DHS 75.20(1)(a)4.
4. Maintain each case record in a format that provides for consistency and facilitates information retrieval.
DHS 75.20(1)(a)5.
5. Whenever an edit to a signed entry in a patient's case record is made, the service shall document the date of the edit, the name of the individual making the edit, and a brief statement about the reason for the edit, if the prior version of the edited information is not retained by the service.
DHS 75.20(1)(b)
(b) A patient's case record shall include all of the following:
DHS 75.20(1)(b)1.
1. The patient's name, physical residence, address, and phone contact information.
DHS 75.20(1)(b)2.
2. The patient's date of birth, self-identified gender, and self-identified race or ethnic origin.
DHS 75.20(1)(b)3.
3. Consent for treatment forms signed by the patient or the patient's legal guardian, if applicable, that are maintained in accordance with s.
DHS 94.03.
DHS 75.20(1)(b)4.
4. An acknowledgment by the patient or the patient's legal guardian, if applicable, that the service policies and procedures were explained to the patient or the patient's legal guardian.
DHS 75.20(1)(b)5.
5. A copy of the signed and dated patient notification that was reviewed with and provided to the patient or the patient's legal guardian, if applicable, 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 75.20(1)(b)6.
6. Results of all screening, examinations, tests, and other assessment information.
DHS 75.20(1)(b)7.
7. A completed copy of the standardized placement criteria and level of care assessment at admission, and subsequent reviews of level of care placement criteria.
DHS 75.20(1)(b)8.
8. Treatment plans, including all reviews and updates to the treatment plan.
DHS 75.20(1)(b)9.
9. Records for any medications prescribed or administered by the service, including any medication consent records required by s.
DHS 94.09.
DHS 75.20(1)(b)10.
10. Copies of any incident reports or documentation of medication errors applicable to the patient.
DHS 75.20(1)(b)13.
13. Records of any referrals by the service, including documentation that referral follow-up activities occurred.
DHS 75.20(1)(b)14.
14. Correspondence relevant to the patient's care and treatment, including dated summaries of relevant telephone or electronic contacts and letters.
DHS 75.20(1)(b)15.
15. Consents authorizing disclosure of specific information about the patient.
DHS 75.20(1)(b)16.
16. Progress notes that include documentation of all services provided.
DHS 75.20(1)(b)19.
19. Documentation of each transfer from one level of care to another. Documentation shall identify the applicable criteria from ASAM or other department-approved placement criteria, and shall include the dates the transfer was recommended and initiated.
DHS 75.20(1)(c)
(c) For patients that discharge from a service and are subsequently re-admitted, a new case record shall be established for each episode of care.
DHS 75.20(1)(e)
(e) If the service discontinues operations or is taken over by another service, records containing patient identifying information shall be turned over to the replacement service, as permitted by applicable state and federal confidentiality requirements.
DHS 75.20(2)
(2)
Case records for persons receiving only screening and referral. A treatment service shall have a written policy and procedure regarding case records for individuals that receive only screening, consultation, or referral services. The policy and procedure shall include:
DHS 75.20(2)(a)
(a) Information to be obtained for phone and in-person screening, consultation, or referral.
DHS 75.20(2)(b)
(b) Assurance that screening includes an individual's pregnancy status.
DHS 75.20(2)(c)
(c) Assurance that screening, consultation, and referral procedures address individual risks and needs.
DHS 75.20 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22; correction in (1) (a) 3., (b) 3., 9. made under s.
35.17, Stats.,
Register October 2021 No. 790.
DHS 75.21
DHS 75.21
Confidentiality. A service shall have written policies, procedures and staff training to ensure compliance with applicable confidentiality provisions of
42 CFR part 2,
45 CFR parts 164 and
170, ss.
51.30,
146.816 and
146.82, Stats., and ch.
DHS 92. Each staff member shall sign a statement acknowledging responsibility to maintain confidentiality of personal information about persons served.
DHS 75.21 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22; correction made under s.
35.17, Stats.,
Register October 2021 No. 790.
DHS 75.22(1)(1)
Application. A service under this chapter that delivers treatment services to minors shall identify within their application to the department each level of care that will provide treatment services for minors.
DHS 75.22(2)
(2)
Statutory requirements. A service that delivers treatment services to minors shall adhere to all applicable requirements outlined in ss.
51.13,
51.138,
51.14,
51.47 and
51.48, Stats.
DHS 75.22(3)
(3)
Family involvement. Services for minors shall include the involvement of a parent, guardian, or other family members whenever possible.
DHS 75.22(4)
(4)
Staff qualifications. Staff delivering services to minors shall have training, experience, or education specific to the treatment of substance use and mental health for minors and shall practice within their scope. A record of relevant training, experience, or education shall be documented in the personnel record.
DHS 75.22(5)
(5)
Staff training. A service that delivers treatment services to minors shall provide training to clinical staff in the areas of adolescent development, family systems, child abuse and neglect, and involuntary treatment laws for minors, unless the service is able to provide documentation of the staff member's previous training, professional education, or supervised experience addressing these areas. A record of required training shall be documented in the personnel record.
DHS 75.22(6)
(6)
Separation of services. Services for minors shall be separate from adult services, with the exception of specialized groups addressing the needs of transitional-age youth. Services for transitional-age youth shall be separate from other services for minors or adults.
DHS 75.22(7)
(7)
Policies and procedures. A service that delivers treatment services to minors shall have written policies and procedures to address specific safety needs of minors, including consideration of vulnerability related to adult populations served within the facility, adequacy of supervision for service delivery, and services addressing specific needs of youth.
DHS 75.22 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22.
DHS 75.23(1)(a)(a) Services delivered under this chapter shall adhere to standardized levels of care as defined in this chapter. A service shall apply the ASAM criteria or other department-approved placement criteria to determine the appropriate level of care, and services shall be delivered consistent with that level of care.
DHS 75.23(1)(b)
(b) A service shall not deliver or purport to deliver a service for which they do not possess certification by the department under this chapter.
DHS 75.23(2)
(2)
Use of asam or other department-approved placement criteria. DHS 75.23(2)(a)(a) A service shall utilize ASAM placement criteria or other department-approved placement criteria to determine the level of care that is matched to a patient's needs and risk level.
DHS 75.23(2)(b)
(b) In order to be approved by the department, other placement criteria must include all of the following:
DHS 75.23(2)(b)1.
1. A multi-dimensional assessment tool that captures behavioral health, physical health, readiness for change, social risk levels and directly correlates risk level to service levels of care based on frequency and intensity of the service.
DHS 75.23(2)(b)2.
2. Proof that the criteria is accepted and utilized within professional organizations in the field of healthcare and allows for consistency of interpretation across settings and providers.
DHS 75.23 Note
Note: Copies of the ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (published October 24, 2013) are on file in the department's division of care and treatment services and the legislative reference bureau, and may be obtained from ASAM at 11400 Rockville Pike, Suite 200, Rockville, MD 20852, or https://www.asam.org/asam-criteria/text. DHS 75.23(3)
(3)
Level of care transfer. A service that offers more than one level of care under this chapter shall identify in the clinical record which level of care the patient is receiving based on the clinical assessment. When a level of care transfer is completed as indicated by assessment or treatment plan review, the service shall document the level of care transfer in the record and shall thereafter meet the service requirements for the indicated level of care.
DHS 75.23(4)(a)(a) If a patient is receiving services in more than one level of care at a given time, the service shall adhere to all applicable standards for each level of care, and to the level of care standard with the highest requirement when more than one apply.
DHS 75.23(4)(b)
(b) If a patient is receiving services in more than one level of care at a given time, the patient shall be listed on a roster or patient list for each level of care in which they receive services.
DHS 75.23 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22.
DHS 75.24(1)(a)(a) A service shall complete an initial screening for an individual that presents for services. The screening shall include all of the following:
DHS 75.24(1)(a)1.
1. Sufficient assessment of dimensional risk and severity of need to determine preliminary level of care.
DHS 75.24(1)(a)2.
2. A determination of the patient's needs for immediate services related to withdrawal risk, acute intoxication, overdose risk, induction of pharmacotherapy, or emergency medical needs.
DHS 75.24(1)(b)
(b) A screening is preliminary, and is either confirmed or modified based on completion of the full assessment and ASAM or other department-approved level of care placement criteria.
DHS 75.24(1)(c)
(c) The screening completed under this subsection may be combined with a more comprehensive assessment.
DHS 75.24(2)
(2)
Emergency services. If a need is identified for immediate services related to withdrawal, acute intoxication, overdose, or other reason, the service may initiate treatment prior to completion of the comprehensive assessment or treatment plan. The patient's record for emergency services shall include documentation of all of the following:
DHS 75.24(2)(b)
(b) A consent for services to be received, signed by the patient or the patient's legal guardian.
DHS 75.24(2)(c)
(c) A progress note for all services delivered to the patient.
DHS 75.24(2)(d)
(d) A reason for the initiation of emergency services and a completed initial screening that evaluates biomedical, mental health, and substance use indicators, and guides decision-making regarding the initial level of care placement and referral.
DHS 75.24(3)
(3)
After hours emergency response. A service shall have a written policy and procedure for how the clinic will provide or arrange for, the provision of services to address a patient's behavioral health emergency or crisis during hours when its offices are closed, or when staff members are not available to provide behavioral health services.
DHS 75.24(4)(a)(a) When a patient's pattern of behavior or acute symptoms of a substance use or mental health disorder indicate the likelihood for significant, imminent harm to the individual or others, including affected family members, the service shall develop a safety plan within 24 hours of the contact.
DHS 75.24(4)(b)
(b) The service shall have written policies and procedures that outline the requirements and process for safety planning.
DHS 75.24(5)(a)(a) A service shall have Naloxone on-site at each facility and branch location, to be administered in the event of an opioid overdose.
DHS 75.24(5)(b)
(b) Naloxone medication shall be maintained and unexpired, and shall be stored in an accessible location.
DHS 75.24(5)(c)
(c) The service shall have written policies and procedures for administration of Naloxone by service staff.
DHS 75.24(5)(d)
(d) The service shall train all staff in recognition of overdose symptoms and administration of Naloxone.
DHS 75.24(5)(e)
(e) Administration of Naloxone by the service to any individual shall be documented in the clinical record or in a facility incident report.
DHS 75.24(6)
(6)
Service delivery for intoxicated individuals. A service shall have written policies and procedures regarding clinically-appropriate response and services for individuals that present with symptoms of acute intoxication, withdrawal, or at risk of withdrawal. The policies and procedures shall include the following:
DHS 75.24(6)(a)
(a) The process for obtaining medical consultation, when indicated.
DHS 75.24(6)(b)
(b) The process for admitting the patient to a higher level of care, withdrawal management service, or direct linkage to medical services, when indicated.
DHS 75.24(6)(c)
(c) The process for ensuring the safety of an intoxicated individual or persons experiencing withdrawal, including an individual operating while intoxicated.
DHS 75.24(6)(d)
(d) The process for follow-up and treatment engagement after an intervention for acute intoxication or withdrawal.
DHS 75.24(7)
(7)
Tobacco use disorder treatment and smoke-free facility. A service shall have written policies outlining the service's approach to assessment and treatment for concurrent tobacco use disorders, and the facility's policy regarding a smoke-free environment.
DHS 75.24(8)
(8)
Culturally and linguistically appropriate services. A service shall have a written policy and procedure for assessing the cultural and linguistic needs of the population to be served, and to ensure that services are responsive and appropriate to the cultural and linguistic needs of the community to be served.
