Wisconsin Legislature: DHS 35.23(1)(a)10.

(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.

(4) Retention and disposal.

(a) The clinic shall implement a written policy governing the retention of treatment records that is in accordance with s. DHS 92.12 and any other applicable laws.

(b) Upon termination of a staff member’s association with the clinic, the treatment records for which the staff member was responsible shall remain in the custody of the clinic.

(5) Electronic record-keeping systems.

(a) Clinics may maintain treatment records electronically if the clinic has a written policy describing the record and the authentication and security policy.

(b) Electronic transmission of information from treatment records to information systems outside the outpatient mental health clinic may not occur without voluntary written consent of the consumer unless the release of confidential treatment information is permitted under s. 51.30, Stats., or other applicable law.

Note: Transmission of information must comply with 45 CFR parts 160, 162, and 164, s. 51.30, Stats., and ch. DHS 92.

(c) If treatment records are kept electronically, the confidentiality of the treatment records shall be maintained as required under subs. (2) to (4). A clinic shall maintain a paper or electronic back-up system for any treatment records maintained electronically.

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

DHS 35.24 Consumer rights.

(1) A clinic shall implement written polices and procedures that are consistent with s. 51.61, Stats., and ch. DHS 94 to protect the rights of consumers.

(2) If a staff member no longer is employed by or contracts with the outpatient mental health clinic, the clinic shall offer consumers who had been served by that staff member options for ongoing services.

(3)

(a) A consumer may be involuntarily discharged from treatment because of the consumer’s inability to pay for services or for behavior that is reasonably a result of mental health symptoms only as provided in par. (b).

(b) Before a clinic may involuntarily discharge a consumer under par. (a), the clinic shall notify the consumer in writing of the reasons for the discharge, the effective date of the discharge, sources for further treatment, and of the consumer’s right to have the discharge reviewed, prior to the effective date of the discharge, by the subunit of the department that certifies clinics under this chapter, with the address of that subunit. A review under this paragraph is in addition to and is not a precondition for any other grievance or legal action the consumer may bring in connection with the discharge, including a grievance or action under s. 51.61, Stats. In deciding whether to uphold or overturn a discharge in a review under this paragraph, the department may consider:

1. Whether the discharge violates the consumer’s rights under s. 51.61, Stats.

2. In cases of discharge for behavior that is reasonably a result of mental health symptoms, whether the consumer’s needs can be met by the clinic, whether the safety of staff or other consumers of the clinic may be endangered by the consumer’s behavior, and whether another provider has accepted a referral to serve the consumer.

Note: The address of the subunit of the department that certifies clinics under this chapter is Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969.

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

DHS 35.25 Death reporting. The clinic shall report the death of a consumer to the department if required under s. 51.64 (2), Stats.

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