Wisconsin Legislature: DHS 36.18(3)(f)

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 36.18 Consumer 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.

(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.

8. Reports of treatment, or other activities from outside resources that may be influential in the CCS’s service planning.

(f) A list of current prescription medication and regularly taken over the counter medications. Documentation of each prescribed medication shall include all of the following:

1. Name of the medication and dosage.

2. Route of administration.

3. Frequency.

4. Duration, including the date the medication is to be stopped.

5. Intended purpose.

6. Name of the prescriber. The signature of prescriber is also required if the CCS prescribes medication as a service.

7. Activities related to the monitoring of medication including monitoring for desired responses and possible adverse drug reactions, as well as an assessment of the consumer’s ability to self-administer medication.

7m. Medications may be administered only by a physician, nurse, a practitioner, a person who has completed training in a drug administration course approved by the department, or by the consumer.

8. If a CCS staff member administers medications, each medication administered shall be documented on the consumer’s individual medication administration record (MAR) including, the time the medication was administered and by whom and observation of adverse drug reactions, including a description of the adverse drug reaction, the time of the observation and the date and time the prescriber of the medication was notified. If a medication was missed or refused by the consumer, the record shall explicitly state the time that it was scheduled and the reason it was missed or refused.

(g) Signed consent forms for disclosure of information and for medication administration and treatment.

(h) Legal documents addressing commitment, guardianship, and advance directives.

(i) Discharge summary and any related information.

(j) Any other information that is appropriate for the consumer service record.

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 36.19 Consumer rights.

(1) The CCS shall comply with the patient rights and grievance resolution procedures in s. 51.61, Stats., and ch. DHS 94, and all of the following:

(a) Choice in the selection of recovery team members, services, and service providers.

(b) The right to specific, complete and accurate information about proposed services.

(c) For Medical Assistance consumers, the fair hearing process under s. DHS 104.01 (5). For all other consumers how to request a review of a CCS determination by the department.

(1m) Consumers shall not be required to use telehealth to receive services and an in-person option must be available. Providers are not required to provide services via telehealth to an individual or a program.

(2) The service facilitator shall ensure that the consumer understands the options of using the formal and informal grievance resolution process in s. DHS 94.40 (4) and (5).

History: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 23-053: cr. (1m) Register September 2023 No. 813, eff. 10-1-23.