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DHS 75.03 Note Note: According to s. SPS 160.03, a person may use the title “addiction counselor," “substance abuse counselor," “alcohol and drug counselor," “substance use disorder counselor" or “chemical dependency counselor" only if he or she is certified as a substance abuse counselor or a clinical substance abuse counselor under s. 440.88, Stats., or as allowed under the provisions of s. 457.02 (5m), Stats.
DHS 75.03(4)(e) (e) Any staff who provides clinical supervision, as defined in s. SPS 160.02 (6), shall be a clinical supervisor, as defined in s. SPS 160.02 (7), except for a physician knowledgeable in addiction treatment, licensed psychologist with a knowledge of psychopharmacology and addiction treatment, or professional possessing a clinical social worker, marriage and family therapist, or professional counselor license granted under ch. 457, Stats., and knowledgeable in addiction treatment.
DHS 75.03(4)(f) (f) All staff who provide mental health treatment services to dually diagnosed clients shall meet the appropriate qualifications under appendix B.
DHS 75.03(4)(g) (g) Provision of clinical supervision for a substance abuse counselor shall be evidenced in that person's personnel file by documentation which identifies hours of supervision provided, issues addressed in the areas of counselor development, counselor skill assessment and performance evaluation, management and administration and professional responsibility and plans for problem resolution. The documentation shall be signed by the clinical supervisor.
DHS 75.03(5) (5)Staff development. A service shall have written policies and procedures for determining staff training needs, formulating individualized training plans and documenting the progress and completion of staff development goals.
DHS 75.03(6) (6)Training staff in assessment and management of suicidal individuals.
DHS 75.03(6)(a) (a) Each service shall have a written policy requiring each new staff person who may have responsibility for assessing or treating patients who present significant risks for suicide to do one of the following:
DHS 75.03(6)(a)1. 1. Receive documented training in assessment and management of suicidal individuals within two months after being hired by the service.
DHS 75.03(6)(a)2. 2. Provide written documentation of past training or supervised experience in assessment and management of suicidal individuals.
DHS 75.03(6)(b) (b) Staff who provide crisis intervention or are on call to provide crisis intervention shall, within one month of being hired to provide these services, receive specific training in crisis assessment and treatment of persons presenting a significant risk for suicide or document that they have already received the training. The service shall have written policies and procedures covering the nature and extent of this training to ensure that crisis and on-call staff will be able to provide the necessary services given the range of needs and symptoms generally exhibited by patients receiving care through the service.
DHS 75.03(6)(c) (c) Staff employed by the program on August 1, 2000, shall either receive training in assessment and management of suicidal individuals within one year from that date or provide documentation of past training.
DHS 75.03(7) (7)Confidentiality. Services shall have written policies, procedures and staff training to ensure compliance with provisions of 42 CFR Part 2, confidentiality of alcohol and drug abuse patient records, and s. 51.30, Stats., and ch. DHS 92, confidentiality of records. Each staff member shall sign a statement acknowledging his or her responsibility to maintain confidentiality of personal information about patients.
DHS 75.03(8) (8)Patient case records.
DHS 75.03(8)(a) (a) There shall be a case record for each patient. For a person receiving only emergency services under s. DHS 75.06, 75.07 or 75.15, the case record requirements are found in sub. (9).
DHS 75.03(8)(b) (b) A staff person of the service shall be designated to be responsible for the maintenance and security of patient case records.
DHS 75.03(8)(c) (c) Patient case records shall be safeguarded as provided in sub. (7) and maintained with the security precautions specified in 42 CFR Part 2.
DHS 75.03(8)(d) (d) The case record format shall provide for consistency and facilitate information retrieval.
DHS 75.03(8)(e) (e) A patient's case record shall include all of the following:
DHS 75.03(8)(e)1. 1. Consent for treatment forms signed by the patient or, as appropriate, the patient's legal guardian.
DHS 75.03(8)(e)2. 2. An acknowledgment by the patient or the patient's legal guardian, if any, that the service policies and procedures were explained to the patient or the patient's legal guardian.
DHS 75.03(8)(e)3. 3. A copy of the signed and dated patient notification that was reviewed with and provided to the patient and patient's legal guardian, if any, which identifies patient rights, and explains provisions for confidentiality and the patient's recourse in the event that the patient's rights have been abused.
DHS 75.03(8)(e)4. 4. Results of all screening, examinations, tests and other assessment information.
DHS 75.03(8)(e)5. 5. A completed copy of the most current placement criteria summary for initial placement or for documentation of the applicable approved placement criteria or WI-UPC assets and needs criteria if the patient has been transferred to a level of care different from the initial placement. Alternative forms that include all the information from the WI-UPC summary or other approved placement criteria may be used in place of the actual scoring document.
DHS 75.03(8)(e)6. 6. Treatment plans.
DHS 75.03(8)(e)7. 7. Medication records that allow for ongoing monitoring of all staff-administered medications and the documentation of adverse drug reactions.
DHS 75.03(8)(e)8. 8. All medication orders. These shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication.
DHS 75.03(8)(e)9. 9. Reports from referring sources, each to include the name of the referral source, the date of the report and the date the patient was referred to the service.
DHS 75.03(8)(e)10. 10. Records of referral by the service, including documentation that referral follow-up activities occurred.
DHS 75.03(8)(e)11. 11. Multi-disciplinary case conference and consultation notes signed by the primary counselor.
DHS 75.03(8)(e)12. 12. Correspondence relevant to the patient's treatment, including all letters and dated notations of telephone conversations.
DHS 75.03(8)(e)13. 13. Consent forms authorizing disclosure of specific information about the patient.
DHS 75.03(8)(e)14. 14. Progress notes, including staffings, in accordance with the service's policies and procedures.
DHS 75.03(8)(e)15. 15. A record of services provided that includes documentation of all case management, education, services and referrals.
DHS 75.03(8)(e)16. 16. Staffing notes signed by the primary counselor and the clinical supervisor, and by the mental health professional if the patient is dually diagnosed.
DHS 75.03(8)(e)17. 17. Documentation of transfer from one level of care to another. Documentation shall identify the applicable criteria from approved placement criteria, and shall include the dates the transfer was recommended and initiated.
DHS 75.03(8)(e)18. 18. Discharge documentation.
DHS 75.03(8)(f) (f) A service shall have policies and procedures to ensure the security and confidentiality of all case records when clinical supervision is provided off site.
DHS 75.03 Note Note: An example of when clinical supervision may be provided off site is a staffing held at a central location attended by counselors from one or more branch clinics.
DHS 75.03(8)(g) (g) If the service discontinues operations or is taken over by another service, records containing patient identifying information may be turned over to the replacement service or any other service provided the patient consents in writing. If no patient consent is obtained, the records shall be sealed and turned over to the department to be retained for 7 years and then destroyed.
DHS 75.03(8)(h) (h) A patient's case record shall be maintained by the service for a period of 7 years from the date of termination of treatment or service.
DHS 75.03(8)(i) (i) A service is the custodian and owner of the patient file and may release information only in compliance with sub. (7).
DHS 75.03(9) (9)Case records for persons receiving emergency services.
DHS 75.03(9)(a)(a) A service shall keep a case record for every person requesting or receiving emergency services under s. DHS 75.06, 75.07 or 75.15, except where the only contact made is by telephone.
DHS 75.03(9)(b) (b) A case record prepared under this subsection shall comply with requirements under s. DHS 124.14, if the service is operated by a hospital, or include all of the following:
DHS 75.03(9)(b)1. 1. The individual's name and address.
DHS 75.03(9)(b)2. 2. The individual's date of birth, sex and race or ethnic origin.
DHS 75.03(9)(b)3. 3. Time of first contact with the individual.
DHS 75.03(9)(b)4. 4. Time of the individual's arrival, means of arrival and method of transportation.
DHS 75.03(9)(b)5. 5. Presenting problem.
DHS 75.03(9)(b)6. 6. Time emergency services began.
DHS 75.03(9)(b)7. 7. History of recent substance use, if determinable.
DHS 75.03(9)(b)8. 8. Pertinent history of the problem, including details of first aid or emergency care given to the individual before being seen by the emergency service.
DHS 75.03(9)(b)9. 9. Description of clinical and laboratory findings.
DHS 75.03(9)(b)10. 10. Results of emergency screening, diagnosis or other assessment completed.
DHS 75.03(9)(b)11. 11. Detailed description of services provided.
DHS 75.03(9)(b)12. 12. Progress notes.
DHS 75.03(9)(b)13. 13. Condition of the individual on transfer or discharge.
DHS 75.03(9)(b)14. 14. Final disposition, including instructions given to the individual regarding necessary follow-up care.
DHS 75.03(9)(b)15. 15. Record of services provided, which shall be signed by the physician in attendance when medical diagnosis or treatment has been provided.
DHS 75.03(9)(b)16. 16. Name, address and phone number of a person to be notified in case of an emergency provided that there is a release of information signed by the patient that enables the agency to contact that person, unless the person is incapacitated and is unable to sign a release of information.
DHS 75.03(10) (10)Screening.
DHS 75.03(10)(a) (a) A service shall complete withdrawal screening for a patient who is currently experiencing withdrawal symptoms or who presents the potential to develop withdrawal symptoms.
DHS 75.03(10)(b) (b) 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.
DHS 75.03(10)(c) (c) 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.
DHS 75.03(11) (11)Intake.
DHS 75.03(11)(a) (a) 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.
DHS 75.03(11)(b) (b) Policies and procedures for intake. A service shall have written policies and procedures to govern the intake process, including all of the following:
DHS 75.03(11)(b)1. 1. A description of the types of information to be obtained from an applicant before admission.
DHS 75.03(11)(b)2. 2. A written consent to treatment statement attached to the initial service plan, which shall be signed by the prospective patient before admission is completed.
DHS 75.03(11)(b)3. 3. 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:
DHS 75.03(11)(b)3.a. a. The general nature and purpose of the service.
DHS 75.03(11)(b)3.b. b. Patient rights and the protection of privacy provided by the confidentiality laws.
DHS 75.03(11)(b)3.c. c. 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.
DHS 75.03(11)(b)3.d. d. The hours during which services are available.
DHS 75.03(11)(b)3.e. e. Procedures for follow-up after discharge.
DHS 75.03(11)(b)3.f. f. Information about the cost of treatment, who will be billed and the accepted methods of payment if the patient will be billed.
DHS 75.03(11)(c) (c) Initial assessment. The initial assessment shall include all of the following:
DHS 75.03(11)(c)1. 1. An alcohol and drug history that identifies:
DHS 75.03(11)(c)1.a. a. The substance or substances used.
DHS 75.03(11)(c)1.b. b. The duration of use for each substance.
DHS 75.03(11)(c)1.c. c. Pattern of use in terms of frequency and amount.
DHS 75.03(11)(c)1.d. d. Method of administration.
DHS 75.03(11)(c)1.e. e. Status of use immediately prior to entering into treatment.
DHS 75.03(11)(c)2. 2. 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.
DHS 75.03(11)(c)3. 3. Documentation of how the information identified in subds. 1. and 2. relate to the patient's presenting problem.
DHS 75.03(11)(c)4. 4. Documentation about the current mental and physical health status of the patient.
DHS 75.03(11)(d) (d) Preliminary service plan. A preliminary service plan shall be developed, based upon the initial assessment.
DHS 75.03(11)(e) (e) 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.
DHS 75.03(11)(f) (f) 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.
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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.