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.
DHS 75.24(9)(a)(a) A service shall have written policies and procedures for intake, including all of the following:
DHS 75.24(9)(a)1.
1. A written consent for treatment, which shall be signed by the prospective patient before admission is completed.
DHS 75.24(9)(a)2.
2. Information concerning communicable illnesses, such as sexually transmitted infections, hepatitis, tuberculosis, and HIV, and shall refer patients with communicable illness for treatment when appropriate.
DHS 75.24(9)(a)4.
4. A method for informing the patient about, and obtaining the patient's signed acknowledgment of having been informed and understanding all of the following:
DHS 75.24(9)(a)4.b.
b. Patient rights and the protection of privacy provided by confidentiality laws.
DHS 75.24(9)(a)4.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 75.24(9)(a)4.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 75.24(9)(a)4.g.
g. Sources of collateral information that may be used for screening and assessment.
DHS 75.24(9)(b)
(b) If the patient is seeking treatment related to opioid use, and the service does not provide medication-assisted treatment for patients with opioid use disorders, the service shall provide information about the benefits and effectiveness of medication as an effective treatment for opioid use disorders. If the patient is not already receiving medication treatment, the service shall obtain the patient's written consent to participate in non-medication treatment, shall provide a referral to a service that offers medication-assisted treatment for opioid use disorders.
DHS 75.24(10)(a)(a) A service shall prioritize admission in the following order:
DHS 75.24(10)(b)
(b) When a waitlist exists for services for pregnant women, the service shall either initiate interim services or notify the department within 2 business days.
DHS 75.24(10)(c)
(c) When a waitlist exists for services for individuals who inject drugs, the service shall either initiate interim services or notify the department within 14 business days.
DHS 75.24(11)(a)(a) Clinical staff of a service, operating within the scope of their knowledge and practice, shall assess each patient through interviews, information obtained during intake, counselor observation, and collateral information.
DHS 75.24(11)(b)
(b) The service shall promote assessments that are trauma-informed.
DHS 75.24(11)(c)
(c) If a comprehensive clinical assessment has been conducted by a referring substance use treatment service and is less than 90 days old, the assessment may be utilized in lieu of conducting another one.
DHS 75.24(11)(d)
(d) Information for the assessment shall include the following:
DHS 75.24(11)(d)1.
1. The clinical staff's evaluation of the patient, and documentation of psychological, social, and physiological signs and symptoms of substance use and/or mental health disorders, based on criteria in the DSM.
DHS 75.24(11)(d)2.
2. The summarized results of all psychometric, cognitive, vocational, and physical examinations provided as part of the assessment.
DHS 75.24(11)(d)4.
4. Documentation about the current mental and physical health status of the patient.
DHS 75.24(11)(d)5.
5. Psychosocial history information shall include all of the following areas that relate to the patient's presenting problem:
DHS 75.24(11)(d)5.i.
i. Other factors that appear to have a relationship to the patient's substance use and physical and mental health.
DHS 75.24(11)(d)6.
6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following:
DHS 75.24(11)(d)6.d.
d. Consultation with the patient's physician or other medical or behavioral health provider.
DHS 75.24(11)(d)6.e.
e. Consultation with department of corrections or child protective services when applicable.
DHS 75.24(11)(d)7.
7. Level of care recommendation based on ASAM or other department-approved placement criteria.
DHS 75.24(11)(e)
(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
DHS 75.24(11)(f)
(f) The clinical staff's recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.
DHS 75.24(11)(g)
(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.
DHS 75.24(11)(h)
(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
DHS 75.24(11)(i)
(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.
DHS 75.24(11)(j)
(j) In the event that the assessed level of care is not available, a service shall:
DHS 75.24(11)(j)1.
1. Document accurately the level of care indicated by the clinical assessment.
DHS 75.24(11)(j)2.
2. Indicate on the treatment plan what alternative level of care is available or agreed upon.
DHS 75.24(11)(j)3.
3. Identify on the treatment plan what efforts will be made to access the appropriate level of care, additional services or supports that will be offered to bridge the gap in level of care, and ongoing assessment for clinical needs and level of care review.
DHS 75.24(11)(k)
(k) For assessments completed by a substance abuse counselor in-training or a graduate student QTT, the assessment and recommendations shall be reviewed and signed by the clinical supervisor within 7 days of the assessment date.
DHS 75.24(11)(L)
(L) 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 is not required.
