CSAS) |
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Clinical Supervisor (CS) |
8. Intermediate/Independent Clinical Supervisor (ICS) |
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Volunteer |
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3. |
Substance Abuse Counselor (SAC) |
6. |
9. Prevention Specialist (PS) |
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12. |
Admin / Mgmt |
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Function(s) |
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DHS 12 Caregiver Backgrounds |
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Position Description |
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Credential / |
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DHS 64 |
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License No. |
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BID |
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within past |
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listed above. |
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(mo/yr) |
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(mo/yr) |
4 Years? |
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Yes |
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Yes |
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Yes |
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