A service shall complete withdrawal screening for a patient who is currently experiencing withdrawal symptoms or who presents the potential to develop withdrawal symptoms.
Acceptance of a patient for substance abuse services shall be based on a written screening procedure and the application of approved patient placement criteria. The written screening procedure shall clearly state the criteria for determining eligibility for admission.
All substance abuse screening procedures shall include the collection of data relating to impairment due to substance use consistent with the WI-UPC, ASAM patient placement criteria or other similar patient placement criteria approved by the department.
Basis for admission.
Admission of an individual to a service for treatment shall be based upon an intake procedure that includes screening, placement, initial assessment and required administrative tasks.
Policies and procedures for intake.
A service shall have written policies and procedures to govern the intake process, including all of the following:
A description of the types of information to be obtained from an applicant before admission.
A written consent to treatment statement attached to the initial service plan, which shall be signed by the prospective patient before admission is completed.
A method of informing the patient about and ensuring that the patient understands all of the following, and for obtaining the patient's signed acknowledgment of having been informed and understanding all of the following:
Patient rights and the protection of privacy provided by the confidentiality laws.
Service regulations governing patient conduct, the types of infractions that result in corrective action or discharge from the service and the process for review or appeal.
Information about the cost of treatment, who will be billed and the accepted methods of payment if the patient will be billed.
The initial assessment shall include all of the following:
Available information regarding the patient's family, significant relationships, legal, social and financial status, treatment history and other factors that appear to have a relationship to the patient's substance abuse and physical and mental health.
Documentation of how the information identified in subds. 1.
relate to the patient's presenting problem.
Documentation about the current mental and physical health status of the patient.
Preliminary service plan.
A preliminary service plan shall be developed, based upon the initial assessment.
Explanation of initial assessment and service plan.
The initial assessment and preliminary service plan shall be clearly explained to the patient and, when appropriate, to the patient's family members during the intake process.
Information and referral relating to communicable diseases.
The service shall provide patients with information concerning communicable diseases, such as sexually transmitted diseases (STDs), hepatitis B, tuberculosis (TB), and human immunodeficiency virus (HIV), and shall refer patients with communicable disease for treatment when appropriate.
Staff of a service shall assess each patient through screening interviews, data obtained during intake, counselor observation and talking with people who know the patient. Information for the assessment shall include all of the following:
The substance abuse counselor's evaluation of the patient and documentation of psychological, social and physiological signs and symptoms of substance abuse and dependence, mental health disorders and trauma, based on criteria in DSM-IV.
The summarized results of all psychometric, cognitive, vocational and physical examinations taken for, or as a result of, the patient's enrollment into treatment.
The counselor's recommendations for treatment shall be included in a written case history that includes a summary of the assessment information leading to the conclusions and outcomes determined from the counselor's evaluation of the patient's problems and needs.
If a counselor identifies symptoms of a mental health disorder and trauma in the assessment process, the service shall refer the individual for a mental health assessment conducted by a mental health professional.
If a counselor identifies symptoms of physical health problems in the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
Initial assessment shall be conducted for treatment planning. The service shall implement an ongoing process of assessment to ensure that the patient's treatment plan is modified if the need arises as determined through a staffing at least every 30 days.
Basis and signatures.
A service shall develop a treatment plan for each patient. A patient's treatment plan shall be based on the assessment under sub. (12)
and a discussion with the patient to ensure that the plan is tailored to the individual patient's needs. The treatment plan shall be developed in collaboration with other professional staff, the patient and, when feasible, the patient's family or another person who is important to the patient, and shall address culture, gender, disability, if any, and age-responsive treatment needs related to substance use disorders, mental disorders and trauma. The patient's participation in the development of the treatment plan shall be documented. The treatment plan shall be reviewed and signed first by the clinical supervisor and the counselor and secondly reviewed and signed by the patient and the consulting physician.
The treatment plan shall describe the patient's individual or distinct problems and specify short and long-term individualized treatment goals that are expressed in behavioral and measurable terms, and are explained as necessary in a manner that is
understandable to the patient.
The treatment plan shall specify the treatment, rehabilitation, and other therapeutic interventions and services to reach the patient's treatment goals.
The treatment plan shall describe the criteria for discharge from services.
The treatment plan shall provide specific goals for treatment of dual diagnosis for those who are identified as being dually diagnosed, with input from a mental health professional.
Tasks performed in meeting the goals shall be reflected in progress notes and in the staffing reports.
A patient's treatment plan constitutes a treatment contract between the patient and the service.
A patient's treatment plan shall be reviewed at regular intervals as identified in sub. (14)
and modified as appropriate with date and results documented in the patient's case record through staffing reports.
Staffing shall be completed for each patient and shall be documented in the patient's case record as follows:
Staffing for patients in an outpatient treatment service who attend treatment sessions one day per week or less frequently shall be completed at least every 90 days.
Staffing for patients who attend treatment sessions more frequently than one day per week shall be completed at least every 30 days.
A staffing report shall include information on treatment goals, strategies, objectives, amendments to the treatment plan and the patient's progress or lack of progress, including applicable criteria from the approved placement criteria being used to recommend the appropriate level of care for the patient.
The counselor and clinical supervisor shall review the patient's progress and the current status of the treatment plan in regularly scheduled case conferences and shall discuss with the patient the patient's progress and status and make an appropriate notation in the patient's progress notes.
If a patient is dually diagnosed, the patient's treatment plan shall be reviewed by the counselor and a mental health professional and appropriate notation made in the patient's progress notes.
A staffing report shall be signed by the primary counselor and the clinical supervisor, and by a mental health professional if the patient is dually diagnosed. The consulting physician shall review and sign the staffing report.
A service shall enter progress notes into the patient's case record for each contact the service has
with a patient or with a collateral source regarding the patient. Notes shall be entered by the counselor and may be entered by the consulting physician, clinical supervisor, mental health professional and other staff members to document the content of the contact with the patient or with a collateral source for the patient. In this paragraph, “collateral source" means a source from which information may be obtained regarding a patient, which may include a family member, clinical records, a friend, a co-worker, a child welfare worker,
a probation and parole agent or a health care provider.
Progress notes shall include, at a minimum, all of the following:
Chronological documentation of treatment that is directly related to the patient's treatment plan.
The person making the entry shall sign and date progress notes that are continuous and unbroken. Blank lines or spaces between the narrative statement and the signature of the person making the entry shall be connected with a continuous line to avoid the possibility of additional narrative being inserted.
Staff shall make efforts to obtain reports and other case records for a patient receiving concurrent services from an outside source. The reports and other case records shall be made part of the patient's case record.
If the service transfers a patient to another provider or if a change is made in the patient's level of care, documentation of the transfer or change in the level of care shall be made in the patient's case record. The transfer documentation shall include the date the transfer is recommended and initiated, the level of care from which the patient is being transferred and the applicable criteria from approved placement criteria that are being used to recommend the appropriate level of care to which the patient is being transferred.
The service shall forward a copy of the transfer documentation to the service to which the patient has been transferred within one week after the transfer date.
A patient's discharge date shall be the date the patient no longer meets criteria for any level of care in the substance abuse treatment service system, and is excluded from each of these levels of care as determined by approved placement criteria.
A discharge summary shall be entered in the patient's case record within one week after the discharge date.
A final evaluation of the patient's progress toward the goals set forth in the treatment plan.
The signature of the patient, the counselor, the clinical supervisor and, if the patient is dually diagnosed, the mental health professional, with the signature of the consulting physician included within 30 days after the discharge date.
The patient shall be informed of the circumstances under which return to treatment services may be needed.
Treatment terminated before its completion shall also be documented in a discharge summary. Treatment termination may occur if the patient requests in writing that treatment be terminated or if the service terminates treatment upon determining and documenting that the patient cannot be located, refuses further services or is deceased.
A service shall have written policies and procedures for referring patients to other community service providers.
The service director shall approve all relationships of the service with outside resources.
Any written agreement with an outside resource shall specify all of the following:
The maximum extent of services available during the period of the agreement.
The procedure to be followed in making referrals to the outside resource.
The reports that can be expected from the outside resource and how and to whom this information is to be communicated.
The degree to which the service and the outside resource will share responsibility for the patient's care.