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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.
DHS 75.03(21) (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).
DHS 75.03(22) (22)Unlawful alcohol or psychoactive substance use. The unlawful, illicit or unauthorized use of alcohol or psychoactive substances at the service location is prohibited.
DHS 75.03(23) (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.
DHS 75.03(24) (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 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 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.
DHS 75.04 DHS 75.04 Prevention service.
DHS 75.04(1)(1)Service description. A prevention service makes use of universal, selective and indicated prevention measures described in appendix A. Preventive interventions may be focused on reducing behaviors and actions that increase the risk of abusing substances or being affected by another person's substance abuse.
DHS 75.04(2) (2)Requirements. To receive certification from the department under this chapter, a prevention service shall comply with all requirements included in s. DHS 75.03 that apply to a prevention service, as shown in Table 75.03, and, in addition, a prevention service shall comply with the requirements of this section. If a requirement in this section conflicts with an applicable requirement in s. DHS 75.03, the requirement in this section shall be followed.
DHS 75.04(3) (3)Required personnel.
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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.