Wisconsin Legislature: DHS 40.14(1)(a)

(c) The youth or legal representative shall be asked to participate in identifying additional members of the interdisciplinary team. With consent of the youth or legal representative, reasonable efforts should be made to include all of the following:

1. An occupational therapist or a registered nurse, based on youth needs identified in the screening summary.

2. An educational professional from the youth’s school.

3. Representatives of any other profession or agency necessary in order to adequately and appropriately respond to the treatment needs of the youth which were identified in the referral materials or the intake screening process.

4. Family members who are involved in the life of the youth.

5. If the youth has been placed under the supervision of a county department, the social worker who has been assigned to the case.

(2) Assessment.

(a) The purpose of the assessment is to identify the individual strengths and needs of the youth to address the level of functioning as well as specific strategies that will be utilized to treat the youth. The clinical coordinator shall prepare a written report describing and evaluating all of the following:

1. Biopsychosocial information that is sufficient to identify the goals that the youth or legal representative want to accomplish through their participation in the program, the needs that will have to be addressed to reach those goals, and the strengths of the youth that can form the foundation of the individual treatment plan to meet the identified needs and achieve the chosen goals, through conducting a respectful and thorough series of interviews that engage the youth or legal representative. Biopsychosocial information includes developmental history, significant past events, significant past relationships and prominent influences, behavioral history, financial history, and overall life adjustment.

2. The current mental health status of each youth including frequency, severity and duration of the symptoms and behaviors and the manner in which the symptoms and behaviors impact the youth’s ability to function, attitude, judgement, memory, speech, thought content, perception, intellectual functioning, general appearance, diagnosis, or medical impression.

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.

3. Completing an evaluation of all of the following:

a. Current living arrangements, social relationships, support systems, including the youth’s level of social and behavioral functioning in the home, school and community, and the youth’s relationship with his or her family members, including an assessment of family member strengths and weaknesses which might affect treatment.

b. A youth’s trauma history and experiences and how treatment approaches will avoid re-traumatization.

c. A youth’s ability to work in a group setting.

d. The youth’s level of academic functioning and educational history, including areas where the youth shows interest, skill and achievement.

e. A youth’s history of criminal activity, including sexual perpetration, peer-to-peer violence, battery, and safety concerns.

f. The youth’s health, medical history, and prescribed medications, including a youth’s prior history of dangerous reactions to psychotropic medications, including procedures for assessing and monitoring the desired objectives and side effects of medications which the youth is taking, dealing with the results of possible medication interactions, medication overdose, an error in medication administration, an unanticipated reaction to the medication, the effects of a concurrent medical illness or condition occurring while the client is receiving the medication, and monitoring the medication regime to determine if any of the medications, solely or in combination, may mask or mimic psychiatric symptoms or behaviors.

g. Suicide risk and self-harm history and risk including criteria for deciding when the level of risk of suicide requires the use of crisis response services or hospitalization.

h. For a youth over the age of 15, the youth’s vocational and independent living history, skills and needs.

i. The youth’s current or recent use of drugs or alcohol and the possible presence of any co-occurring disorder that will have to be addressed through the treatment plan.

j. Any other assets and needs of the youth which affect the youth’s ability to participate effectively in relationships and activities in home, community and school environments.

k. Past treatment, including where it occurred, for how long, and by whom.

L. Recommendations for completing any new test or evaluation which the interdisciplinary treatment team finds is necessary for development of an effective treatment plan for the youth, including psychological, neuropsychological functional, cognitive, behavioral, developmental or early and periodic screening and diagnosis under s. DHS 107.22.

(b) The written assessment shall inform and be completed prior to development of the treatment plan.

History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.

DHS 40.14 Treatment Plan.

(1) Treatment plan.

(a) The interdisciplinary treatment team shall prepare a written treatment plan for a youth based upon the written assessment under s. DHS 40.13 (2) within 15 calendar days after admission. The treatment plan shall describe measurable objectives that will be met and services that will be provided to the youth.

(b) The written treatment plan shall include all of the following:

1. The youth’s strengths, treatment strategies, and measurable outcomes to be accomplished.

2. Clinical and support services to reduce or eliminate the symptoms causing the youth’s problems or inability to function in day to day living, and to increase the youth’s ability to function as independently as possible.

3. The schedules, frequency, nature of services recommended to support the achievement of the youth’s goals, irrespective of the availability of services or funding, and the responsible party for that intervention.

4. The proposed length of time the youth will participate in the program and the amount of time that the youth will attend the program each week.

5. The involvement of a youth’s legal representative with the program and any services that a legal representative will participate in while the youth is in the program.

6. A summary of other services the youth will receive while enrolled in the program, including educational services, other services that the program will be providing for the youth, and services and supports that will be provided by other agencies or providers and the process by which those educational and other services will be coordinated with services provided by the program.

6m. If any part of the services will be delivered via telehealth, a description of those services and clinical justification for delivering services via telehealth rather than in person.

7. The procedure for monitoring and managing any risk of suicide if the assessment identified risks.

8. Any medication the youth is receiving, the name of the physician prescribing the medication, the dosages prescribed, the purpose for which it is prescribed, the frequency of administration, a plan for monitoring its administration and effects by the physician, and a plan for care coordination with a psychiatrist or advanced practice nurse prescriber.

9. A transition services component that establishes when a transition process should begin, the staff member responsible for supporting transition services, and a process for the reintegration of the youth who is completing the program into family, community and school activities.

(c) The treatment plan shall be signed by the youth or legal representative and the clinical coordinator. With informed consent, a service provider who is part of the treatment plan may also review and sign the treatment plan.

(2) Review of treatment progress.

(a) At a minimum, the care coordinator shall reconvene the interdisciplinary treatment team as follows:

1. In community-based programs, within 30 calendar days following approval of the initial treatment plan and at least every 30 days thereafter.

2. In hospital-based programs, within 15 calendar days following approval of the initial treatment plan and at least every 15 days thereafter.

(b) In reviewing case progress, the interdisciplinary treatment team shall determine all of the following:

1. The degree to which the measurable objectives in the treatment plan have been met.

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

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

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

(c) As part of its review of case progress, the interdisciplinary treatment team shall prepare a written report which includes all of the following:

1. A description of the youth’s progress toward measurable objectives established in the treatment plan.

2. Documentation of clinical contacts with youth and interventions required as part of the treatment plan.

3. Identification of all days on which services were actually delivered to the client, and the amount of time the client spent in the program on those days.

(d) The written report shall be prepared as follows:

1. At least every 30 days in community-based programs.

2. At least every 15 days in hospital-based programs.

(e) The written report shall be maintained as a permanent part of the youth’s record.

(f) A youth may continue to participate in a day treatment program as long as the review of the youth’s treatment plan under par. (b) indicates that the youth remains appropriate for the continued services being offered and services support the achievement of the measurable objectives identified in the treatment plan.

(3) Termination of services.

(a) Decision. Services provided to a youth under an individual treatment plan may be terminated by the program before the youth’s goals for discharge are attained under any of the following circumstances:

1. By agreement between the youth or legal representative, the program director, and the clinical coordinator.

2. By direction of the program director and the clinical coordinator acting upon recommendation of the interdisciplinary treatment team, if the team determines any of the following:

a. Further participation of the youth in the program is unlikely to provide any reasonable benefit to the youth.

b. The youth’s condition requires a greater or more restrictive level of care than can be provided by the program.

c. The youth’s behavior or condition is such that it creates a serious risk of harm to other clients in the program or to program staff members and no modifications of the program procedures or services are possible which will ensure the safety of other clients or staff members.

(b) Notice.

1. Unless the youth poses an immediate risk of harm to other clients or staff members or subd. 2. applies, the program shall provide the youth or legal representative and other agencies providing services to the client pursuant to the treatment plan with at least 7 days prior notice of the intent to terminate services.

2. When a youth has been placed in the program by order of a court under ch. 48, 51, 55, or 938, Stats., the program shall provide that court and the social worker responsible for supervising the implementation of the court order with 14 days prior notice of the intent to end services, unless the youth poses an immediate risk of harm to other clients or staff members, in order to permit the court to enter an alternative order regarding the care of the youth.

History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (3) (b) 2. made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: cr. (1) (b) 6m. Register September 2023 No. 813, eff. 10-1-23.

DHS 40.15 Client records.

(1) Location and format. Client records shall be managed in accordance with standard professional practices and any applicable legal requirements for the maintenance of client mental health records, and arranged in a format which provides for consistent recordkeeping within the program and which facilitates accurate and efficient record retrieval.

(2) Elements. All entries in each client file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the staff member making the entry. An electronic representation of the staff member’s signature shall be used only by the staff member who makes the entry. The program shall possess a statement signed by the staff member, which certifies that only that staff member shall use the electronic representation via use of a personal password.

(3) Confidentiality and retention of records. Client records shall be kept confidential and safeguarded and retained as required under 42 CFR part 2, 45 CFR parts 160, 162, 164, and s. 51.30, Stats., ch. DHS 92, and any other applicable law.

(4) Consent. The treatment record shall document that the youth or legal representative were informed of the nature and policies of the program in their primary language and that the youth or legal representative understood and agreed to participation in the program.

(5) Client treatment record. A treatment file or electronic record shall include all of the following:

(a) Initial referral materials.

(b) Notes and reports made while screening the youth for admission.

(d) The safety plan under s. DHS 40.12 (4).

(e) The written, signed assessment under s. DHS 40.13 (2).

(f) Reports and other evaluations of the youth which were used in developing the assessment, and any necessary releases or authorizations for acquiring and using these reports and evaluations.

(g) Results of additional evaluations and other assessments performed while the youth is enrolled in the program.

(h) The initial, signed individual treatment plan.

(i) Descriptions of significant events that are related to the youth’s treatment plan and contribute to an overall understanding of the youth’s ongoing level and quality of functioning.

(j) Any recommended changes or improvements of the treatment plan resulting from clinical collaboration or clinical oversight.

(k) Written documentation of the services that have been provided to the youth or their legal representative as required under s. DHS 40.07 (4).

(L) Written summaries of the reviews of the treatment plan pursuant to s. DHS 40.14 (2) (c).