DHS 75.24(16)(b)
(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.
DHS 75.24(16)(c)
(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.
DHS 75.24(16)(d)
(d) The person making the entry shall sign and date the note, and if a designee, shall indicate who provided the service.
DHS 75.24(17)(b)
(b) A service shall have written policies and procedures regarding group counseling that include, at minimum, the following:
DHS 75.24(17)(b)3.
3. Consideration of needs related to special populations or considerations for co-mingled groups.
DHS 75.24(17)(c)
(c) Each group therapy contact shall be documented as a progress note in each patient's case record.
DHS 75.24(18)(a)(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.
DHS 75.24(18)(b)
(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.
DHS 75.24(18)(c)
(c) A service shall have written policies and procedures to address confidentiality, conflicts of interest, and ethics related to family services.
DHS 75.24(19)(a)(a) All medical services provided under this chapter shall be provided by appropriately credentialed staff operating within their scope of practice,
DHS 75.24(19)(b)
(b) Prescribers providing substance use treatment services or supervision of substance use treatment services shall be knowledgeable in addiction treatment.
DHS 75.24(19)(c)
(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.
DHS 75.24(19)(d)
(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:
DHS 75.24(19)(d)2.
2. Prescriber checks and use of the Wisconsin Prescription Drug Monitoring Program database.
DHS 75.24(19)(d)3.
3. Procedures for obtaining and updating patient consents for medications received.
DHS 75.24(19)(d)4.
4. Procedures for reporting and reviewing medication errors via facility incident reports or other documentation.
DHS 75.24(19)(e)
(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.
DHS 75.24(19)(f)
(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.
DHS 75.24(19)(g)
(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.
DHS 75.24(19)(h)
(h) A service that receives, stores, or dispenses medications shall have written policies and procedures regarding storage, dispensing, and disposal of medications, including:
DHS 75.24(19)(h)1.
1. Patient name, medication name, amount of medication, dosage, date of receipt, and date of dispensing or disposal.
DHS 75.24(19)(i)
(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.
DHS 75.24(20)(a)(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.
DHS 75.24(20)(b)
(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.
DHS 75.24(20)(c)
(c) A service shall have a method for obtaining confirmation of drug testing results.
DHS 75.24(20)(d)
(d) A service shall inform patients of the costs for drug testing services.
DHS 75.24(20)(e)
(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.
DHS 75.24(21)
(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:
DHS 75.24(21)(b)
(b) A completed copy of the standardized placement criteria and level of care recommended.
DHS 75.24(21)(c)
(c) Documentation of communication and follow-up that ensures continuity of care from one provider or level of care to another.
DHS 75.24(22)(a)(a) A patient may be discharged from a service for any of the following reasons:
DHS 75.24(22)(a)1.
1. Successful completion of recommended services and treatment plan goals.
DHS 75.24(22)(a)2.
2. No longer meeting placement criteria for any level of care in the substance use treatment system.
DHS 75.24(22)(b)
(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.
DHS 75.24(22)(c)
(c) A service shall have written policies and procedures for the service director's review of discharges due to patient death from overdose.
DHS 75.24(22)(d)
(d) A discharge summary shall be entered into the patient's case record, including the following:
DHS 75.24(22)(d)1.
1. A completed copy of the standardized placement criteria and level of care indicated.
DHS 75.24(22)(d)5.
5. A final evaluation of the patient's progress toward the goals identified in the treatment plan.
DHS 75.24(22)(e)
(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.
DHS 75.24(23)(a)(a) An outpatient substance use treatment service under s.
DHS 75.49 or an outpatient integrated behavioral health treatment service under s.
DHS 75.50 may provide ongoing recovery monitoring, continuing care, aftercare, or behavioral health check-ups at the outpatient level of care.
DHS 75.24(23)(b)
(b) A patient who has completed services and been discharged may continue contact with the provider at agreed upon intervals without completing a new clinical assessment, intake, or treatment plan.
DHS 75.24(23)(c)
(c) Each contact with a patient in continuing care service shall be documented in a progress note.
DHS 75.24(23)(d)
(d) If, during the provision of continuing care services, there is indication that a higher level of care or additional services may be needed due to substance use relapse or other behavioral, mental, or physical health indicators, the service shall complete an updated level of care placement criteria screening or updated mental health assessment and make appropriate referrals and transfers of care.
DHS 75.24(23)(e)
(e) The continuing care service shall obtain valid and updated releases of information for any referrals or collateral communications regarding patients in continuing care.
DHS 75.24 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22; correction in (11) (b), (13) (m), (14) (e) 2., (g) made under s.
35.17, Stats., and correction in numbering in (21) made under s.
13.92 (4) (b) 1., Stats.,
Register October 2021 No. 790;
CR 23-053: am. (12) (a) Register September 2023 No. 813, eff. 10-1-23. DHS 75.25
DHS 75.25
Outcome monitoring and quality improvement plan. DHS 75.25(1)(1)
A service shall have a written plan for monitoring outcomes and improving service quality, which includes all of the following:
DHS 75.25(1)(a)
(a) Measurable goals relating to service quality, participant satisfaction, and outcomes.
DHS 75.25(1)(b)
(b) Related initiatives for service improvement and key indicators of identified goals and outcomes.
DHS 75.25(1)(c)
(c) An annual report that summarizes the service's quality improvement activities and program outcomes. The report shall be available to patients and their families, the public, and the department upon request.
DHS 75.25(2)
(2) A service shall have a process for collecting, analyzing, and reporting a patient's demographic and outcome data. At minimum, the following data shall be recorded at admission and discharge:
DHS 75.25 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22; correction in numbering in sub. (2) made under s.
13.92 (4) (b ) 1., Stats.,
Register October 2021 No. 790.
DHS 75.26(2)
(2) A residential service that is approved as a hospital under ch.
DHS 124 is not required to meet the requirements in this subchapter.
DHS 75.26 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22.
DHS 75.27
DHS 75.27
Organizational requirements. Before operating or expanding a residential service, a facility shall meet all residential facility requirements included in this subchapter.
DHS 75.27 History
History: CR 20-047: cr.
Register October 2021 No. 790, eff. 10-1-22.
DHS 75.28
DHS 75.28
Definitions. In this subchapter:
DHS 75.28(1)
(1) “Ambulatory” means the ability to walk without difficulty or help.
DHS 75.28(2)
(2) “Non-ambulatory” means a person who is unable to walk, but who may be mobile with the help of a wheelchair or other mobility devices.
