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.
There shall be documentation that the service director has annually reviewed and approved the referral policies and procedures.
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.
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.
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.
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.
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.
A service shall have an evaluation plan. The evaluation plan shall include all of the following:
A written statement of the service's goals, objectives and measurable expected outcomes that relate directly to the service's patients or target population.
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.
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.
Methods for evaluating and measuring the effectiveness of services and using the information for service improvement.
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.
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.
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.
A service shall collect data on patient outcomes at patient discharge and may collect data on patient outcomes after discharge.
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.
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.
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.
(21) Communicable disease screening.
Service staff shall discuss risk factors for communicable diseases with each patient upon admission and at least annually while the patient continues in the service and shall include in the discussion the patient's prior behaviors that could lead to sexually transmitted diseases (STDs), human immunodeficiency virus (HIV), hepatitis B and C or tuberculosis (TB).
(22) Unlawful alcohol or psychoactive substance use.
The unlawful, illicit or unauthorized use of alcohol or psychoactive substances at the service location is prohibited.
(23) Emergency shelter and care.
A service that provides 24-hour residential care shall have a written plan for the provision of shelter and care for patients in the event of an emergency that would render the facility unsuitable for habitation.
(24) Reporting of deaths due to suicide or the effects of psychotropic medicine.
Each service shall adopt written policies and procedures for reporting deaths of patients due to suicide or the effects of psychotropic medicines, as required by s. 51.64 (2)
, Stats. A report shall be made on a form furnished by the department.
DHS 75.03 Note
Copies of Form DQA F-62470 for reporting deaths under this subsection may be obtained from any Division of Quality Assurance regional office or the department's website at: http://www.dhs.wisconsin.gov/forms/DQAnum.asp
. See Appendix C for the address and phone number of the Division of Quality Assurance Office.
DHS 75.03 History
Cr. Register, July, 2000, No. 535
, eff. 8-1-00; correction in (9) (a) made under s. 13.93 (2m) (b) 7., Stats., Register, June, 2001, No. 546
; CR 06-035
: am. (1), (2), and Table 75.03, Register November 2006 No. 611
, eff. 12-1-06; corrections in (1), (3) (e), (4) (b), (7), and (9) (b) (intro.) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635
; CR 09-109
: am. (2) (a), (h) and (4) (e) Register May 2010 No. 653
, eff. 6-1-10; correction in (4) (e) made under s. 13.92 (4) (b) 6., 7., Stats., Register November 2011 No. 671
; 2017 Wis. Act 262
: am. (4) (e) Register April 2018 No. 748
, eff. 5-1-18.