Wisconsin DHS 31 establishes the certification requirements for Crisis Urgent Care and Observation Facilities (CCFs), which provide short-term crisis stabilization services for individuals experiencing behavioral health crises, including mental health and substance use emergencies. Operators must obtain department certification, meet detailed program requirements covering staffing, admissions, treatment documentation, emergency safety interventions, and client rights, and comply with physical facility standards. CCFs may serve adults and, if specifically certified to do so, minors, and must maintain 24/7 staffing, sight-and-sound separation between adult and minor clients, and coordinate care with external providers including inpatient psychiatric facilities and county crisis programs.
View official sourcePublished under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 1 DEPARTMENT OF HEALTH SERVICES DHS 31.03 Chapter DHS 31 CRISIS URGENT CARE AND OBSERVATION FACILITY CERTIFICATION Subchapter I — General Provisions and Requirements DHS 31.01 Authority and purpose. DHS 31.02 Applicability. DHS 31.03 Definitions. DHS 31.04 Certification. DHS 31.05 Variance and waiver. DHS 31.06 Department action. Subchapter II — Program Requirements DHS 31.07 Required policies and procedures. DHS 31.08 Personnel. DHS 31.09 Staffing requirements. DHS 31.10 Personnel development. DHS 31.11 Admissions, transfers, discharges, and holds on admissions. DHS 31.12 Services. DHS 31.13 Treatment documentation. DHS 31.14 Emergency safety interventions. DHS 31.15 Investigation, notification, and reporting requirements. DHS 31.16 Client rights and grievance procedure. Subchapter III — Facilities DHS 31.17 Applicability. DHS 31.18 General facility requirements. DHS 31.19 Physical environment. DHS 31.20 Building design. DHS 31.21 Infection control program. DHS 31.22 Food service. DHS 31.23 Fire safety requirements. DHS 31.24 Fire protection systems. DHS 31.25 Oxygen storage. DHS 31.26 Records retention and posting. Subchapter IV — Grant Program Requirements DHS 31.27 Grant program overview. DHS 31.28 Application. DHS 31.29 Awards. DHS 31.30 Restrictions. DHS 31.31 Records and reports. Subchapter I — General Provisions and Requirements DHS 31.01 Authority and purpose. This chapter is promulgated under the authority of ss. 51.036 (4), and 227.11 (2), Stats., for the purpose of certifying and regulating crisis urgent care and observation facilities. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.02 Applicability. (1) This subchapter estab- lishes general program requirements that apply to crisis urgent care and observation facilities, including those facilities that are also licensed as a hospital under ch. 50, Stats. The requirements under this chapter shall not prohibit, limit, or otherwise interfere with services provided by a county, hospital, or other facility that are provided under the facility’s existing licensure or certifica- tion. This chapter shall apply to any of the following: (a) A publicly or privately operated facility providing crisis urgent care and observation facility services, in accordance with s. 51.036, Stats. (b) A publicly or privately operated hospital providing crisis urgent care and observation facility services, in accordance with s. 51.036, Stats. This applies to co-located and off-site facilities. (2) The certification requirements of this chapter do not ap- ply to any facility meeting the criteria under s. 51.036 (2) (f) , Stats. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.03 Definitions. In this chapter: (1) “Assessment” means the procedure by which staff of the program, operating within their scope of practice, gathers rele- vant information to assess risk, identifies client care needs, and determines intervention or treatment options. (2) “Bed” means a piece of furniture designed to accommo- date a person sleeping in an outstretched position and includes a reclining chair, convertible sofa, or recovery couch. (3) “Behavioral health assessment” means the process of gathering relevant information regarding a client’s behavioral and mental health status. (4) “Care coordination” means the deliberate organization of a person’s care across multiple care providers and support networks. (5) “CCF” means a crisis urgent care and observation facility. (6) “Certification” means the approval granted by the depart- ment that a CCF meets the requirements of this chapter. (7) “Client” means a person receiving care at a CCF. Unless otherwise indicated in this chapter, “client” does not include a person who is screened for services but is not admitted. (8) “Clinical supervision” means a process of oversight of an employees’ professional development and practice to ensure that each client is receiving quality care. (9) “Cognitive assessment” means the process of gathering relevant information regarding a client’s cognitive, developmen- tal, or intellectual status. (10) “County department” means a county department of hu- man services under s. 46.23, Stats., or a county department of community programs under s. 51.42 (1) (b), Stats. (11) “Crisis” has the meaning provided in s. 51.036 (1) (a) Stats. (12) “Crisis counseling” means brief and crisis specific sup- port provided to help ameliorate symptoms of an immediate crisis and promote safety, including active listening, validation, and identification of coping skills. (13) “Crisis plan” means a plan prepared for an individual so that, if a crisis occurs, the individual and persons supporting them and responding to the situation will have the information and resources they need to meet the person’s individual needs. (14) “Crisis urgent care and observation facility” or “crisis care facility” has the meaning provided in s. 51.036 (1) (b), Stats. (15) “Day” means calendar day, unless otherwise indicated. (16) “De-escalation” means the use of interventions to stabi- lize, slow, or reduce the intensity of a crisis. (17) “Department” means the Wisconsin department of health services. (18) “Direct care” means care provided by staff directly re- lated to clients. “Direct care” does not include training, orienta- tion, or non-client related administrative tasks. (19) “Elopement” means when a client leaves a CCF without Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.03 WISCONSIN ADMINISTRATIVE CODE 2 authorization or supervision and may be a threat to their health or safety. (20) “Follow-up” means the process of assessing the well-be- ing of a client, including those who have been discharged. (21) “Hub-and-spoke health home pilot program” means a network of treatment, resources, and support for persons with substance use and health care needs. (22) “Ligature resistant” means an object designed to reduce the ability of securing a ligature to it. (23) “Medication management” means services that include prescribing, transcribing, verifying, dispensing, delivering, ad- ministering, monitoring, and reporting over the counter and pre- scription medication. (24) “Nursing assessment” means the process of gathering relevant information regarding a client’s physical and medical health status. (25) “Observation unit” means a space for client care and ob- servation for client stays less than 24 hours where multiple clients may occupy a single room. (26) “Opioid reversal medication” means a medication ap- proved by the federal food and drug administration that blocks the effects of opioids. (27) “Peer clinical consultation” means a process where staff review cases and seek advice and feedback from professional peers for the purpose of improved clinical practice and client outcomes. (28) “Prescriber” means a physician, physician assistant, or nurse prescriber who is operating within the scope of their li- cense to deliver services under this chapter. (29) “Psychiatric Bed Locator” means a tool to assist in iden- tifying potentially available psychiatric beds. (30) “Psychosocial assessment” means an assessment of a client’s psychological and social functioning. (31) “Psychotherapy” means licensed clinicians applying therapeutic services to assist a client, family, or group to achieve behavioral health stability. (32) “Reassessment” means the procedure by which staff of the program, operating within their scope of practice, gather rele- vant information to update a client’s initial assessment based on a change in symptoms, status, needs, or risk. (33) “Risk assessment” means the process of gathering rele- vant information regarding a client’s risk of harm to self or others. (34) “Safety plan” means a personalized set of written guide- lines to be used as a tool to assist someone prior to or during a cri- sis to identify coping skills and access supports. (35) “Secure” or “secured” means a locked area within a CCF. (36) “Sight and sound separation” means the maintenance of physical separation between minors and adults so that both sus- tained visual contact and direct and sustained oral communica- tion between them is not possible. (37) “Screening” means a process of identification of needs and risk including urgent medical, mental health, psychiatric, or substance use crisis needs. (38) “Stabilization” means a service aimed at reducing or eliminating a client’s symptoms to reduce the need for inpatient hospitalization. (39) “Staffing plan” means a document to strategically iden- tify and anticipate the workforce required to effectively deliver client care. (40) “Substance use disorder assessment” means the process of gathering relevant information regarding a client’s substance use status. “Substance use disorder assessment” does not include rendering treatment as defined in s. 51.45 (2) (g), Stats. (41) (a) “Telehealth” means the use of telecommunications technology by a certified provider to deliver services allowable under ss. 49.45 (61) and 49.46 (2) (b) 21. to 23., Stats., this chap- ter, and s. DHS 107.02 (5), including assessment, diagnosis, con- sultation, treatment, or transfer of medically relevant data in a functionally equivalent manner as that of an in-person contact. (b) “Telehealth” may include real-time interactive audio-only communication. (c) “Telehealth” does not include communication between a certified provider and a recipient that consists solely of an elec- tronic mail, text, or facsimile transmission. (42) “Transfer” means the movement of a client or individual in need of services between approved treatment facilities, from an approved treatment facility to the community, or from the com- munity to an approved treatment facility. (43) “Variance” means an alternate means of meeting a re- quirement in this chapter. (44) “Waiver” means an exemption from a requirement of this chapter. (45) “Wisconsin Prescription Drug Monitoring Program database” or “PDMP database” means an online tool used to pro- vide information about monitored prescription drugs that are dis- pensed in the state. (46) “Withdrawal abatement” means providing care and in- terventions to address an individual’s physical or psychosocial needs related to acute intoxication or withdrawal until the crisis is resolved. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (2), (7), (12), (18), (28), (40), (42) made un- der s. 35.17, Stats., and correction in (26) made under s. 13.92 (4) (b) 6., Stats., Reg- ister February 2026 No. 842. DHS 31.04 Certification. (1) GENERAL. (a) No person, agency, or facility may operate a CCF without a certification from the department. (b) Any facility licensed as a hospital under ch. 50, Stats., that provides services consistent with those described in this chapter may apply for CCF certification under this section. (c) This chapter shall not prevent co-location of a CCF with other facilities, including hospitals, or shared staffing arrangements. (2) APPLICATION. All of the following materials shall be sub- mitted to the department when applying for CCF certification: (a) A completed application specifying the population and ge- ographic region to be served, and which demonstrates the pro- gram’s ability to do all the following: 1. Accept referrals for crisis services for adults and, if specif- ically identified in the application, for minors, including all the following: a. Involuntary clients brought under s. 51.15, Stats. b. Voluntary clients for services arriving as walk-ins or brought by law enforcement, emergency medical responders, or county crisis personnel. 2. Abstain from requiring medical clearance before admis- sion assessment. 3. Provide assessments for physical health, mental health, and substance use. 4. Provide screening for suicide and violence risk. 5. Provide medication management and therapeutic counseling. 6. Provide coordination of services for basic needs. 7. Provide for the safety and security of staff and clients. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 3 DEPARTMENT OF HEALTH SERVICES DHS 31.05 8. Provide voluntary and involuntary treatment of individu- als in crisis and allow for an effective conversion from involun- tary to voluntary treatment, or conversion from voluntary to in- voluntary treatment. 9. Demonstrate how sight and sound separation between ser- vices for minors and adults will be achieved, if certified to serve minors. 10. Maintain adequate staffing 24 hours a day, 7 days a week, including through the use of telehealth. 11. Contribute, from at least one nonstate, federal, or 3rd- party revenue source, at minimum 5 percent of biennial operating costs, in addition to any grant awarded by the department. Note: Application forms are available at: https://www.dhs.wisconsin.gov/regula- tions/mentalhealth/certification.htm. (b) Payment for the application fee required under s. 51.04, Stats. Note: Fee information is available at: https://www.dhs.wisconsin.gov/regula- tions/mentalhealth/certification.htm. (c) A copy of the proposed CCF’s policies and procedures, as specified under s. DHS 31.07. (d) A floor plan of the proposed CCF which demonstrates all of the following: 1. Dimensions, exits, and planned room usage. 2. The proposed number of single-occupancy client rooms, double-occupancy client rooms, observation units and beds in the unit, seclusion rooms, and private treatment spaces and the ratio- nale for these numbers. 3. The floor plan, which shall demonstrate compliance with s. 51.61, Stats., and include all the following: a. An accessible and easily identified walk-in area for per- sons seeking immediate services to be triaged. b. A locked unit for service provision to accommodate clients under s. 51.15 Stats., which may also serve voluntary clients. c. Methods to ensure privacy for each client. d. Measures to ensure the safety of clients, visitors, and staff. (e) All inspection reports completed during the last 12 months, as required under s. DHS 31.26 (2). (f) Proof of building insurance, risk insurance, liability insur- ance, and agency-owned vehicle insurance if providing transportation. (g) Payment of any forfeitures, fees, or assessments related to any licenses or certifications issued by the department to the ap- plicant, or a written statement signed by an authorized represen- tative stating that no fees, forfeitures, or assessments are owed. (h) Any additional information requested by the department. (3) COMPLIANCE REVIEW. Upon receipt of all completed ap- plication materials under sub. (2), the applicant shall permit the department to conduct an on-site inspection of the facility and a review of any documentation necessary to determine compliance with this chapter. (4) CERTIFICATION DETERMINATION. (a) The department shall make a certification determination in accordance with s. 51.036 (2), Stats. The department shall consider all the following before making certification determinations: 1. The region of the state to be served, and existing certified CCFs in that region or close proximity. 2. Whether any hospital facilities granted certification as a CCF are in the region or close proximity to the proposed CCF. 3. Whether the proposed CCF is in the region or close prox- imity to a state treatment facility designated for emergency deten- tions under s. 51.15 (2), Stats. (b) In accordance with s. 51.036 (2) (a), Stats., the department may limit the number of certifications issued. Note: Additional information about CCF certifications is available at: https://www.dhs.wisconsin.gov/regulations/mentalhealth/certification.htm. (c) As a condition of certification, a CCF shall agree to allow the department to make unannounced inspections and conduct complaint investigations of a CCF as it deems necessary, at rea- sonable times and in a reasonable manner. (5) NOTIFICATION OF CHANGES. A CCF that has received cer- tification from the department shall notify the department of any change of administration, ownership, program name, or any other change that may affect compliance with this chapter before the ef- fective date of the change. A certification is non-transferable. A new application will be required if the department determines there is a substantial change to a CCF. (6) DURATION OF CERTIFICATION. (a) A certification is valid until suspended or terminated by the department. (b) A certification becomes invalid upon non-payment of bi- ennial fees. (7) BIENNIAL REPORT AND FEES. (a) Every 24 months, by the date determined by the department and specified on the CCF cer- tification, the program shall submit a biennial report on the form provided by the department and shall submit payment of certifi- cation continuation fees for the purpose of renewing certification of the program for 2 years. (b) The department will send the re-certification materials to the provider, which the provider is expected to fill out and submit to the department according to instructions provided. (c) A certification may be suspended or terminated if biennial reports are not submitted by the date required under par. (a). History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (b), (2) (a) 11., (7) (c) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.05 Variance and waiver. (1) EXCEPTION TO A REQUIREMENT. (a) A CCF certified under this chapter may apply for a discretionary waiver or variance to a requirement under this chapter. A written request for a waiver or variance shall be sent to the department on a form provided by the department. The appli- cation shall address all of the criteria in par. (b). A variance ap- plication shall include a description of the alternative means planned to meet the intent of the requirement. Note: More information about variances and waivers is available on the depart- ment’s website at https://www.dhs.wisconsin.gov/regulations/waiver-variance.htm. A variance or waiver request form is available at https://www.dhs.wisconsin.gov/li- brary/f-60289.htm. (b) The department may grant an application for a waiver or variance if the department determines that all of the following criteria are met: 1. Strict enforcement of the requirement for which a waiver or variance is sought would result in an unreasonable hardship for the CCF. 2. The proposed waiver or variance will not diminish the ef- fectiveness of the services provided at the CCF. 3. The proposed waiver or variance increases client access to care and sufficiently supports the efficient and economic opera- tion of the service. 4. The proposed waiver or variance will not jeopardize the health, safety, welfare, or rights of any client. 5. Any waiver or variance proposed in the application is con- sistent with all state and federal laws. (2) RESCINDING A WAIVER OR VARIANCE. (a) The depart- ment may rescind or limit a waiver or variance if any of the fol- lowing occurs: 1. The department determines the waiver or variance has ad- versely affected the health, safety, or welfare of a client. 2. The service fails to comply with any of the conditions of the waiver or variance as granted. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.05 WISCONSIN ADMINISTRATIVE CODE 4 3. Rescinding the waiver or variance is required by federal or state law. 4. There is no longer sufficient justification that the waiver or variance increases client access to care or sufficiently supports the efficient and economic operation of a service. (b) The department shall notify a CCF in writing if it rescinds or limits a waiver or variance in accordance with par. (a). History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (a), (2) (b) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.06 Department action. (1) INSPECTIONS. The department shall make unannounced, on-site inspections at a CCF to conduct program reviews, complaint investigations, or death investigations or to determine progress in correcting a defi- ciency cited by the department. The department may use a ran- dom selection process for reviewing client records during pro- gram reviews. Complaint-driven program reviews shall include the records related to the complaint and may include additional records and interviews. (2) STATEMENT OF DEFICIENCIES. (a) If the department de- termines that a CCF has a deficiency, the department shall issue a statement of deficiency within 30 days of the on-site survey. The statement of deficiency may place restrictions on a CCF or its ac- tivities, or suspend or terminate the certification, pursuant to sub. (3). (b) A CCF shall submit a plan of correction to the department within 30 days of receipt of as the statement of deficiency under par (a). The plan of correction shall propose the specific steps the CCF will take to correct the deficiency, the timelines within which the corrections will be made, and the personnel who will implement the plan and monitor for future compliance. (c) If the department determines that the plan of correction submitted by the CCF does not adequately address the deficien- cies listed in the statement of deficiency, the department may re- quest a new plan of correction or may impose a plan of correction created by the department. (3) TERMINATION AND SUSPENSION OF CERTIFICATION. (a) The department may terminate certification at any time for a ma- jor deficiency by issuing a notice of termination to a CCF. The notice shall specify the reason for the department action and in- clude the appeal information under sub. (4). (b) The department may suspend a CCF’s certification if the department determines that immediate action is required to pro- tect the health, safety, and welfare of individuals utilizing the pro- gram. Written notice of suspension shall specify the reason for the department action and the date the action becomes effective. Within 14 days after the order is issued, the department shall ei- ther lift or impose conditions on the suspension of a CCF certifi- cation or proceed to terminate the program’s certification. (4) APPEALS. If the department denies, suspends, or termi- nates certification, or imposes conditions on a certification, a CCF may request a hearing under ch. 227, Stats. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842 , eff. 3-1-26; correction in (1) made under s. 35.17, Stats., Register February 2026 No. 842. Subchapter II — Program Requirements DHS 31.07 Required policies and procedures. A CCF shall have written policies and procedures for all of the following: (1) Communicating bed availability via the department-ap- proved psychiatric bed locator in accordance with s. DHS 31.11 (7) and a dedicated 24/7 phone line for incoming external calls. (2) Coordination requirements, including all of the following: (a) Procedures for coordinating crisis care for individuals in need of services but not admitted to a CCF. (b) Procedures for follow-up and care coordination with exter- nal providers, as appropriate, including any of the following: 1. County crisis providers 2. Inpatient psychiatric facilities 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. A hub-and-spoke health home pilot program, or other transition facilities (3) Admission, screening and assessment policies and proce- dures meeting the requirements of ss. DHS 31.11 and 31.12. At minimum, these policies should include all of the following: (a) The minimum age requirements for admission. (b) The arrangement of rooms and space, including all of the following, as applicable: 1. The number of client rooms in a secured setting and whether they are single or dual occupancy. 2. The number of client rooms in an unsecured setting and whether they are single or dual occupancy. 3. The size of any observation unit for client stays less than 24 hours and how this space is designed. (c) The total number of beds available, and how those beds are allocated across the spaces identified in par. (b) 1. to 3. (d) Eligibility requirements, including how a CCF will coordi- nate care for individuals in need of crisis services who do not meet eligibility requirements. (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). (f) Policies regarding involuntary admission of a client under s. 51.15, Stats., and s. DHS 31.11 (3). (g) Policies regarding voluntary admission of a client in accor- dance with s. 51.10 (5), Stats., and, if serving minors, s. 51.13, Stats. (h) Policies specific to admission and placement coordination with law enforcement and county crisis personnel which shall in- clude the following: 1. Circumstances under which a voluntary person may be re- ferred or transported for services and procedures for referral. 2. Placement determination for involuntary persons which includes detention and placement authorization confirmation prior to admission. 3. Circumstances under which medical clearance is and is not required prior to admission. (i) A method for obtaining informed consent for treatment consistent with s. DHS 94.03. (j) A method for obtaining the client’s signed acknowledge- ment of having been informed of the following: 1. The general nature and purpose of the service. 2. Client rights and the protection of privacy provided by confidentiality laws. 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. Information about the cost of treatment, who will be billed, and the accepted methods of payment if the client is billed. (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. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 5 DEPARTMENT OF HEALTH SERVICES DHS 31.08 (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: (a) Managing common medical conditions. (b) Managing medical emergencies. (c) Identifying what personal care needs can be safely pro- vided and how. (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. (e) Treating an individual under the influence of alcohol or other drugs. (f) Administration of opioid reversal medication by staff. (6) Policies for medication management, including all of the following: (a) Policies and procedures for prescribing and administering medications. (b) Prescriber checks and use of the PDMP database, includ- ing policies identifying when it is clinically necessary to check the PDMP database. Note: The Wisconsin Prescription Drug Monitoring Program database is avail- able online at https://pdmp.wi.gov/. (c) Procedures for obtaining and updating client consents for medications received and acknowledgement of risks and benefits explained consistent with DHS 94.09. (d) Procedures for reporting and reviewing medication errors via facility incident reports or other documentation. (e) Prescriber access or consultation relationships to prescribe or consult on psychiatric medications. (f) Policies on medication storage, security, management, and administration, and which staff is responsible. (g) Policies identifying which licensed pharmacy or pharma- cies a CCF will use and copies of the pharmacy’s license. (h) Policies on clients’ access to medications prescribed to them, post discharge. (7) Personnel policies and documentation, which shall be made available upon request for review by the department. Per- sonnel policies and documentation shall include all of the following: (a) Job positions and descriptions for each employee. (b) Employee qualifications including copies of licenses or certifications as applicable. (c) Onboarding, orientation, training, and continuing educa- tion for each employee. (d) Training exemption determination. (e) Clinical supervision of staff and performance reviews for each employee. (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) Policies and procedures regarding guests and visitors, in- cluding all of the following: (a) Procedures to ensure confidentiality for clients, including information on ensuring recording devices are not utilized. (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) Facility rules and how they are communicated with clients. (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 lin- guistic needs of the community to be served. (12) Policies on service notes, treatment documentation, and client records including information on the following: (a) Client information to be documented and by which staff. (b) Frequency of documentation. (c) Maintenance of client records. (d) Confidentiality requirements. (13) Policies on safety concerns specific to clients, visitors, and staff including policies on the following: (a) Facility entrances and exits. (b) Facility design such as ligature and barricade risk preven- tion, tamper-resistant electrical outlets, control of sharps, impact resistant glass, and anchoring of weighted furniture. (c) Search of clients and property. (d) Levels of staff observation required to address client needs. (e) Emergency safety interventions in the event of client re- lated emergencies, natural disasters, structural or environmental emergencies, and imminent internal or external threats. (f) Elopement and procedures for responding to client elopement. (g) Emergency safety interventions. This policy must be con- sistent 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) Policies on telehealth, artificial intelligence, and consul- tation via electronic communication, including all of the following: (a) When telehealth, artificial intelligence, or electronic com- munications can be used and by whom. (b) Client privacy and information security considerations. (c) A client’s right to decline services provided via telehealth, artificial intelligence, or electronic communication. (15) Discharge and transfer policy criteria consistent with s. DHS 31.11 (5), and including all the following: (a) Transfers related to a client’s physical health care needs, including emergency medical health care. (b) Transfers when longer-term care beyond 5 days is required. (16) A CCF that serves minors shall have written, specific policies and procedures for the care of minors consistent with this subchapter. (17) Policies regarding mandated reporting requirements consistent with s. 48.081, Stats. 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. DHS 31.08 Personnel. (1) GENERAL STAFF QUALIFICA- TIONS. Program staff retained to provide services at a CCF shall be qualified as follows: (a) Psychiatrists shall be licensed to practice medicine in Wis- consin under ch. 448, Stats., and be certified by the medical ex- amining board to practice as a psychiatrist. (b) Psychologists shall be licensed to practice in Wisconsin under ch. 455, Stats. (c) Psychology residents shall hold a doctoral degree in psy- chology meeting the requirements of s. 455.04 (1) (c), Stats. (d) Psychiatric residents shall hold a doctoral degree in medicine and be in training to become a psychiatrist. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.08 WISCONSIN ADMINISTRATIVE CODE 6 (e) Physicians shall be licensed and board certified to practice medicine or osteopathy under ch. 448, Stats. (f) Physician assistants shall be certified and registered pur- suant to ss. 448.05 and 448.07, Stats. (g) Nurse practitioners or clinical specialists shall hold a cur- rent license as a registered nurse under ch. 441, Stats., hold a master’s degree from an accredited graduate school of nursing, and be board certified by an applicable national nurse certifying body. (h) Advanced practice nurse prescribers certified under ch. N 8 shall be nurse practitioners or clinical specialists, hold a current license as a registered nurse under ch. 441, Stats., hold a master’s degree from an accredited graduate school of nursing, and be board-certified by an applicable national nurse certifying body. (i) Registered nurses shall meet the qualifications established in ch. 441, Stats., and be certified by the board of nursing. (j) Licensed practical nurses shall be licensed under 441, Stats. (k) Nursing assistants shall be certified in the department’s registry of nurse aids. (L) Certified social workers, certified advance practice social workers and certified independent social workers shall meet the qualifications established in ch. 457, Stats., and chs. MPSW 1, 3, 6,19, and 20 and have received certification by the examining board of social workers, marriage and family therapists and pro- fessional counselors. (m) Licensed clinical social workers shall meet the qualifica- tions established in ch. 457, Stats., and be licensed by the exam- ining board of social workers, marriage and family therapists and professional counselors with 3,000 hours of supervised clinical experience where the majority of clients are children or adults with mental disorders or substance-use disorders. (n) Professional counselors and marriage and family thera- pists shall meet the qualifications established in ch. 457, Stats., and be certified by the examining board of social workers, mar- riage and family therapists and professional counselors. (o) Master’s level clinicians shall have a master’s degree and coursework in areas directly related to providing mental health services including master’s in clinical psychology, psychology, school or educational psychology, rehabilitation psychology, counseling and guidance, counseling psychology or social work. (p) Other qualified mental health professionals shall have at least a bachelor’s degree in a relevant area of education or human services and a minimum of 6 months of combined experience providing mental health services, or work experience and training equivalent to a bachelor’s degree including a minimum of 4 years of work experience providing mental health services. (q) Substance abuse counselors shall meet any of the follow- ing qualifications: 1. A clinical substance abuse counselor as defined in s. SPS 160.02 (5). 2. A substance abuse counselor as defined in s. SPS 160.02 (26). 3. A substance abuse counselor-in-training as defined in s. SPS 160.02 (27). 4. An individual who holds a physician, psychologist, clini- cal social worker, marriage and family therapist, or professional counselor license, or an advanced practice social worker certifi- cate or independent social worker certificate granted under chs. 448, 455, 457, Stats., and practices within their scope. (r) Certified peer specialist shall meet all the following qualifications: 1. Lived experience with mental illness or substance use dis- orders, or both. 2. Completed the Wisconsin certified peer specialist training and passed the examination. (s) Certified parent peer specialist shall meet all the following qualifications: 1. Lived experience caring for an individual with mental ill- ness or substance use disorders, or both. 2. Completed the Wisconsin certified parent peer specialist training and passed the examination. (t) Peer recovery coaches shall meet the training and experi- ence requirements in subch. II of ch. DHS 72. (u) Specialists in specific areas of therapeutic assistance, such as recreational, art, and music therapies, shall have complied with the appropriate certification or registration procedures for their profession as required by state statute or administrative rule or the governing body regulating their profession. (v) Occupational therapists and assistants shall meet the re- quirements of subch. VII of ch. 448, Stats. (w) Behavioral health technicians or similarly titled staff pro- viding direct client care and serving in a clinically supportive role shall be paraprofessionals who are employed based on personal aptitude and life experience which demonstrates their ability to provide effective emergency behavioral health services and have professional health care experience. (2) REQUIRED PERSONNEL. A CCF shall have all of the fol- lowing minimum staff positions at staffing levels identified in their staffing plan: (a) Treatment or medical director. A CCF shall have a treat- ment or medical director who is qualified under sub. (1) (a) or (b) and responsible for all of the following: 1. Assuming clinical responsibility and direction for the pro- vision of care. 2. Providing clinical psychiatric services consistent with their scope of practice. 3. Assuming responsibilities afforded a treatment director which are consistent with ch. 51, Stats. (b) Nursing administrator. A CCF shall have a nursing ad- ministrator who is qualified under sub. (1) (e) to (i), and responsi- ble for the medical health services provided by the program. The nursing administrator shall also be responsible for ensuring that all staff members providing medical health services have the qualifications required for their role in the program and comply with all requirements relating to medical and physical health as- sessment, treatment planning, service delivery, and documentation. (c) Clinical director. A CCF shall have a clinical director who is qualified under sub. (1) (a), (b), (m) or (n) who is responsible for all of the following: 1. The day-to-day clinical crisis services provided by the program. 2. Ensuring that staff providing these services have the qual- ifications required for their role in a CCF and comply with all re- quirements relating to crisis assessment, care planning, service delivery, and documentation. (d) Program administrator. A CCF shall have a program ad- ministrator who is responsible for all of the following: 1. Administration and overall operation of a CCF. 2. Ensuring that appropriate policies and procedures for ser- vices are developed and carried out in compliance with this chapter. 3. Administrative oversight of the job performance and ac- tion of service staff. 4. Compliance with regulations governing the care and treat- ment of clients and the standards of practice for behavioral health professionals. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 7 DEPARTMENT OF HEALTH SERVICES DHS 31.10 (3) PERMISSIBLE DUAL ROLES. (a) The treatment director un- der sub. (2) (a) may also serve as the clinical director under sub. (2) (c). (b) The treatment director, nursing administrator, or clinical director under sub. (2) (a), (b), or (c) may also serve as the pro- gram administrator under sub. (2) (d). (4) BACKGROUND CHECKS. A CCF shall comply with the criminal history and patient abuse record search requirements in s. 50.065, Stats. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (h), (m), (p), (q) 4., (v), (2) (c) (intro.) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.09 Staffing requirements. (1) STAFFING RE- QUIREMENTS. (a) In this subsection, “24/7” means 24 hours per day, 7 days per week. (b) On-site staffing levels shall be adequate to allow for all of the following: 1. Persons to receive services on a 24/7 basis, including through telehealth. 2. Safety and security of clients, staff, and visitors. (c) A CCF shall maintain the following minimum staffing requirements: 1. The treatment director or their designee shall be available on-site or by electronic communication 24/7. 2. The nursing administrator or their designee shall be avail- able on-site 24/7. 3. The clinical director or their designee shall be available on-site or by electronic communication 24/7. 4. A prescriber shall be available on-site or by electronic communication 24/7. 5. A nurse qualified under s. DHS 31.08 (1) (g) to (i), or a physician qualified under s. DHS 31.08 (1) (e) to (f) shall be on- site 24/7. This may include the nursing administrator under s. DHS 31.08 (2) (b) or their designee. 6. Staff qualified under s. DHS 31.08 (1) (o) shall be on-site 8 hours a day, 7 days a week to provide and support the social and behavioral health services. This may include the clinical director under s. DHS 31.08 (2) (c) or their designee. 7. At all times, a minimum of 4 staff, including those identi- fied in subds. 1. to 6., shall be on-site 24/7. Available staff shall be capable of providing services identified in this chapter. 8. At all times, a minimum of 2 staff on-site 24/7 at a CCF shall have completed training in each of the following: a. Basic cardiac life support and use of an automated exter- nal defibrillator equipment. b. Administration of an opioid reversal medication. c. Emergency safety interventions. (d) A CCF shall ensure staffing is adequate to maintain com- pliance with requirements in s. 51.15, Stats. (2) STAFFING PLAN AND SCHEDULES. (a) A CCF shall make available to the department a staffing plan which shall include all the following: 1. Methodology used for determining staffing levels. 2. Staffing levels for required personnel under sub. (1) and s. DHS 31.08 (2), to include both the number of positions needed and the actual number hired. 3. Staff availability, including staff available on-site, on-call, via telehealth, and via electronic communication. 4. A plan for responding to fluctuations in acuity, serving clients with high needs, staffing shortages, and surges in referrals and admissions. (b) A CCF shall make available to the department, as re- quested, a daily staff schedule which identifies shifts, work hours, and scheduled positions. (c) A CCF shall consider the acuity levels and clinical and safety needs of clients being served and adjust staffing levels based on those needs while meeting staffing requirements as out- lined in sub. (1). (d) A staffing plan must demonstrate adequate staffing is available for the provision of care if minors are being served. (e) A staffing plan shall be updated when needed to meet the needs of a CCF. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.10 Personnel development. (1) ORIENTA- TION AND TRAINING. (a) Orientation program. A CCF shall de- velop and implement an orientation for all new staff to ensure that staff know and understand all of the following: 1. Pertinent parts of this chapter. 2. The program’s policies and procedures. 3. Job responsibilities and scope of practice for staff and vol- unteers of the program. 4. Applicable parts of chs. 51 and 55, Stats., ch. DHS 34, and chs. DHS 33 (effective March 1, 2026), 50, 75, and 94 related to the provision of emergency mental health services and care for voluntary and involuntary clients. 5. The provisions of ss. 51.30 and 51.61, Stats., related to client rights and confidentiality of treatment records. (b) All employee training. A CCF shall provide, obtain, or otherwise ensure adequate training for all employees in all of the following: 1. Standard precautions. 2. Fire safety. 3. First aid and choking. 4. Abuse, neglect, and misappropriation prevention. 5. Basic mental health and psychopharmacology concepts applicable to crisis situations. 6. Techniques and procedures for non-violent crisis interven- tion with clients, including verbal de-escalation, positional de-es- calation, methods for obtaining backup, and acceptable methods for self-protection and protection of the client and others. 7. Emergency safety interventions consistent with s. 51.61 (1) (i) (1), Stats., and industry best practices for seclusion and re- straint training that emphasize prevention, safety, and least re- strictive interventions. 8. Crisis intervention considerations for all of the following populations: a. Clients with intellectual or developmental disabilities. b. Clients with dementia. c. Clients who are suicidal or engage in self-harm. d. Clients with acute symptoms related to mental health or substance use. 9. Training on the use of opioid reversal medications. (c) Task-specific training. A CCF shall provide, obtain or otherwise ensure adequate training for employees who, based on their position will provide any of the following services: 1. Screening, assessment, and intervention of clients in crisis including those exhibiting or verbalizing acute, threatening, or dangerous behaviors, suicidal behaviors, and those using alcohol or drugs. 2. Crisis, safety, and discharge planning with individuals in crisis. 3. Medication administration and management. (d) Training program for serving minors. A CCF treating mi- Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.10 WISCONSIN ADMINISTRATIVE CODE 8 nors shall provide training on all of the following to all staff work- ing with minors: 1. Applicable parts of chs. 48 and 938, Stats. 2. Content specific to minors and families in crisis and their care and treatment needs. (e) Orientation and training requirements. 1. Each newly hired staff with less than 6 months of experience providing be- havioral or mental health, or substance use services shall com- plete a minimum of 40 hours of documented orientation and training within 3 months after beginning work with the program. 2. Each newly hired staff person who has had 6 months or more of prior experience providing behavioral or mental health, or substance use services shall complete a minimum of 20 hours of documented orientation and training within 3 months after be- ginning work with the program. 3. Training topics covered in pars. (a) to (d) count toward the minimum required orientation and training hours in subds. 1. and 2. 4. All staff shall receive annual refresher training on standard precautions, client rights, prevention and reporting of abuse ne- glect and misappropriation, fire safety, emergency safety inter- ventions, and first aid. 5. Staff who administer or manage medication shall receive annual refresher training on medication administration and management. 6. Staff with credentials, licensure, or certification that re- quires continuing educational requirements shall maintain com- pliance with those requirements as it relates to their professional role within a CCF. 7. Staff without continuing education requirements shall re- ceive at least 8 hours per year of in-service training on topics re- lated to clients and relevant to the services provided at a CCF. This is in addition to annual refresher training requirements in subd. 3. (f) Exemptions for training requirements. 1. Employees who, based on their professional education and training have com- pleted training or coursework that is minimally equivalent, in content and duration, to those required may be exempt from re- quired training under pars. (b) to (d). 2. Exemptions do not apply for standard precautions, fire safety, first aid and choking, abuse neglect and misappropriation, and emergency safety interventions. 3. A CCF shall ensure and determine the training or course- work is relevant, current, and meets the requirements of this subchapter. 4. Employees shall provide documentation of the profes- sional education or training and a CCF shall have that available. (2) CLINICAL SUPERVISION AND CONSULTATION. (a) A CCF shall have written policies and procedures for clinical supervision of, and consultation with staff to ensure that: 1. The services provided by the program are appropriate and being delivered in a manner most likely to result in positive out- comes for clients. 2. Staff have the training and experience needed to carry out the roles for which they have been retained and receive the ongo- ing support and supervision they need to provide effective services. (b) Staff with credentials, licensure, or certification that re- quires clinical supervision shall maintain compliance with those requirements as it relates to their professional role within a CCF. (c) Staff who have not had 3,000 hours of supervised clinical experience, or who do not possess at least one of the qualifica- tions in s. DHS 31.08 (1) (a) to (h), shall receive a minimum of one hour of clinical supervision per week or for every 30 hours of direct care they provide. (d) Staff who have completed 3,000 hours of supervised clin- ical experience and who have at least one of the qualifications in s. DHS 31.08 (1) (a) to (i), (m) to (n), or (q) 4., shall participate in a minimum of one hour of peer clinical consultation per month or for every 120 hours of direct care they provide. (e) Clinical supervision of staff includes review, assessment, and feedback regarding each staff member’s delivery of services and can be accomplished by one or more of the following means: 1. Individual consultation with staff to review cases, assess performance, and provide feedback. 2. Side-by-side sessions in real time in which the supervisor is present while staff provides services and in which the supervi- sor assesses, coaches, and gives feedback. 3. Group supervision and clinical staffing to review and as- sess cases and provide consultation or clinical direction. 4. Other professionally recognized methods of supervision as described in a program’s written policies and procedures and approved by the department. (f) Clinical supervision shall be provided by at minimum, a master’s level clinical practitioner, who is fully licensed, creden- tialed, or certified in Wisconsin in the field of psychology, psy- chiatry, counseling, social work, or psychiatric nursing. (3) PERSONNEL RECORDS. A CCF shall maintain current copies of its orientation and training program, evidence of cur- rent licensure and certification of staff as applicable, and proof that training and supervision requirements are met. These records should be documented in writing and made available to the department upon request. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (a) 5., (e) 3., (f) 1. made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.11 Admissions, transfers, discharges, and holds on admissions. (1) SCREENING AND ADMISSION RE- QUIREMENTS. (a) A CCF shall screen all adults and admit those determined eligible for services 24 hours a day, 7 days a week, in- cluding all of the following: 1. Voluntary adults who walk-in. 2. Voluntary adults brought in by law enforcement, emer- gency medical responders, or county crisis personnel. 3. Adults brought in under s. 51.15, Stats. (b) A voluntary client may be detained under s. 51.15, Stats., if conditions exist in accordance with s. 51.15 (10), Stats. (c) A CCF shall be able to provide services to clients experi- encing a crisis, including those with any of the following: 1. Serious mental illness or serious emotional disturbance. 2. Substance use related needs. 3. Acute behavioral or mental health symptoms. 4. An intellectual or developmental disability. 5. Dementia. (d) A CCF shall not admit clients for stays longer than 5 days unless all of the following apply: 1. The treatment director or designee determines that a stay beyond 5 days is clinically appropriate and documents the basis for that conclusion. 2. The treatment director or designee determines that there are no other less restrictive alternatives available to meet the client’s needs. 3. The county of responsibility consents to the continued stay, if applicable. (e) If a determination for a stay beyond 5 days is made in ac- cordance with par. (d) 1. to 3., that determination shall be re- Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 9 DEPARTMENT OF HEALTH SERVICES DHS 31.12 viewed by the treatment director or designee every day following the initial determination to ensure the continued stay is necessary. (f) A CCF shall not admit persons with physical or health care needs that require medical or personal care attention beyond what can be safely provided at a CCF. (2) ADDITIONAL SCREENING AND ADMISSION REQUIREMENTS FOR CCFS CERTIFIED TO SERVE MINORS. (a) A CCF shall screen all minors and admit those determined eligible for services 24 hours a day, 7 days a week, including the following: 1. Voluntary minors who walk-in, accompanied by a parent or guardian. 2. Voluntary minors brought in by law enforcement, emer- gency medical responders, or county crisis personnel. 3. Minors brought in under s. 51.15, Stats. (b) Voluntary admission for minors must be consistent with s. 51.13 (6) (a) 1. to 3, Stats. (c) A CCF shall adhere to all applicable requirements out- lined in ss. 51.47 and 51.48, Stats. (3) ADMISSIONS UNDER INVOLUNTARY STATUS. (a) A county crisis assessment under s. 51.15 (2) (c), Stats., is required prior to admission for purposes of an emergency detention for adults and minors. (b) For the purpose of involuntary treatment, a CCF shall meet all procedural requirements under s. 51.15 (5), Stats. (c) The treatment director has the authority to dismiss an emergency detention at a CCF under s. 51.15, Stats. (d) CCF staff shall coordinate with the county of responsibil- ity to ensure clients can attend and participate in legal hearings. (4) INTERFACILITY TRANSFER. (a) A CCF may transfer a client on emergency detention for any of the following reasons: 1. The client has health care needs that cannot be provided at a CCF. 2. A change in legal status prohibiting admission, such as a conversion to protective placement. 3. The client exhibits violent or abusive behaviors that can- not be safely mitigated at a CCF. 4. The county of responsibility initiated a transfer, and it is in the best interest of the client. (b) A CCF shall coordinate the safe transfer of care in coordi- nation with the county of responsibility, if applicable. (c) Clients may only be transferred to a facility upon confir- mation that the receiving facility will accept that client. (d) The treatment director or designee shall determine and document in writing the need for transferring a client on emer- gency detention. (5) DISCHARGE. (a) A CCF shall discharge a client for any of the following reasons: 1. A client is of voluntarily status and no longer needs or de- sires services and is discharged in accordance with s. 51.10 (5), Stats. 2. A client is of involuntarily status and in need of different services requiring a discharge and transfer of care. 3. Other clinical, legal, or safety reasons consistent with pro- gram policy and approved and documented by the treatment di- rector or designee. (b) Minors shall be discharged in accordance with s. 51.13 (7) (b) 3., Stats. (c) Discharges under s. 51.15 (4) (b) or (5), Stats., for clients under involuntary status shall be done in coordination with the county of responsibility. (d) The client’s personal property and medications shall be re- turned upon discharge. (e) A discharge summary consistent with s. DHS 31.13 (2) shall be completed. (6) HOLD ON ADMISSIONS. (a) The treatment director or de- signee may temporarily hold admissions if a CCF is at capacity or it is determined that a CCF is unable to safely deliver services due to extraordinary circumstances, such as a natural disaster. A hold may apply to some service areas or the entire CCF. (b) A CCF shall notify the department within one business day about any holds on admissions lasting longer than 24 hours and include the following information: 1. The anticipated duration of the hold and date and time when the hold may be lifted. 2. The plan to resume admissions. 3. The service areas affected by the admissions hold. 4. The rationale for the decision to temporarily hold admissions. (c) A CCF shall develop and maintain documented contingen- cies with other local hospitals, emergency medical services, county crisis providers, and law enforcement for when temporary holds on admissions are in effect. (d) A recurrence of admission refusals, client transfers, or holds on admissions may result in a site visit and review of certi- fication by the department. (e) Admission holds shall be communicated to community partners through the department-approved psychiatric bed locator. (7) AVAILABILITY. A CCF shall communicate the availability of beds to referring community partners through the department- approved psychiatric bed locator. A CCF shall report all of the following information to the department-approved psychiatric bed locator at least every 6 hours: (a) The number of available client rooms and beds in these rooms. (b) The number of available beds in the observation unit, if applicable. (c) Contact information for referrals. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (e), (6) (a), (7) (intro.) made under s. 35.17, Stats., and (7) (title) added under s. 13.92 (4) (b) 2., Stats., Register February 2026 No. 842. DHS 31.12 Services. (1) GENERAL OBJECTIVES. A CCF shall have the following general objectives: (a) To provide integrated services and interventions to prevent and stabilize a crisis and reduce symptoms for clients with emer- gent mental and behavioral health and substance use crisis needs. (b) To reduce or eliminate the need for unnecessary restrictive and intensive interventions. (c) To assist in the coordination and linkage of care for the in- dividual to return to the community. (d) To assist in the coordination and linkage of care when ser- vices cannot be provided at a CCF, or a client is not eligible for services. (2) GENERAL REQUIREMENTS. A CCF shall do all of the following: (a) Provide services to involuntary clients under s. 51.15, Stats., in a secure setting. (b) Provide services to voluntary individuals who walk-in for care or are brought in by law enforcement, emergency medical re- sponders, or county crisis personnel. (c) Provide clients receiving any service for 24 hours or longer a client room with a bed. (d) Provide clients with basic needs. (e) Use standard protocols for monitoring withdrawal from Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.12 WISCONSIN ADMINISTRATIVE CODE 10 substances, such as alcohol and opioids, and the capability to ini- tiate medications to medically support withdrawal. If withdrawal monitoring supports the need for additional medical care that ex- ceeds the capacity of a CCF, the nursing administrator, treatment director, or their designee shall initiate transfer to a medical facility. (f) If the client is seeking treatment related to opioid use, a CCF shall provide information about the benefits and effective- ness of medication as treatment for opioid use disorders. If the client is not already receiving medication treatment, a CCF shall provide a referral, along with client consent, to a service that of- fers medication-assisted treatment for opioid use disorders. (g) 1. A facility shall have opioid reversal medication on-site and available to staff to be administered in the event of an opioid overdose. 2. The opioid reversal medication shall be maintained and unexpired and shall be stored in an accessible location. 3. Administration of an opioid reversal medication by the service to any individual shall be documented in the clinical record or in a facility incident report. (3) SERVICES PROVIDED OR COORDINATED BY A CCF. (a) Initial screening. 1. An initial screening completed by personnel possessing at least one of the qualifications listed in s. DHS 31.08 (1) (a) to (j) or (L) to (q) shall be completed for all referrals, in- cluding those presenting for voluntary services and involuntary clients who present in accordance with s. 51.15, Stats. 2. An initial screening must include the following: a. Determination of need for CCF services. b. Risk for suicide or harm to self. c. Risk for violence or harm to others. d. Risk related to overdose, acute intoxication, and withdrawal. e. Need for urgent medical care. f. Medication information from the PDMP database, if applicable. 3. Screening completed under this subsection may be com- bined with an assessment under par. (b). 4. Screening may determine need for alternative or addi- tional services which could include services provided at a CCF, linkage to outpatient resources, or other facility-based or inpa- tient services requiring a transfer of care. 5. Information collected and documented by county crisis personnel who have assessed a client admitted under the custody of s. 51.15, Stats., may be used for screening purposes. (b) Assessment. 1. Clients determined in need of and eligible for services during screening under par. (a) shall receive all of the following: a. A nursing assessment completed by personnel possessing at least one of the qualifications listed in s. DHS 31.08 (1) (c) to (i). b. A behavioral health assessment completed by personnel possessing at least one of the qualifications listed in s. DHS 31.08 (1) (a) to (j), (L) to (p), or (q) 4.. c. A risk assessment completed by personnel possessing at least one of the qualifications listed in s. DHS 31.08 (1) (a) to (j), (L) to (p), or (q) 4. 2. The following assessments may be performed based on client needs identified during screening under par. (a): a. A substance use assessment completed by personnel pos- sessing at least one of the qualifications listed in s. DHS 31.08 (1) (a) to (j) or (L) to (q). b. A cognitive assessment completed by personnel possess- ing at least one of the qualifications listed in s. DHS 31.08 (1) (a) to (j), (L) to (p), or (q) 4. 3. A psychosocial assessment completed by personnel pos- sessing at least one of the qualifications listed in s. DHS 31.08 (1) (L) to (o) or (q) 4. for clients admitted for 24 hours or longer. 4. Assessments shall include recommendations for care. (c) Screening and assessment tools and methods. Assess- ments and screenings shall be completed using valid screening and assessment tools and may include information gathered through the following means: 1. Evaluation and observation of the client. 2. Direct client interviews. 3. Through collateral information. (d) Reassessment. Reassessments of one or more of the as- sessments identified in par. (b) shall be completed as clinically necessary, or if any of the following apply: 1. Legal status change. 2. Significant changes in risk factors or symptoms. (e) Required services. A CCF shall provide any of the follow- ing services to a client, based on the client’s needs: 1. De-escalation. 2. Safety planning. 3. Crisis planning. 4. Medication management. 5. Crisis counseling. 6. Stabilization. 7. Care coordination. 8. Treatment of minor physical health concerns. 9. Follow-up or coordination with external providers for fol- low-up. 10. Withdrawal abatement. (f) Additional services. A CCF may provide the following services to a client, based on the client’s needs: 1. Peer support services. 2. Individual and family psychotherapy. 3. Therapeutic or psychoeducational group counseling. 4. Additional services targeted at the alleviation of crisis symptoms. (g) Discharge planning. Discharge planning shall be provided to all clients and meet the following requirements: 1. A discharge plan shall be developed with the client, to the extent possible. 2. Discharge planning shall include care coordination efforts, to the extent possible. 3. A written discharge summary shall be documented in writing, include items identified in s. DHS 31.13 (2), and be pro- vided to the client. (h) Delivery of services. 1. All medical and clinical services under this chapter shall be provided by appropriately credentialed or licensed staff operating with their scope of practice. 2. Services shall be delivered in a manner that allows clients to be informed of and participate in their treatment and care. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (2) (e), (3) (a) 1., 3., 5., (b) 1. (intro.), 2. (in- tro.), (3) (d) (intro.), (g) 3. made under s. 35.17, Stats., Register February 2026 No. 842; (3) (d) a., b. renum. to (3) (d) 1., 2. under s. 13.92 (4) (b) 1., Stats., Register March 2026 No. 843. DHS 31.13 Treatment documentation. (1) COORDI- NATED PLAN OF CARE. (a) A coordinated plan of care shall be developed for each client and include, whenever possible, all the following: Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 11 DEPARTMENT OF HEALTH SERVICES DHS 31.14 1. Information gathered during screening, assessment, and reassessment. 2. The circumstances resulting in the need for services in- cluding the potential for harm to self or others, including severity and lethality. 3. Services and interventions to be applied. 4. Any prescription or medication management services. (b) For clients with ongoing substance use related needs, a co- ordinated plan of care shall include level of care recommenda- tions consistent with any department approved placement criteria. (c) A coordinated plan of care shall be reviewed and signed by the treatment director, clinical director, or designee within 3 busi- ness days of admission. (d) The coordinated plan of care shall be documented in writ- ing and include a notation indicating the reason any items from par. (a) or (b) were not included. (2) DISCHARGE SUMMARY. (a) A written discharge summary for each client shall be completed and provided to the client prior to discharge. The discharge summary shall include, whenever possible, all of the following information: 1. Recommendations for care after discharge including the following: a. Care coordination efforts, including referrals or appoint- ments made on behalf of a client. b. Information on follow-up with client by CCF staff. c. Information on accessing prescribed medications, if applicable. 2. A safety plan which includes information on available emergency mental health services in the client’s geographic area of the client’s current residence or intended residence. 3. The client’s legal status and condition at discharge. 4. Department approved placement criteria, as applicable and necessary for clients being discharged to a facility requiring this. 5. A crisis plan for all clients admitted for 24 hours or more. (b) The discharge summary shall be reviewed and signed by the treatment director, clinical director, or designee within 3 days of discharge, not including Saturdays, Sundays, or legal holidays. (c) The discharge summary shall include a notation indicating the reason any items from par. (a) were not included. (d) The discharge summary shall be provided to the county of responsibility and external providers as applicable and with the client’s written consent. (3) SERVICE NOTES. (a) Staff providing services shall docu- ment the content of contacts with clients or collateral sources and clinical observations as it relates to a client’s care and treatment. (b) Service notes shall include documentation of services, in- terventions, or treatment provided and client response to those services. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (d), (2) (c) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.14 Emergency safety interventions. (1) GENERAL REQUIREMENTS. (a) A CCF may use seclusion and re- straint as an emergency intervention only. (b) Seclusion and restraint shall only be administered by staff who have completed orientation and training described in s. DHS 31.10 (1) (b) 7., and shall comply with all of the requirements for emergency safety interventions under s. 51.61 (1) (i) 1., Stats., s. DHS 94.10, and this chapter. (2) PROHIBITED INTERVENTIONS. Chemical restraints in- tended to control behavior or for prolonged sedation or incapaci- tation are prohibited. This does not include emergency medica- tion used to treat symptoms. (3) SECLUSION AND RESTRAINT ADMINISTRATION REQUIRE- MENTS. (a) Seclusion and restraint may only be administered when all other less restrictive methods have been exhausted. (b) Seclusion and restraint shall be administered for the short- est time possible and only until the client is no longer a danger to self or others. (c) Seclusion and restraint shall be administered in a manner that is attentive to, and respectful of the trauma history, dignity, and civil rights of the client. (d) Seclusion and restraint shall be administered in a manner that avoids or causes the least possible physical or emotional dis- comfort, harm, and pain to the client. (e) Regular access to bathroom facilities, drinking water, and necessary medication shall be provided according to the client’s needs during the administration of seclusion or physical restraint. Temperature and lights shall be maintained at levels which are comfortable to the client. (4) SPECIFIC REQUIREMENTS FOR SECLUSION. (a) A client may only be kept in the seclusion area by means of one of the following: 1. A staff member is in a position, such as in a doorway, to prevent a client from leaving the seclusion area. 2. A door to a seclusion room is latched by positive pressure applied by staff’s hand without which the latch would spring back allowing the door to open on its own accord, or a program may use a magnet door lock or a lock which requires the turn of a knob to unlock a door. Other designs of door locks shall not be used, including pad lock, key lock, or other locks of similar design. (b) Staff shall provide uninterrupted supervision and monitor- ing of the client and the seclusion area during seclusion by being in the room with the client or by observation through a window to the room. (c) Seclusion rooms shall be free of objects or fixtures with which the client could inflict bodily harm. (d) Only one client at a time may be placed in a seclusion room. (5) SPECIFIC REQUIREMENTS FOR PHYSICAL RESTRAINT. (a) Physical restraint shall only be administered during an emer- gency, when there is a serious threat of violence to other clients or a staff member, personal injury, or attempted suicide. (b) At a minimum, 2 staff trained in the use of emergency safety interventions shall be physically present during the admin- istration of restraint and shall continually monitor the condition of the client and the safe use of restraint throughout the duration of the intervention. (c) All of the following are prohibited forms of physical restraint: 1. Pressure or weight on the chest, lungs, sternum, di- aphragm, back, or abdomen, such as straddling or sitting on the torso. 2. Pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise ob- structs or restricts the circulation of blood or obstructs an airway, such as chokeholds or sleeper holds. 3. Wrestling holds or martial arts techniques. 4. Covering the face with any object. 5. Pain or pressure points. 6. Hyperextension of limbs, fingers, or neck. 7. Forcible take downs from a standing position to the floor. 8. Any other physical restraint that is not administered dur- Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.14 WISCONSIN ADMINISTRATIVE CODE 12 ing an emergency, that is administered for longer than necessary to prevent immediate injury to a client or others, or that is admin- istered for a purpose other than to prevent immediate injury to a youth or others. (d) Immediately, upon the termination of a physical restraint, a medical staff member, such as a physician, advanced practice nurse prescriber, physician assistant, or registered nurse shall conduct a follow-up assessment of the condition of the client to ensure that the client was not injured and shall document the find- ing of the assessment in the client’s clinical record. (e) If any injury is noted following a physical restraint, a staff member shall make a referral for any medical care needed and in- form a client’s guardian, if applicable. (6) SPECIFIC REQUIREMENTS FOR MECHANICAL RESTRAINT. Mechanical restraints shall only be used as a last resort when all other interventions are unsuccessful. A CCF that intends to uti- lize mechanical restraints shall meet all the following requirements: (a) Mechanical restraints may only be used under a medical order made by the treatment or medical director or their designee, and that order shall be reviewed by a physician within 8 hours. (b) Mechanical restraints must be observed every 15 minutes, and a record kept of observations. (c) Mechanical restraints may only be used for clients admit- ted involuntarily. (d) Mechanical restraints shall not be used with minors. (7) DEBRIEFING. (a) Unless clinically contraindicated, within a reasonable time following the administration of a seclu- sion or restraint, staff shall talk with the client about each of the following: 1. The circumstances that contributed to the seclusion or restraint. 2. The client’s psychological well-being and impact of the intervention. 3. Any modifications that can be made in the client’s ser- vices or plan for care to prevent seclusion or restraint in the future. (b) A CCF shall notify a guardian of any seclusion or restraint within 12 hours of being administered. The CCF shall document in the client’s record any situation in which notification has been attempted and the CCF has been unable to contact a guardian. (c) Each administration of seclusion or restraint shall be docu- mented in the client’s clinical record and shall specify all of the following: 1. Events precipitating the seclusion or restraint. 2. Less restrictive interventions attempted prior to the seclu- sion or restraint. 3. Length of time the seclusion or restraint was used. 4. Assessment of the appropriateness of the seclusion or re- straint based on threat of harm to self or others. 5. Assessment of any physical injury to the client, other clients, or staff. 6. The client’s response to the use of seclusion or restraint. (d) The treatment director, clinical director, or nursing admin- istrator or their designee shall review all seclusion and restraint documentation within 24 hours of intervention, and in consulta- tion with others determine whether changes in services are neces- sary, including whether a different level of care is necessary. These findings and recommendations shall be documented in the client’s clinical record. (8) REPORTING. (a) A CCF shall report to the department all incidences of seclusion, restraint, injury, or elopement to the de- partment within 24 hours of the incident occurring. Reporting shall be completed through the department’s online reporting system. (b) The department will evaluate the circumstances of each incident, conduct any appropriate follow-up, and identify pro- grams in need of technical assistance, training, policy develop- ment, or other quality improvement. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.15 Investigation, notification, and report- ing requirements. (1) DEATH REPORTING. (a) Client death related to physical restraint, psychotropic medication, or suicide. If a CCF has reasonable cause to believe that a client’s death was a suicide, or was caused by the use of physical restraint, seclu- sion, or psychotropic medication, a CCF shall report the death within 24 hours of the client’s death as required under s. 51.64, Stats. Note: Death reporting process and forms are available on the department’s web- site at: https://www.dhs.wisconsin.gov/regulations/report-death/proc-report- ingdeath.htm. (b) Client death related to an accident, injury, natural causes, or other reasons. When a client dies for any reason other than the use of a physical restraint, seclusion, psychotropic medication, or suicide, a CCF shall send a report to the department within 3 business days of the client’s death. Note: The department’s reporting link is available on the department’s website at: https://www.dhs.wisconsin.gov/crisis/place.htm. (2) INVESTIGATING AND REPORTING ABUSE, NEGLECT, THEFT OF PROPERTY, OR INJURIES OF AN UNKNOWN SOURCE. (a) A CCF is an entity subject to caregiver misconduct reporting require- ments under ch. DHS 13. Caregiver misconduct must be reported within 7 days of the incident or the date the entity knew or should have known of the incident. Note: The department’s caregiver misconduct reporting link is: https://www.dhs.wisconsin.gov/misconduct/reporting.htm. (b) Physical, sexual, or mental abuse, or neglect by non-care- givers or clients shall be reported to the department within 24 hours of the incident or the date the entity knew or should have known the incident occurred. Note: The department’s reporting link is: https://www.dhs.wisconsin.gov/mis- conduct/reporting.htm. (c) Theft of property by non-caregivers or minors shall be re- ported to the department within 7 days of the incident or the date the entity knew or should have known of the incident. Note: The department’s reporting link is: https://www.dhs.wisconsin.gov/mis- conduct/reporting.htm. (d) A CCF shall investigate any of the following: 1. An injury that was not observed by any person. 2. The source of an injury to a client that cannot be ade- quately explained by the client. 3. An injury to a client that appears suspicious because of the extent of the injury or the location of the injury on the client. (e) A CCF shall maintain documentation of each investigation of an injury referenced under par. (d). A CCF shall report the in- cident as required under this subchapter. (3) NOTIFYING OTHER INTERESTED PARTIES. (a) In this sub- section, “legal representative” means any of the following: 1. A guardian of the person, as defined under s. 54.01 (12), Stats. 2. A parent of a minor, as defined in s. 48.02 (13), Stats., a guardian of a minor, as defined in s. 48.02 (8), Stats., or a legal custodian of a minor, as defined in s. 48.02 (11), Stats. (b) A CCF shall immediately notify a client ’s legal represen- tative when there is an allegation of physical, sexual or mental abuse, or neglect of a client that occurred at a CCF or under the supervision of CCF staff. (c) A CCF shall notify the client’s legal representative within Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 13 DEPARTMENT OF HEALTH SERVICES DHS 31.19 72 hours when there is an allegation of misappropriation of property. (d) A CCF shall follow all procedures required of mandated reporters. (4) DOCUMENTATION OF THE INCIDENT. All written reports required under this section shall include, at a minimum, the time, date, and place of the incident, the individuals involved, the de- tails of the occurrence, and the action taken by the provider to safeguard the client’s health, safety, and well-being. (5) REPORTING REQUIREMENTS. (a) For each quarter subse- quent to the first March of operation, a CCF that has been certi- fied for 24 months or less, shall submit a quarterly report to the department no later than 30 days after the end of the previous quarter. (b) A CCF that has been certified for 24 months or more, shall submit an annual report to the department no later than March 30th. (c) The quarterly and annual reports shall include all of the following information: 1. The number of admissions, including both voluntary and involuntary. 2. The number of voluntary admissions converted to invol- untary, and the number of involuntary admissions converted to voluntary. 3. The number of persons served, both screened and admit- ted and reason for those not admitted after screening. 4. Facility capacity, specifically the number of staffed beds. 5. Data regarding how clients are arriving for admission, in- cluding through transport by law enforcement, family, emergency medical responders, or county crisis personnel. 6. Average wait times, including for admission, treatment, discharge, law enforcement drop-off time, and any other signifi- cant aspect of services provided by a CCF. 7. The length of client stays, separated by voluntary and in- voluntary at admission. 8. The time-of-day each client was admitted. 9. The source of payments for client care, including private payment sources or payment under the medical assistance pro- gram under subch. IV of ch. 49, Stats. 10. The county of residence for each client. 11. The county of responsibility for each client admitted involuntarily. 12. The estimated number of diversions from Winnebago Mental Health Institute, hospitals, or other facilities. 13. The number of repeat clients and readmissions. 14. Any follow-up services utilized, as applicable. 15. The number of transfers to other facilities, including Winnebago Mental Health Institute, hospitals, or other facilities. 16. A description of any injuries, assaults, or other safety-re- lated incidents. 17. The number of times law enforcement was contacted due to intervention needed at the facility, and description of the need. 18. A description of the number and type of employees pro- viding staffing during the various times of day, including by telehealth. 19. Legal status upon discharge and number of clients who discharge against medical advice. 20. A breakdown of funding, including the amounts and sources of funding. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (2) (e), (4) made under s. 35.17, Stats., Reg- ister February 2026 No. 842. DHS 31.16 Client rights and grievance procedure. All CCF operations, policies, and services shall comply with s. 51.61, Stats. and ch. DHS 94, relating to patient rights and resolu- tion of patient grievances. CCFs admitting minors should comply with 51.13 (3), Stats. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. Subchapter III — Facilities DHS 31.17 Applicability. (1) This subchapter applies to publicly or privately operated and certified CCFs. (2) A CCF that is approved as a hospital under ch. 50, Stats., is not required to meet the requirements under this subchapter. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.18 General facility requirements. (1) A CCF shall operate 24 hours per day, 7 days per week. (2) The facility of a CCF shall be constructed and maintained so that it is functional for assessment and treatment and for the delivery of health services appropriate to the needs of the com- munity and with due regard for protecting the health and safety of the clients. (3) No CCF shall have more clients at any given time than the maximum capacity indicated on the department-approved certification. (4) A CCF shall be physically separated from other entities, programs, and services. (5) A CCF shall comply with the Group I-2 occupancy state building code requirements in chs. SPS 361 and 366, and any ap- plicable local ordinances or municipal building regulations. (6) A CCF shall maintain all rooms in the facility in a state of good repair and in a clean, safe, and sanitary condition. (7) A CCF shall comply with the Americans with Disabilities Act, 42 USC 12101 et seq. (8) A CCF shall provide separate entrances or intakes for walk-in clients, law enforcement, and, if applicable, minor clients. (9) A CCF shall provide a nurse station that facilitates direct staff visual observation of unit corridors and client care areas. (10) A CCF shall have a clean workroom, soiled holding, and environmental services room. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842 , eff. 3-1-26; correction in (8) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.19 Physical environment. (1) SPACE RE- QUIREMENTS. (a) Client examination room. A CCF shall have a client examination room that shall include the following: 1. A wall that physically separates the client examination room from client rooms, living areas, staff areas, or facility com- mon areas. 2. A functioning sink that is equipped with appropriate equipment and supplies for infection prevention. (b) Medication storage areas. A CCF shall comply with physical security requirements in 21 CFR 1301.72. The medica- tion storage area shall be clean and shall be separated by a wall from any restroom, cleaning products, or food-preparation stor- age areas. (c) Observation unit. A CCF that has an observation unit for clients receiving services for less than 24 hours shall do all of the following: 1. Ensure that each bed in the observation unit is dedicated to one client at a time. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.19 WISCONSIN ADMINISTRATIVE CODE 14 2. Provide a minimum floor area that allows for 3 feet be- tween beds. (d) Individual or dual occupancy client rooms. 1. A CCF shall have a minimum of 3 client rooms and 4 beds. 2. A CCF shall have a minimum of one single occupancy client room. 3. Designated client rooms shall not serve a multi-functional purpose. 4. Visual privacy shall be provided for each client in dual oc- cupancy rooms. 5. The minimum floor area per bed shall be 80 square feet in multiple client rooms and 100 square feet in single client rooms. The distance between client beds in multi-client rooms shall be at least 3 feet. 6. Clients’ clothing and personal items may be stored in a separate designated area. 7. Corridors and spaces connected to a corridor that are not separable by a door shall not be used for client rooms, observa- tion units, or hazardous areas. (e) Toilet rooms. 1. ‘Client rooms.’ a. One toilet room shall serve no more than 6 dedicated client beds. b. A handwashing sink shall be provided either in each client’s room or in the toilet room. c. A shower shall be provided either in each client’s room or adjoining the toilet room. 2. ‘Observation unit.’ a. An observation unit shall have at least one toilet room with a sink per 10 beds. b. An observation unit shall have at least one shower stall available to clients. c. An observation unit shall have at least one soiled linen holding room. 3. ‘Access to toilet rooms.’ Every toilet door shall be de- signed to allow opening from the outside during an emergency when locked. (f) Client call system. A reliable call mechanism shall be pro- vided in locations where clients may be left unattended, including client rooms, toilet and bathing areas and designated high risk treatment areas from which persons may need to summon assistance. (g) Visitor space and phone calls. A CCF shall allow space for visitors and telephone calls. (h) Family space for minors. A CCF certified to serve minors shall have designated space available for families to assemble. (2) LAUNDRY SERVICES. (a) Handling laundry. A CCF shall have a designated laundry area to sort, process and store clean and soiled laundry in a manner that prevents the spread of infection. (b) Storage and transport. A CCF shall have separate clean and dirty laundry storage areas or containers. A CCF shall not transport, wash, or rinse soiled laundry in areas used for food preparation, serving or storage. (c) Clothes dryers. A CCF shall enclose any clothes dryer having a rated capacity of more than 37,000 British Thermal Units an hour in a one-hour fire resistive rated enclosure. If the clothes dryer requires a vent, a CCF shall use dryer vent tubing that is of rigid material with a fire rating that exceeds the temper- ature rating of the dryer. The dryer vent tubing shall be clean and maintained according to the manufacturer’s recommendations. (3) BUILDING MAINTENANCE AND SITE. (a) Maintenance. The condition of the physical plant for the CCF and its exterior areas shall be maintained in good repair, free of hazards, and in such a manner that assures the safety and well-being of clients, staff, and visitors. (b) Pest control. A CCF shall implement safe, effective pro- cedures for control and extermination of insects, rodents, and vermin. (c) Garbage and refuse. A CCF shall promptly dispose of garbage and refuse. Garbage and refuse in inside areas shall be kept in leak-proof, non-absorbent closed containers. Garbage and refuse in outside areas shall be stored in closed containers. (d) Storage of toxic substances. A CCF shall ensure that any cleaning compounds, polishes, insecticides, and toxic substances are labeled and stored in a secure area. (4) BUILDING SUPPORT SYSTEMS. (a) Heating. 1. A CCF shall maintain a heating system in a safe and properly functioning condition that can maintain temperatures between 70 and 75 de- grees Fahrenheit in areas occupied by clients. 2. . A CCF shall ensure that a heating contractor or local util- ity company completes regular maintenance and provides docu- mentation of the maintenance performed. 3. A CCF may not use a fuel-fired heater, wood burning stove, fireplace, portable space heater, or any other open flame combustible fuel-burning device. (b) Public water supply. A CCF shall use a public water sup- ply when available. If a public water supply is not available, a CCF shall have a well that is approved by the state department of natural resources. A CCF shall have the well water tested at least annually by the state laboratory of hygiene or other laboratory ap- proved under ch. NR 149. A CCF shall maintain documentation of annual testing results. (c) Electrical. 1. ‘Installation and maintenance.’ a. A CCF shall be supplied with electrical service, wiring, outlets, and fix- tures, which shall be properly installed and maintained in good and safe working condition. b. Electrical outlets shall be located to limit the use of exten- sion cords. Extension cords shall not be used in lieu of permanent wiring and shall not be used in any space where a client may be. c. All temporary wiring and exposed wiring, whether in use or abandoned, shall be removed. 2. ‘Service size.’ The electrical service shall be of the proper size to handle the connected load. 3. ‘Protection.’ a. Tamper-resistant fuses or circuit breakers not to exceed the ampere capacity of the smallest wire size in the circuit shall protect the branch circuits. b. Ground fault interrupt protection shall be required for all outlets within 6 feet of a plumbing fixture, all outlets on the exte- rior of a CCF. c. Electrical receptacles shall be of a tamper-resistant type when located within client toilet rooms and bathing facilities, client bedrooms, and other client care spaces. 4. ‘Minimum number of fixtures.’ Every client room, bath- room, kitchen or kitchenette, dining room, laundry room and fur- nace room shall contain at least one approved or listed ceiling or wall-type electric light fixture equipped with sufficient lamps or tubes to provide at least 5 foot-candles at floor level at the center of room. Where more than one fixture is used or required, the ad- ditional fixture or fixtures shall be equally spaced as far as is practical. A switched outlet may be substituted for a ceiling or wall fixture in client rooms and dining rooms. 5. ‘Minimum number of outlets.’ a. In common rooms, din- ing rooms and client rooms, there shall be one electric duplex outlet per 75 square feet of floor area, with a minimum of 2 per room. b. In kitchens, there shall be one electric duplex outlet per 8 lineal feet or fraction thereof of countertop and preparation area, including island-type areas. If a kitchen is also used for dining purposes, there shall be at least one electric duplex outlet per 75 Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 15 DEPARTMENT OF HEALTH SERVICES DHS 31.23 square feet of floor area. Separate outlets shall be provided for refrigerators. c. In laundry rooms, there shall be a minimum of one electric duplex outlet. d. In toilet rooms, there shall be a minimum of one electric duplex outlet, which may be part of the wall fixture if located 72 inches or less from the floor. e. In any other habitable rooms not specified above, there shall be a minimum of 2 electric duplex outlets. 6. ‘Night lighting.’ Client bedrooms shall have night lighting with at least one light fixture controlled at the room entrance, and corridors shall have illumination with provisions for reducing light levels at night. 7. ‘Switches.’ Switches or equivalent devices for turning on at least one light in each room or passageway shall be located to conveniently control the lighting in the area. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (4) (c) 4. made under s. 35.17, Stats., Regis- ter February 2026 No. 842. DHS 31.20 Building design. A CCF shall meet the fol- lowing building design requirements: (1) STORAGE AREAS. A CCF shall have adequate and desig- nated storage space for client care supplies and equipment. A CCF shall maintain storage areas in a safe, dry, and orderly condition. (2) DOORS. (a) All doors shall have latching hardware to per- mit opening from the inside with a one-hand, one-motion opera- tion without the use of a key or special tool. (b) All doors and door hardware shall be ligature resistant. (c) The on-site nursing administrator or their designee shall have a means of opening all locks or security devices on all doors in a CCF. (d) Doors to client rooms may not be lockable from the inside. (e) All interior doors equipped with locks shall be designed to unlock from either side in case of emergency. (f) Doors in secured client spaces may be locked if complying with SPS 361-366. (3) WINDOWS. Windows in any client rooms shall have cover- ing material or device that affords privacy and light control. (4) FURNISHINGS. Furnishings in a CCF shall be clean, safe, maintained in good repair, intended for the use of the room, and intended to minimize the risk of ligature, weaponization, con- cealment, and barricade. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.21 Infection control program. (1) PROGRAM ESTABLISHMENT. A CCF shall establish and follow an infection control program based on current standards of practice to prevent the development and transmission of communicable disease and infection. (2) POLICIES AND TRAINING. The infection control program shall include written policies and training for employees. (3) HAND WASHING PROCEDURES. Employees shall follow hand washing procedures according to centers for disease control and prevention standards. (4) EMPLOYEE COMMUNICABLE DISEASE CONTROL. (a) A CCF shall obtain documentation from a physician, physician as- sistant, clinical nurse practitioner, or a licensed registered nurse indicating all employees have been screened for clinically appar- ent communicable disease including tuberculosis. Screening for tuberculosis shall be conducted using centers for disease control and prevention standards. The screening and documentation shall be completed within 90 days before the start of employ- ment. A CCF shall keep screening documentation confidential, except the department shall have access to the screening docu- mentation for verification purposes. (b) Employees shall be re-screened for clinically apparent communicable disease as described in par. (a) based on the likeli- hood of exposure to communicable disease, including tuberculosis. (c) A person who has a communicable disease shall not be permitted to work or be present in a CCF if the disease would present a risk to the health or safety of clients. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (4) (a), (b) made under s. 35.17, Stats., Reg- ister February 2026 No. 842. DHS 31.22 Food service. (1) GENERAL REQUIRE- MENTS. (a) Food supply. A CCF shall maintain a food supply that is adequate to meet the needs of clients. Individual patient nutritional needs must be met in accordance with recognized di- etary practices. (b) Equipment. A CCF shall store equipment and utensils in a clean manner and shall maintain all utensils and equipment in good repair. (2) SANITATION AND SAFETY. (a) Infection control. 1. Each employee who prepares or serves food shall be free from open, infected wounds and from communicable disease and shall main- tain clean and safe work habits. 2. A CCF shall provide hand-washing facilities in the kitchen for use by food handlers. Use of a common towel is prohibited. (b) Food safety. Whether food is prepared at a CCF or off- site, a CCF shall store, prepare, distribute, and serve food under sanitary and safe conditions for the prevention of food borne ill- nesses, including food prepared off-site. Refrigerators and freez- ers shall be maintained in accordance with the manufacturer’s recommendations. (c) Dishwashing. 1. Whether washed by hand or mechanical means, all equipment and utensils shall be cleaned using separate steps for pre-washing, washing, rinsing, and sanitizing. 2. Kitchens shall have a commercial dishwasher for washing and sanitizing equipment and utensils in accordance with stan- dard practices described in the Wisconsin food code. 3. A CCF shall have a 3-compartment sink for washing, rins- ing, and sanitizing utensils, with drain boards at each end. Wash- ing, rinsing, and sanitizing procedures shall be in accordance with standard practices described in the Wisconsin food code. In addition, a single compartment sink or overhead spray wash lo- cated adjacent to the soiled drain board is required for pre- washing. (d) Reporting. A CCF is required under s. DHS 145.04 to re- port suspected incidents of food borne disease to the local public health officer. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.23 Fire safety requirements. (1) FIRE SAFETY PLAN. A CCF shall have a written fire safety plan that provides for all of the following: (a) Use of alarm in accordance with s. DHS 31.24 (1) to (3). (b) Transmission of alarms to fire department. (c) Emergency phone call to fire department. (d) Response to alarms. (e) Procedures for isolating and extinguishing the fire. (f) Procedures for evacuating the immediate area. (g) Procedures for evacuating the smoke compartment. (h) Procedures for preparing floors and building for evacuation. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.23 WISCONSIN ADMINISTRATIVE CODE 16 (2) EVACUATION CAPABILITIES. A CCF shall have all of the following: (a) An up-to-date floor plan identifying client area, provided to the local fire department. (b) An exit diagram posted on each floor of a CCF in a con- spicuous place where it can be seen by clients and staff. The dia- gram shall identify the exit routes from the floor, including inter- nal horizontal exits when applicable, smoke compartments or a designated meeting place outside and away from the building when evacuation to the outside is the planned response to a fire alarm. (3) FIRE AND OTHER EVACUATION DRILLS AND PLANS. (a) Fire drills shall be conducted quarterly on each shift to familiar- ize facility personnel with the signals and emergency action re- quired under varied conditions complying with chs. SPS 314. (b) Tornado, flooding, or other emergency or disaster evacua- tion drills shall be conducted at least semi-annually. (c) The local fire department shall be made aware of the areas of refuge, if any, and the potential number of clients who would use the areas of refuge. Evacuation procedures involving fire de- partment personnel shall be conducted at the option of the fire department. (d) Phone numbers for emergency services shall be posted near phones used by CCF employees. (4) FIRE INSPECTION. A CCF shall arrange for fire inspec- tions in accordance with ch. SPS 314. (5) FIRE EXTINGUISHERS. A CCF shall provide fire extin- guishers consistent with ch. SPS 314. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.24 Fire protection systems. (1) INTERCON- NECTED SMOKE AND HEAT DETECTION SYSTEM. (a) A CCF shall have an interconnected smoke detection system and shall have an interconnected heat detection system to protect the entire CCF so that if any detector is activated, an alarm audible throughout the building will be triggered. (b) Smoke and heat detectors shall be installed and main- tained in accordance with national fire alarm provisions and the manufacturer’s recommendation. Smoke detectors powered by a CCF’s electrical system shall be tested by CCF staff according to manufacturer’s recommendation, but not less than once every other month. CCFs shall maintain documentation of tests and maintenance of the detection system. (2) TESTING. (a) After the first year following installation, fire detection systems shall be inspected, cleaned, and tested an- nually by certified or trained and qualified personnel in accor- dance with national fire alarm and manufacturer specifications and procedures. (b) Sensitivity testing shall be performed at intervals in accor- dance with national fire alarm specifications. (c) All smoke and heat detectors suspected of exposure to a fire condition shall be inspected, cleaned, and tested by a certi- fied or trained and qualified person within 5 days after each expo- sure in accordance with national fire alarm and the manufacturer specifications and procedures. Each detector shall operate within the manufacturer’s intended response, or it shall be replaced within 10 days after exposure to a fire condition. (3) LOCATION. A CCF shall have at least one smoke detector located at each of the following locations: (a) At the top of every open stairway. (b) On the corridor side of every enclosed stairway on each floor level. (c) Spaced not more than 30 feet apart in every corridor, and not further than 15 feet from any wall or in accordance with the manufacturer’s separation specifications. (d) In each common use room excluding a kitchen, bathroom, or laundry room. (e) In each client room. (f) In all non-client used areas, except the furnace, bathroom, kitchen, and laundry room. (g) Where wall projections from the ceiling or lintels exceed 8 inches. (h) In the basement, or in each room of the basement except a furnace or laundry room. (4) SPECIFIC LOCATIONS FOR HEAT DETECTORS. A CCF shall have at least one heat detector integrated with the smoke detec- tion system at all of the following locations or in accordance with the heat detector manufacturer’s specifications: (a) Kitchen. (b) Furnace room. (c) Laundry room. (5) SPRINKLER SYSTEMS. (a) General requirements. 1. A complete automatic sprinkler system shall be provided in accor- dance with ch. SPS 361. 2. The sprinkler system shall be equipped with sprinkler heads in all client rooms, common areas, and all other habitable rooms and corridors. (b) Installation and maintenance. 1. All sprinkler systems shall be installed by a state-licensed sprinkler contractor. All sprinkler systems shall be maintained, inspected and tested at least annually or at intervals determined by the requirements chs. SPS 314. 2. Sprinkler heads shall be placed at the top of each linen or trash chute and in the rooms where the chutes terminates. 3. The sprinkler system flow alarm shall be connected to a CCF’s fire alarm system and the local fire department. (c) Reliable water supply. All sprinkler systems shall have a reliable water supply. If the sprinkler system requires a mechani- cal device such as a compressor, pump or motor, the device shall be supplied by a reliable source of emergency power in accor- dance with ch. SPS 361. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (3) (g), (5) (a) 1., (c) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.25 Oxygen storage. (1) Oxygen storage shall be in an area that is well ventilated and safe from environmental hazards, tampering, or the chance of accidental damage to the valve stem. If oxygen cylinders are in use, oxygen cylinders shall be secured in an upright position. If stored upright, cylinders must be secured. If stored horizontally, cylinders shall be on a level surface where they will remain stationary. (2) Storage and use of oxygen shall comply with national medical gas standards, referenced in the International Building Code as adopted in s. SPS 361.05. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.26 Records retention and posting. (1) RECORDS RETENTION. (a) A CCF shall retain records consistent with s. DHS 92.12. (b) Employee records shall be retained for 3 years following an employee’s separation from employment at a CCF. (c) Menus shall be retained for 60 days. (2) POSTING. A CCF shall post all the following in a promi- nent public place accessible to clients, employees, and visitors: (a) The department-issued certification. (b) Any statement of deficiency, notice of revocation and any Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. 17 DEPARTMENT OF HEALTH SERVICES DHS 31.29 other notice of enforcement action. A statement of deficiency shall remain posted for 90 days following receipt. Notices of re- vocation and other notices of enforcement action shall remain posted until a final determination is made. (c) Copies of CCF rules and client rights and grievance procedures. (d) A CCF’s exit diagram as required under s. DHS 31.23 (2) (b). (e) Emergency phone numbers as required under s. DHS 31.23 (3) (d). History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. Subchapter IV — Grant Program Requirements DHS 31.27 Grant program overview. (1) The depart- ment shall allocate funds available under ss. 20.435 (5) (ck) and 51.036 (2), Stats., for the development and support of CCFs. The monies to support these programs shall be in the form of grants and shall be awarded based on the criteria set out in this subchapter. (2) In this subchapter, “GFO” means grant funding opportu- nity solicited by the department in accordance with this subchapter. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842 , eff. 3-1-26; correction in (1) made under s. 35.17, Stats., Register February 2026 No. 842. DHS 31.28 Application. (1) WHO MAY APPLY. Any of the following may apply for a grant under this subchapter: (a) A publicly or privately operated facility proposing to pro- vide CCF services, in accordance with s. 51.036, Stats. (b) A publicly or privately operated hospital proposing to pro- vide CCF services, in accordance with s. 51.036, Stats. This ap- plies to co-located and off-site facilities. (2) SOLICITATION. The department shall solicit applications for grants by preparing one or more grant funding opportunities, and posting a notice regarding the availability of the grant fund- ing opportunity including how to access those documents. (3) MAKING APPLICATION. (a) An application for a grant shall be made in accordance with the format specified in the grant funding opportunity application instructions. (b) An application for a grant shall be submitted to the depart- ment, as specified in the grant funding opportunity application instructions, and by the deadline shown in those application instructions. (4) CONTENT OF APPLICATION. An application for an initial grant shall include all of the following: (a) An application checklist included in the GFO. (b) An abstract that briefly describes the project and high- lights the project’s purpose. (c) A detailed, proposed budget on the budget form provided. (d) A narrative description of the program. (e) A statement of assurance of compliance with applicable federal statutes and regulations and state statutes, and rules, in- cluding the requirements of this chapter and the GFO. (f) Additional required elements identified in the GFO. (5) PRELIMINARY REVIEW OF APPLICATIONS. All grant appli- cations shall include all of the application contents specified in sub. (4) and the GFO. Applications that fail to meet all of the cri- teria may not be approved by the department. (6) REVIEW OF APPLICATIONS. Grant applications that satisfy the preliminary review requirements shall be further reviewed based on the following evaluation criteria: (a) The applicant’s organizational and programmatic capacity to become certified as a CCF and implement the proposed project. (b) The applicant’s ability to provide integrated crisis services to the target populations. (c) The applicant’s stated purpose, goals, and objectives for the program and timetable for development and implementation of the program. (d) The extent to which the applicant’s proposed budget is clear and justified. (e) An evaluation plan for the project. (7) RANKING APPLICATIONS. (a) The department shall weight the importance of each evaluation criterion by assigning points to it. The criteria weighting shall be provided in the GFO. (b) Using the evaluation criteria specified in subs. (4) and (6), the department shall evaluate each application against each appli- cable criterion and assign points signifying the degree to which the application meets each criterion up to the maximum number of points specified in the GFO. The total points assigned to the application for all applicable criteria will be the score for each application. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.29 Awards. (1) MAKING AWARDS. (a) The de- partment shall make awards based on the recommendations re- sulting from the review under s. DHS 31.28 (7) and take into ac- count the following geographical factors: 1. Proximity to other existing or proposed CCFs. 2. Location of state treatment facilities authorized to accept civil commitments. 3. Geographic diversity among regions in the location of ex- isting or proposed CCFs. (b) The department may reject an incomplete application. (c) The department may negotiate the amount of an award made under par. (a), specific budget items, project goals and ob- jectives, for a potential grant recipient before entering into an agreement. (2) NOTIFICATION. The department shall notify in writing all applicants for grants of award decisions. (3) AGREEMENT. An award shall be contingent upon the signing by both parties of an agreement drawn up by the depart- ment. If an application is submitted by more than one agency or jointly by one or more agencies, only one agency shall sign the agreement and assume responsibility for implementing the con- tract. Failure of a selected grantee to sign the agreement shall re- sult in withdrawal of the offer of award. (4) AVAILABILITY OF FUNDS. (a) All funding decisions shall be contingent upon the availability of funds. Any changes in the amount available which were unforeseen at the time of the de- partment’s issuance of a GFO shall be accommodated by the de- partment, as appropriate, by means of reduction, elimination or increase in existing awards, by awarding of funds to applicants previously denied due to insufficient funds, or by release of a new GFO. (b) Any funds that become available due to denial of an award to a selected grantee as a result of failure of the selected grantee to sign the required agreement or as a result of termination of a project by either party, or failure of a grantee to spend its alloca- tion of grant funds in the required time frame shall be reallocated by the department to either another grantee or an initial non-se- lected applicant at the department’s discretion but within the lim- its of the appropriation and this chapter. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26; correction in (1) (c) made under s. 35.17, Stats., Register February 2026 No. 842. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843 Published under s. 35.93, Wis. Stats., by the Legislative Reference Bureau. DHS 31.30 WISCONSIN ADMINISTRATIVE CODE 18 DHS 31.30 Restrictions. Restrictions on funds made available through grants under ss. 20.435 (5) (ck) and 51.036 (2) (a), Stats., shall be specified in the grant funding opportunity and in agreement under s. DHS 31.29 (3). History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. DHS 31.31 Records and reports. All recipients of grants under this chapter shall maintain records of the projects supported by the grants as required by the department and shall submit to the department reports as required by the department as described by the department in the GFO. Additional require- ments for CCF certification apply to all grant recipients. A recip- ient’s failure to maintain these records or to submit reports may result in the department’s termination of the grant program. History: EmR2507: emerg. cr., eff. 6-16-25; CR 25-051: cr. Register February 2026 No. 842, eff. 3-1-26. Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published. Register March 2026 No. 843