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DHS 75.03(12)(a)1. 1. 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.
DHS 75.03(12)(a)2. 2. The summarized results of all psychometric, cognitive, vocational and physical examinations taken for, or as a result of, the patient's enrollment into treatment.
DHS 75.03(12)(b) (b) 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.
DHS 75.03(12)(c) (c) 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.
DHS 75.03(12)(d) (d) 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.
DHS 75.03(12)(e) (e) 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.
DHS 75.03(13) (13)Treatment plan.
DHS 75.03(13)(a) (a) 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.
DHS 75.03(13)(b) (b) Content.
DHS 75.03(13)(b)1.1. 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.
DHS 75.03(13)(b)2. 2. The goals shall be expressed as realistic expected outcomes.
DHS 75.03(13)(b)3. 3. The treatment plan shall specify the treatment, rehabilitation, and other therapeutic interventions and services to reach the patient's treatment goals.
DHS 75.03(13)(b)4. 4. The treatment plan shall describe the criteria for discharge from services.
DHS 75.03(13)(b)5. 5. 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.
DHS 75.03(13)(b)6. 6. Tasks performed in meeting the goals shall be reflected in progress notes and in the staffing reports.
DHS 75.03(13)(c) (c) Contract. A patient's treatment plan constitutes a treatment contract between the patient and the service.
DHS 75.03(13)(d) (d) Review. 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.
DHS 75.03(14) (14)Staffing.
DHS 75.03(14)(a) (a) Staffing shall be completed for each patient and shall be documented in the patient's case record as follows:
DHS 75.03(14)(a)1. 1. 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.
DHS 75.03(14)(a)2. 2. Staffing for patients who attend treatment sessions more frequently than one day per week shall be completed at least every 30 days.
DHS 75.03(14)(b) (b) 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.
DHS 75.03(14)(c) (c) 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.
DHS 75.03(14)(d) (d) 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.
DHS 75.03(14)(e) (e) 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.
DHS 75.03(15) (15)Progress notes.
DHS 75.03(15)(a) (a) 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.
DHS 75.03(15)(b) (b) Progress notes shall include, at a minimum, all of the following:
DHS 75.03(15)(b)1. 1. Chronological documentation of treatment that is directly related to the patient's treatment plan.
DHS 75.03(15)(b)2. 2. Documentation of the patient's response to treatment.
DHS 75.03(15)(c) (c) 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.
DHS 75.03(15)(d) (d) 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.
DHS 75.03(16) (16)Transfer.
DHS 75.03(16)(a) (a) 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.
DHS 75.03(16)(b) (b) 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.
DHS 75.03(17) (17)Discharge or termination.
DHS 75.03(17)(a) (a) 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.
DHS 75.03(17)(b) (b) A discharge summary shall be entered in the patient's case record within one week after the discharge date.
DHS 75.03(17)(c) (c) The discharge summary shall include all of the following:
DHS 75.03(17)(c)1. 1. Recommendations regarding care after discharge.
DHS 75.03(17)(c)2. 2. A description of the reasons for discharge.
DHS 75.03(17)(c)3. 3. The patient's treatment status and condition at discharge.
DHS 75.03(17)(c)4. 4. A final evaluation of the patient's progress toward the goals set forth in the treatment plan.
DHS 75.03(17)(c)5. 5. 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.
DHS 75.03(17)(d) (d) The patient shall be informed of the circumstances under which return to treatment services may be needed.
DHS 75.03(17)(e) (e) 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.
DHS 75.03(18) (18)Referral.
DHS 75.03(18)(a) (a) A service shall have written policies and procedures for referring patients to other community service providers.
DHS 75.03(18)(b) (b) The service director shall approve all relationships of the service with outside resources.
DHS 75.03(18)(c) (c) Any written agreement with an outside resource shall specify all of the following:
DHS 75.03(18)(c)1. 1. The services the outside resource will provide.
DHS 75.03(18)(c)2. 2. The unit costs for the services, if applicable.
DHS 75.03(18)(c)3. 3. The duration of the agreement.
DHS 75.03(18)(c)4. 4. The maximum extent of services available during the period of the agreement.
DHS 75.03(18)(c)5. 5. The procedure to be followed in making referrals to the outside resource.
DHS 75.03(18)(c)6. 6. The reports that can be expected from the outside resource and how and to whom this information is to be communicated.
DHS 75.03(18)(c)7. 7. The agreement of the outside resource to comply with this chapter.
DHS 75.03(18)(c)8. 8. The degree to which the service and the outside resource will share responsibility for the patient's care.
DHS 75.03(18)(d) (d) There shall be documentation that the service director has annually reviewed and approved the referral policies and procedures.
DHS 75.03(19) (19)Follow-up.
DHS 75.03(19)(a) (a) All follow-up activities undertaken by the service for a current patient or for a patient after discharge shall be done with the written consent of the patient.
DHS 75.03(19)(b) (b) A service that refers a patient to an outside resource for additional, ancillary or follow-up services shall determine the disposition of the referral within one week from the day the referral is initiated.
DHS 75.03(19)(c) (c) A service that refers a patient to an outside resource for additional or ancillary services while still retaining treatment responsibility shall request information on a regular basis as to the status and progress of the patient.
DHS 75.03(19)(d) (d) The date, method and results of follow-up attempts shall be entered in the former patient's or current patient's case-record and shall be signed and dated by the individual making the entry. If follow-up information cannot be obtained, the reason shall be entered in the former patient's or current patient's case record.
DHS 75.03(19)(e) (e) A service shall follow-up on a patient transfer through contact with the service the patient is being transferred to within 5 days following initiation of the transfer and every 10 days after that until the patient is either engaged in the service or has been identified as refusing to participate.
DHS 75.03(20) (20)Service evaluation.
DHS 75.03(20)(a) (a) A service shall have an evaluation plan. The evaluation plan shall include all of the following:
DHS 75.03(20)(a)1. 1. A written statement of the service's goals, objectives and measurable expected outcomes that relate directly to the service's patients or target population.
DHS 75.03(20)(a)2. 2. Measurable criteria and a statistical sampling protocol which are to be applied in determining whether or not established goals, objectives and desired patient outcomes are being achieved.
DHS 75.03(20)(a)3. 3. A process for measuring and gathering data on progress and outcomes achieved with respect to individual treatment goals on a representative sample of the population served, and evaluations of some or all of the following patient outcome areas but including at least those in subd. 3. a., b., c. and f.:
DHS 75.03(20)(a)3.a. a. Living situation.
DHS 75.03(20)(a)3.b. b. Substance use.
DHS 75.03(20)(a)3.c. c. Employment, school or work activity.
DHS 75.03(20)(a)3.d. d. Interpersonal relationships.
DHS 75.03(20)(a)3.e. e. Treatment recidivism.
DHS 75.03(20)(a)3.f. f. Criminal justice system involvement.
DHS 75.03(20)(a)3.g. g. Support group involvement.
DHS 75.03(20)(a)3.h. h. Patient satisfaction.
DHS 75.03(20)(a)3.i. i. Retention in treatment.
DHS 75.03(20)(a)3.j. j. Self-esteem.
DHS 75.03(20)(a)3.k. k. Psychological functioning.
DHS 75.03(20)(a)4. 4. Methods for evaluating and measuring the effectiveness of services and using the information for service improvement.
DHS 75.03(20)(b) (b) A service shall have a process in place for determining the effective utilization of staff and resources toward the attainment of patient treatment outcomes and the service's goals and objectives.
DHS 75.03(20)(c) (c) A service shall have a system for regular review of the appropriateness of the components of the treatment service and other factors that may contribute to the effective use of the service's resources.
DHS 75.03(20)(d) (d) A service shall obtain a completed patient satisfaction survey from a representative sample of all patients at or following their discharge from the service. The service shall keep all satisfaction surveys on file for 2 years and shall make them available for review by authorized representatives of the department upon request.
DHS 75.03(20)(e) (e) A service shall collect data on patient outcomes at patient discharge and may collect data on patient outcomes after discharge.
DHS 75.03(20)(f) (f) The service director shall complete an annual report on the service's progress in meeting goals, objectives and patient outcomes, and shall keep the report on file and shall make it available for review to an authorized representative of the department upon request.
DHS 75.03(20)(g) (g) The governing authority or legal owner of the service and the service director shall review all evaluation reports and make changes in service operations, as appropriate.
DHS 75.03(20)(h) (h) If a service holds current accreditation from a recognized accreditation organization, such as the joint commission on accreditation of health organizations, the commission on accreditation of rehabilitation facilities or the national committee for quality assurance, the requirements under this section may be waived by the department.
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.