Wisconsin Legislature: DHS 35.18 Note

DHS 35.17 Assessment.

(1)

(a) A mental health professional, shall complete an initial assessment of a consumer before a second meeting with a staff member. The information collected during the initial assessment shall be sufficient to identify the consumer’s need for outpatient mental health services.

(b) A comprehensive assessment shall be valid, accurately reflect the consumer’s current needs, strengths and functioning, be completed before beginning treatment under the treatment plan established under s. DHS 35.19 (1), and include all of the following:

1. The consumer’s presenting problems.

2. A diagnosis, which shall be established from the current Diagnostic and Statistical Manual of Mental Disorders, or for children up to age 4, the current Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood.

Note: The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Washington, DC, American Psychiatric Association, 2013. The Diagnostic and Statistical Manual of Mental Disorders may be ordered through http://www.appi.org/Pages/DSM.aspx or other sources. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood is published by the National Center for Clinical Infant Programs: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Arlington, VA, National Center for Clinical Infant Programs, 1994. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood may be ordered https://secure2.convio.net/zttcfn/site/Ecommerce?VIEW_PRODUCT=true&product_id=1681&store_id=1121 or other sources.

3. The recipient’s symptoms which support the given diagnosis.

4. Information on the consumer’s strengths, and current and past psychological, social, and physiological data; information related to school or vocational, medical, and cognitive functioning; past and present trauma; and substance abuse.

5. The consumer’s unique perspective and own words about how the consumer views his or her recovery, experience, challenges, strengths, needs, recovery goals, priorities, preferences, values and lifestyle, areas of functional impairment, and family and community support.

Note: Nothing in this chapter is intended to interfere with the right of providers under s. 51.61 (6), Stats., to use customary and usual treatment techniques and procedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system.

(2) If a consumer is determined to have one or more co-occurring disorders, a licensed treatment professional, mental health practitioner, or a recognized psychotherapy practitioner, shall document the treatments and services concurrently received by the consumer through other providers; whether the clinic can serve the consumer’s needs using qualified staff members or in collaboration with other providers; and any recommendations for additional services, if needed. If a clinic cannot serve a consumer’s needs, independently, or in collaboration with other providers, the clinic shall refer the consumer, with the consumer’s consent, to an appropriate provider.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.18 Consent for outpatient mental health services.

(1) If a clinic determines that a consumer is appropriate for receiving outpatient mental health services through the clinic, the clinic shall inform the consumer or the consumer’s legal representative of the results of the assessment. In addition, the clinic shall inform the consumer or the consumer’s legal representative, orally and in writing, of all of the following:

(b) Treatment alternatives.

(d) Treatment recommendations and benefits of the treatment recommendations.

(e) Approximate duration and desired outcome of treatment recommended in the treatment plan.

(f) The rights of a consumer receiving outpatient mental health services, including the consumer’s rights and responsibilities in the development and implementation of an individual treatment plan.

(g) The outpatient mental health services that will be offered under the treatment plan.

(h) The fees that the consumer or responsible party will be expected to pay for the proposed services.

Note: Consumers receiving Medicaid covered services may not be charged any amount in connection with services other than the applicable cost share, if any, specified by the Wisconsin Medicaid Program.

(i) How to use the clinic’s grievance procedure under ch. DHS 94.

(j) The means by which a consumer may obtain emergency mental health services during periods outside the normal operating hours of the clinic.

(k) The clinic’s discharge policy, including circumstances under which a patient may be involuntarily discharged for inability to pay or for behavior reasonably the result of mental health symptoms.

(2) If a consumer wishes to receive services through the clinic, the consumer or the consumer’s legal representative, where the consent of the legal representative is required for treatment, shall sign a clinic form to indicate the consumer’s informed consent to receive outpatient mental health services.

(3) If a consumer is prescribed medication as part of the consumer’s treatment plan developed under s. DHS 35.19 (1), the clinic shall obtain a separate consent that indicates that the prescriber has explained to the consumer, or the consumer’s legal representative, if the legal representative’s consent is required, the nature, risks and benefits of the medication and that the consumer, or legal representative, understands the explanation and consents to the use of the medication.

(4) The consent to outpatient mental health services shall be renewed in accordance with s. DHS 94.03 (1) (f).

Note: The consent of the patient or legal representative is not required where treatment is ordered pursuant to a court order for involuntary commitment order.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.19 Treatment plan.

(1) Development of the treatment plan.

(a) A licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner, shall develop an initial treatment plan upon completion of the comprehensive assessment required under s. DHS 35.17 (1) (b). The treatment plan shall be based upon the diagnosis and symptoms of the consumer and describe all of the following:

1. The consumer’s strengths and how they will be used to develop the methods and expected measurable outcomes that will be accomplished.

2. The method to reduce or eliminate the symptoms causing the consumer’s problems or inability to function in day to day living, and to increase the consumer’s ability to function as independently as possible.

3. For a child or adolescent, a consideration of the child’s or adolescent’s development needs as well as the demands of the illness.

4. The schedules, frequency, and nature of services recommended to support the achievement of the consumer’s recovery goals, irrespective of the availability of services and funding.

(b) The treatment plan shall reflect the current needs and goals of the consumer as indicated by progress notes and by reviewing and updating the assessment as necessary.

(2) Approval of the treatment plan. As treatment services are rendered, the consumer or the consumer’s legal representative must approve and sign the treatment plan and agree with staff on a course of treatment. If the consumer does not approve of the schedules, frequency, and nature of the services recommended, then appropriate notations regarding the consumer’s refusal shall be made in the consumer file. The treatment plan under this subsection shall include a written statement immediately preceding the consumer’s or legal representative’s signature that the consumer or legal representative had an opportunity to be informed of the services in the treatment plan, and to participate in the planning of treatment or care, as required by s. 51.61 (1) (fm), Stats.

(3) Clinical review of the treatment plan.

(a) Staff shall establish a process for a clinical review of the consumer’s treatment plan and progress toward measurable outcomes. The review shall include the participation of the consumer and be an ongoing process. The results of each clinical review shall be clearly documented in the consumer file. Documentation shall address all of the following:

1. The degree to which the goals of treatment have been met.

2. Any significant changes suggested or required in the treatment plan.

3. Whether any additional assessment or evaluation is recommended as a result of information received or observations made during the course of treatment.

4. The consumer’s assessment of functional improvement toward meeting treatment goals and suggestions for modification.

(b) A mental health professional shall conduct a clinical review of the treatment plan with the consumer as described in par. (a) at least every 90 days or 6 treatment sessions, whichever covers a longer period of time.

(4) The clinic shall develop and implement written policies and procedures for referring consumers to other community service providers for services that the clinic does not or is unable to provide to meet the consumer’s needs as identified in the comprehensive assessment required under s. DHS 35.17 (1) (b). The policies shall identify community services providers to which the clinic reasonably determines it will be able to refer consumers for services the clinic does not or cannot provide.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.20 Medication management.

(1) A clinic may choose whether to provide medication management as part of its services.

(2) Consumers receiving only medication management from a clinic shall be referred by the clinic’s prescriber for psychotherapy when appropriate to the consumer’s needs and recovery.

(3) All medications prescribed by the clinic shall be documented in the consumer file as required under s. DHS 35.23 (1) (a) 10.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.21 Treatment approaches and services.

(1) The clinic shall have and implement a written policy that identifies the selection of treatment approaches and the role of clinical supervision and clinical collaboration in treatment approaches. The treatment approaches shall be based on guidelines published by a professional organization or peer-reviewed journal. The final decision on the selection of treatment approaches for a specific consumer shall be made by the consumer’s therapist in accordance with the clinic’s written policy.

(2) The clinic shall make reasonable efforts to ensure that each consumer receives the recommended interventions and services identified in the consumer’s treatment plan or revision of the treatment plan that is created under s. DHS 35.19 (1), that the consumer is willing to receive as communicated by an informed consent for treatment.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.215 Group therapy. The maximum number of consumers receiving services in a single group therapy session is 16, and the minimum staff to consumer ratio in group therapy is one to 8. If different limits are justified based on guidelines published by a governmental entity, professional organization or peer-reviewed journal indicate, the clinic may request a variance of either the limit of group size or the minimum staff to consumer ratio.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.22 Discharge summary.

(1) Within 30 days after a consumer’s date of discharge, the licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner who was primarily responsible for providing outpatient mental health services for the consumer shall prepare a discharge summary and enter it into the consumer file. The discharge summary shall include all of the following:

(a) A description of the reasons for discharge.

(b) A summary of the outpatient mental health services provided by the clinic, including any medications.

(d) Any remaining consumer needs at the time of discharge and the recommendations for meeting those needs, which may include the names and addresses of any facilities, persons or programs to which the consumer was referred for additional services following discharge.

(2) The discharge summary shall be signed and dated by the licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner who was primarily responsible for providing services to the consumer.

History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.

DHS 35.23 Consumer file.

(1) Records required.

(a) The clinic shall maintain a consumer file for each consumer who receives outpatient mental health services. Each consumer file shall be arranged in a format that provides for consistent recordkeeping that facilitates accurate and efficient retrieval of record information. All entries in the consumer file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the person making the entry. Treatment records contained in a consumer file are confidential to the extent required under s. 51.30, Stats. An electronic representation of a person’s signature may be used only by the person who makes the entry. The clinic shall possess a statement signed by the person, which certifies that only that person shall use the electronic representation via use of a personal password. Each consumer file shall include accurate documentation of all outpatient mental health services received including all of the following:

1. Results of each assessment conducted.

2. Initial and updated treatment plans.

3. The recommendation or prescription for psychotherapy.

4. For consumers who are diagnosed with substance abuse disorder, a completed copy of the most current approved placement criteria summary if required by s. DHS 35.16 (5).

5. Documentation of referrals of the consumer to outside resources.

6. Descriptions of significant events that are related to the consumer’s treatment plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning.

7. Progress notes, which shall include documentation of therapeutic progress, functional status, treatment plan progress, symptom status, change in diagnosis, and general management of treatment.

8. Any recommended changes or improvement of the treatment plan resulting from clinical collaboration or clinical supervision.

9. Signed consent forms for disclosure of information and for medication administration and treatment, and court orders, if any.

10. A listing of medications prescribed by staff prescribers, and a medication administration record if staff dispenses or administers medications to the consumer.

11. Discharge summary and any related information.

12. Notice of involuntary discharge, if applicable.

13. Any other information that is appropriate for the consumer file.

(b) Clinics may keep composite consumer files of a family in treatment as a unit. When information is released, provisions shall be made for individual confidentiality pursuant to s. 51.30, Stats., and ch. DHS 92.

(2) Confidentiality. Treatment records shall be kept confidential as required under s. 51.30, Stats., ch. DHS 92, and 45 CFR Parts 160, 162 and 164, and 42 CFR Part 2 in a designated place in each clinic office at which records are stored that is not accessible to consumers or the public but is accessible to appropriate staff members at all times.

Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b), Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b).

(3) Transferring treatment records. Upon written request of a consumer or former consumer or, if required, that person’s legal representative, the clinic shall transfer to another licensed treatment professional, clinic or mental health program or facility the treatment records and all other information in the consumer file necessary for the other licensed treatment professional, clinic or mental health program or facility to provide further treatment to the consumer or former consumer.