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(k) Substance use.
(L) Trauma and significant life stressors.
(m) Medications.
(n) Crisis prevention and management.
(o) Legal status.
(p) Any other domain identified by the CCS.
(5)Abbreviated Assessment.
(a) The assessment in sub. (3) may be abbreviated if the consumer has signed an admission agreement and one of the following circumstances apply:
1. The consumer’s health or symptoms are such that only limited information can be obtained immediately.
2. The consumer chooses not to provide information necessary to complete a comprehensive assessment at the time of application.
3. The consumer is immediately interested in receiving only specified services that require limited information.
(b) An assessment conducted under this subsection shall meet the requirements under sub. (3) to the extent possible within the context that precluded a comprehensive assessment.
(c) The assessment summary required to be completed under sub. (6) shall include the specific reason for abbreviating the assessment.
(d) An abbreviated assessment shall be valid for up to 3 months from the date of the application. Upon the expiration date, a comprehensive assessment shall be conducted to continue psychosocial rehabilitation services. If a comprehensive assessment cannot be conducted when the abbreviated assessment expires, the applicant shall be given notice of a determination that the consumer does not need psychosocial rehabilitation services pursuant to the requirements of s. DHS 36.14 (3) (b).
(6)Assessment summary. The assessment shall be documented in an assessment summary that shall be prepared by a member of the recovery team and shall include all of the following:
(a) The period of time within which the assessment was conducted. Each meeting date shall be included.
(b) The information on which outcomes and service recommendations are based.
(c) Desired outcomes and measurable goals desired by the consumer.
(d) The names and relationship to the consumer of all individuals who participated in the assessment process.
(e) Significant differences of opinion, if any, which are not resolved among members of the recovery team.
(f) Signatures of persons present at meetings being summarized.
(7)Recovery team.
(a) The consumer shall be asked to participate in identifying members of the recovery team.
(am) The recovery team shall include all of the following:
1. The consumer.
2. A service facilitator.
3. A mental health professional or substance abuse professional. If the consumer has or is believed to have a co-occurring condition, the recovery team shall consult with an individual who has the qualifications of a mental health professional and substance abuse professional or shall include both a mental health professional and substance abuse professional or a person who has the qualifications of both a mental health professional and substance abuse professional on the recovery team.
4. Service providers, family members, natural supports and advocates shall be included on the recovery team, with the consumer’s consent, unless their participation is unobtainable or inappropriate.
5. If the consumer is a minor or is incompetent or incapacitated, a parent or legal representative of the consumer, as applicable, shall be included on the recovery team.
1. The recovery team shall participate in the assessment process and in service planning. The role of each team member shall be guided by the nature of team member’s relationship to the consumer and the scope of the team member’s practice.
2. Team members shall provide information, evaluate input from various sources, and make collaborative recommendations regarding outcomes, psychosocial rehabilitation services and supportive activities. This partnership shall be built upon the cultural norms of the consumer.
History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04.
DHS 36.17Service planning and delivery processes.
(1)Policies and procedures. The CCS shall implement policies and procedures that address the requirements under this section.
(2)Facilitation of service planning.
(a) A written service plan shall be based upon the assessment and completed within 30 days of the consumer’s application for services. The service plan shall include a description of all of the following:
(b) The service planning process shall be explained to the consumer and, if appropriate, a legal representative or family member.
(c) The service planning process shall be facilitated by the service facilitator in collaboration with the consumer and recovery team.
(d) Service planning shall address the needs and recovery goals identified in the assessment.
(2m)Service plan documentation.
(a) The service plan shall include a description of all of the following:
1. The service facilitation activities, that will be provided to the consumer or on the consumer’s behalf.
2. The psychosocial rehabilitation and treatment services, to be provided to or arranged for the consumer, including the schedules and frequency of services provided.
3. The service providers and natural supports who are or will be responsible for providing the consumer’s treatment, rehabilitation, or support services and the payment source for each.
4. Measurable goals and type and frequency of data collection that will be used to measure progress toward desired outcomes.
(b) An attendance roster shall include recovery team members in attendance at each service planning meeting. The roster shall include the date of the meeting and the name of each person attending the meeting. Each original, updated, and partially completed service plan shall be maintained in the consumer’s service record as required in s. DHS 36.18.
(c) The completed service plan shall be signed by the consumer, a mental health or substance abuse professional and the service facilitator.
(d) Documentation of the service plan shall be available to all members of the recovery team.
(3)Service plan review. The service plan for each consumer shall be reviewed and updated as the needs of the consumer change or at least every 6 months. A service plan that is based on an abbreviated assessment shall be reviewed and updated upon the expiration of the abbreviated assessment or before that time if the needs of the consumer change. The review shall include an assessment of the progress toward goals and consumer satisfaction with services.
(4)Service delivery.
(a) Psychosocial rehabilitation and treatment services shall be provided in the most natural and least restrictive manner and most integrated settings practicable consistent with current legal standards, be delivered with reasonable promptness, and build upon the natural supports available in the community.
(b) Services shall be provided with sufficient frequency to support achievement of goals identified in the service plan.
(c) Documentation of the services shall be included in the service record of the consumer under the requirements in s. DHS 36.18.
(5)Discharge.
(a) Discharge from the CCS shall be based on the discharge criteria in the service plan of the consumer unless any one of the following applies:
1. The consumer no longer wants psychosocial rehabilitation services.
2. The whereabouts of the consumer are unknown for at least 3 months despite diligent efforts to locate the consumer.
3. The consumer refuses services from the CCS for at least 3 months despite diligent outreach efforts to engage the consumer.
4. The consumer enters a long-term care facility for medical reasons and is unlikely to return to community living.
5. The consumer is deceased.
6. Psychosocial rehabilitation services are no longer needed.
(am) When a consumer is discharged from the CCS program, the consumer shall be given written notice of the discharge. The notice shall include all of the following:
1. A copy of the discharge summary developed under par. (b).
2. Written procedures on how to re-apply for CCS services.
3. If a consumer is involuntarily discharged from the CCS program and the consumer receives Medical Assistance, the fair hearing procedures prescribed in s. DHS 104.01 (5). For all other consumers, information on how the consumer can submit a written request for a review of the discharge to the department.
Note: A written request for review of the determination of need for psychosocial rehabilitation services should be addressed to the Bureau of Prevention, Treatment and Recovery, 1 W. Wilson Street, Room 850, P.O. Box 7851, Madison, WI 53707-7851.
(b) The CCS shall develop a written discharge summary for each consumer discharged from psychosocial rehabilitation services. The discharge summary shall include all of the following:
1. The reasons for discharge.
2. The consumer’s status and condition at discharge including the consumer’s progress toward the outcomes specified in the service plan.
3. Documentation of the circumstances, as determined by the consumer and recovery team, that would suggest a renewed need for psychosocial rehabilitation services.
4. For a planned discharge, the signature of the consumer, the service facilitator, and mental health professional or substance abuse professional. With the consumer’s consent, this summary shall be shared with providers who will be providing subsequent services.
History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (5) (am) 3. made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 23-053: am. (2m) (b) Register September 2023 No. 813, eff. 10-1-23.
DHS 36.18Consumer service records.
(1)Each consumer service record shall be maintained pursuant to the confidentiality requirements under HIPAA, s. 51.30, Stats., ch. DHS 92 and, if applicable, 42 CFR Part 2. Electronic records and electronic signatures shall meet the HIPAA requirements in 45 CFR 164, Subpart C.
(2)The CCS shall maintain in a central location a service record for each consumer. Each record shall include sufficient information to demonstrate that the CCS has an accurate understanding of the consumer, the consumer’s needs, desired outcomes and progress toward goals. Entries shall be legible, dated and signed.
(3)Each consumer record shall be organized in a consistent format and include a legend to explain any symbol or abbreviation used. All of the following information shall be included in the consumer’s record:
(a) Results of the assessment completed under s. DHS 36.16, including the assessment summary.
(b) Initial and updated service plans, including attendance rosters from service planning sessions.
(c) Authorization of services statements.
(d) Any request by the consumer for a change in services or service provider and the response by the CCS to such a request.
(e) Service delivery information, including all of the following:
1. Service facilitation notes and progress notes.
2. Records of referrals of the consumer to outside resources.
3. Descriptions of significant events that are related to the consumer’s service plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning.
4. Evidence of the consumer’s progress, including response to services, changes in condition and changes in services provided.
5. Observation of changes in activity level or in physical, cognitive or emotional status and details of any related referrals.
6. Case conference and consultation notes.
7. Service provider notes in accordance with standard professional documentation practices.
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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.