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(e) A treatment plan completed by a substance abuse counselor in-training or a graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the development of the plan or the next treatment plan review, whichever is earlier.
(f) The content of the treatment plan shall describe the identified needs and specify individualized treatment goals that are expressed in behavioral and measurable terms.
(g) The treatment plan shall specify each intervention applied to reach the treatment goals.
(h) The treatment plan shall be reviewed at the interval required by the patient’s level of care or based on the patient’s needs and clinical indication. The review shall be documented with a summary of progress and the signature of the patient and primary counselor.
(i) The treatment plan review shall include an updated level of care assessment which follows ASAM or other department-approved placement criteria and recommends continued stay, transfer, or discharge.
(j) An updated treatment plan shall be established during the review if there is a change in the patient’s needs, goals, or interventions and resources to be applied. The updated treatment plan shall be signed by the patient, the primary counselor, and any other behavioral health clinical staff identified in the treatment plan.
(k) Treatment plan reviews and updates completed by a substance abuse counselor in-training or graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the review and update.
(L) For patients with co-occurring disorders receiving services under ss. DHS 75.50, 75.51, 75.52, 75.54, 75.55, 75.56, and 75.59 service shall assign dually-credentialed clinicians whenever possible. When this is not possible, the service shall ensure that mental health needs and substance use needs are included in the treatment plan, and met by appropriately credentialed personnel.
(m) For a patient receiving mental health services under s. DHS 75.50 or 75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria and review is not required.
(14)Clinical consultation.
(a) A service shall have a written policy and procedure that outlines the structure for clinical consultation.
(b) Clinical consultation applies to all clinical staff of a service.
(c) Clinical consultation shall be documented in the patient’s case record.
(d) Clinical consultation for unlicensed staff shall be completed with a clinical supervisor and shall be documented with the clinical supervisor’s signature. Clinical consultation for licensed professionals may occur with a clinical supervisor or another licensed professional who is a staff of the service.
(e) Clinical consultation is required for any of the following:
1. When a patient’s substance use or mental health poses a significant risk to the individual, their family, or the community.
2. When a safety plan has been developed, per s. DHS 75.24 (4).
3. When an individual’s symptoms, pattern of substance use, risk level, or placement criteria indicate transfer to a higher level of care.
(f) When a safety plan requires ongoing monitoring, clinical consultation shall be completed at clinically-determined intervals until the risk level is reduced or appropriately managed with services or collateral supports.
(g) When the recommended level of care cannot be determined, or is not available, or the individual has declined the recommended level of care, clinical consultation shall be completed at clinically-determined intervals until the appropriate level of care is determined, or obtained, or the individual’s risk level decreases.
(15)Clinical staffing.
(a) A service shall have a written policy and procedure that outlines the structure for clinical staffing.
(b) Clinical staffing applies to all clinical staff of a service, and includes the clinical supervisor and medical personnel. Clinical staffing is facilitated at intervals appropriate to the individual’s needs and as prescribed based on the level of care.
(c) For clinical staffing required under ss. DHS 75.49 to 75.59, the following shall apply:
1. Clinical staffing shall include the clinical supervisor of the service.
2. Clinical staffing shall include a patient’s prescriber or medical personnel, if applicable.
3. Clinical staffing may be combined with treatment plan review and level of care review.
4. Clinical staffing shall be documented in the patient’s clinical record.
(16)Progress notes.
(a) A service shall document in the patient’s record each contact the service has with a patient or with a collateral source.
(b) Notes shall be entered by the staff member providing the service to document the content of the contact with the patient or a collateral source; or, if notes are entered by a designee, this must be specified.
(c) Progress notes shall include chronological documentation of treatment that is directly related to the patient’s treatment plan, and documentation of the patient’s response to treatment.
(d) The person making the entry shall sign and date the note, and if a designee, shall indicate who provided the service.
(17)Group counseling.
(a) A service may offer group counseling.
(b) A service shall have written policies and procedures regarding group counseling that include, at minimum, the following:
1. Participant confidentiality.
2. Group rules for safety.
3. Consideration of needs related to special populations or considerations for co-mingled groups.
4. Assurance that groups are trauma-informed.
(c) Each group therapy contact shall be documented as a progress note in each patient’s case record.
(18)Family services.
(a) When requested by a patient’s affected family member or significant other, the service shall offer or refer for supportive services, such as counseling, support groups, or education.
(b) A service shall involve a patient’s family members and significant others in assessment, treatment planning, transfers of care, safety planning, and discharge whenever feasible.
(c) A service shall have written policies and procedures to address confidentiality, conflicts of interest, and ethics related to family services.
(19)Medical services.
(a) All medical services provided under this chapter shall be provided by appropriately credentialed staff operating within their scope of practice,
(b) Prescribers providing substance use treatment services or supervision of substance use treatment services shall be knowledgeable in addiction treatment.
(c) For medical needs of a patient that exceed the scope of the service under this chapter, the service shall coordinate with appropriate medical providers.
(d) A service may offer medication management for treatment of substance use disorders or mental health disorders. A service shall have written policies and procedures for medication management services, including:
1. Prescribing policies and practices.
2. Prescriber checks and use of the Wisconsin Prescription Drug Monitoring Program database.
3. Procedures for obtaining and updating patient consents for medications received.
4. Procedures for reporting and reviewing medication errors via facility incident reports or other documentation.
(e) When a patient’s treatment includes medication management, it shall be documented as a goal in the patient’s treatment plan. The treatment plan shall be signed by the prescriber.
(f) If a patient is prescribed medication as part of the treatment plan, the service shall obtain a separate consent that indicates that the prescriber has explained to the patient, or the patient’s legal representative, if applicable, the nature, risks and benefits of the medication and that the patient, or legal representative, understands the explanation and consents to the use of the medication.
(g) A service shall maintain medication records that allow for ongoing monitoring of any medication prescribed or administered by the service, and documentation of any adverse drug reactions or medication errors. Medication orders shall specify the name of the medication, dose, route of administration, frequency of administration, name of the prescriber who prescribed the medication, prescriber signature, and staff administering the medication, if applicable.
(h) A service that receives, stores, or dispenses medications shall have written policies and procedures regarding storage, dispensing, and disposal of medications, including:
1. Patient name, medication name, amount of medication, dosage, date of receipt, and date of dispensing or disposal.
2. Safeguards to prevent the diversion of medication.
(i) A non-residential service that receives, stores, or dispenses medications shall comply with 21 CFR 1301.72. The medication storage area shall be clean, and shall be separated by a wall from any restroom, cleaning products, or any food-preparation or storage area.
(j) A residential service under ss. DHS 75.53 to 75.58, shall follow the requirements for medication storage provided in s. DHS 75.39.
(20)Drug testing services.
(a) A service shall have written policies and procedures for drug testing, breath analysis, and toxicology services. Patients of a service shall be informed of these policies and procedures upon admission.
(b) A service may utilize drug testing information in conjunction with patient self-report, behavioral observations, collateral information, and clinical assessment to make determinations regarding patient care.
(c) A service shall have a method for obtaining confirmation of drug testing results.
(d) A service shall inform patients of the costs for drug testing services.
(e) A service shall obtain informed consent before releasing patient drug testing results. The service is responsible for ensuring that the patient understands possible consequences of disclosure of drug testing information.
(21)Transfer. If the service transfers a patient to another provider or if a change is made in the patient’s level of care, the transfer or change in the level of care shall be documented in the patient’s case record. A transfer summary shall be entered into the patient’s case record, including the following:
(a) The date of the transfer.
(b) A completed copy of the standardized placement criteria and level of care recommended.
(c) Documentation of communication and follow-up that ensures continuity of care from one provider or level of care to another.
(22)Discharge.
(a) A patient may be discharged from a service for any of the following reasons:
1. Successful completion of recommended services and treatment plan goals.
2. No longer meeting placement criteria for any level of care in the substance use treatment system.
3. Patient discontinuation of services.
4. Administrative discharge.
5. Death of the patient.
(b) A service shall have written policies and procedures for the service director’s review of administrative discharge or discharges due to patient dissatisfaction or attrition.
(c) A service shall have written policies and procedures for the service director’s review of discharges due to patient death from overdose.
(d) A discharge summary shall be entered into the patient’s case record, including the following:
1. A completed copy of the standardized placement criteria and level of care indicated.
2. Recommendations regarding care after discharge.
3. A description of the reasons for discharge.
4. The patient’s treatment status and condition at discharge.
5. A final evaluation of the patient’s progress toward the goals identified in the treatment plan.
(e) The discharge summary shall include a notation indicating the reason that any items from par. (d) were not able to be provided at discharge, if applicable.
(23)Continuing care services.
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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.