DHS 40.13(2)(a)3.g.g. Suicide risk and self-harm history and risk including criteria for deciding when the level of risk of suicide requires the use of crisis response services or hospitalization. DHS 40.13(2)(a)3.h.h. For a youth over the age of 15, the youth’s vocational and independent living history, skills and needs. DHS 40.13(2)(a)3.i.i. The youth’s current or recent use of drugs or alcohol and the possible presence of any co-occurring disorder that will have to be addressed through the treatment plan. DHS 40.13(2)(a)3.j.j. Any other assets and needs of the youth which affect the youth’s ability to participate effectively in relationships and activities in home, community and school environments. DHS 40.13(2)(a)3.L.L. Recommendations for completing any new test or evaluation which the interdisciplinary treatment team finds is necessary for development of an effective treatment plan for the youth, including psychological, neuropsychological functional, cognitive, behavioral, developmental or early and periodic screening and diagnosis under s. DHS 107.22. DHS 40.13(2)(b)(b) The written assessment shall inform and be completed prior to development of the treatment plan. DHS 40.13(2)(c)(c) The written assessment shall be signed by the youth or legal representative and the clinical coordinator. DHS 40.13 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20. DHS 40.14(1)(a)(a) The interdisciplinary treatment team shall prepare a written treatment plan for a youth based upon the written assessment under s. DHS 40.13 (2) within 15 calendar days after admission. The treatment plan shall describe measurable objectives that will be met and services that will be provided to the youth. DHS 40.14(1)(b)(b) The written treatment plan shall include all of the following: DHS 40.14(1)(b)1.1. The youth’s strengths, treatment strategies, and measurable outcomes to be accomplished. DHS 40.14(1)(b)2.2. Clinical and support services to reduce or eliminate the symptoms causing the youth’s problems or inability to function in day to day living, and to increase the youth’s ability to function as independently as possible. DHS 40.14(1)(b)3.3. The schedules, frequency, nature of services recommended to support the achievement of the youth’s goals, irrespective of the availability of services or funding, and the responsible party for that intervention. DHS 40.14(1)(b)4.4. The proposed length of time the youth will participate in the program and the amount of time that the youth will attend the program each week. DHS 40.14(1)(b)5.5. The involvement of a youth’s legal representative with the program and any services that a legal representative will participate in while the youth is in the program. DHS 40.14(1)(b)6.6. A summary of other services the youth will receive while enrolled in the program, including educational services, other services that the program will be providing for the youth, and services and supports that will be provided by other agencies or providers and the process by which those educational and other services will be coordinated with services provided by the program. DHS 40.14(1)(b)6m.6m. If any part of the services will be delivered via telehealth, a description of those services and clinical justification for delivering services via telehealth rather than in person. DHS 40.14(1)(b)7.7. The procedure for monitoring and managing any risk of suicide if the assessment identified risks. DHS 40.14(1)(b)8.8. Any medication the youth is receiving, the name of the physician prescribing the medication, the dosages prescribed, the purpose for which it is prescribed, the frequency of administration, a plan for monitoring its administration and effects by the physician, and a plan for care coordination with a psychiatrist or advanced practice nurse prescriber. DHS 40.14(1)(b)9.9. A transition services component that establishes when a transition process should begin, the staff member responsible for supporting transition services, and a process for the reintegration of the youth who is completing the program into family, community and school activities. DHS 40.14(1)(c)(c) The treatment plan shall be signed by the youth or legal representative and the clinical coordinator. With informed consent, a service provider who is part of the treatment plan may also review and sign the treatment plan. DHS 40.14(2)(a)(a) At a minimum, the care coordinator shall reconvene the interdisciplinary treatment team as follows: DHS 40.14(2)(a)1.1. In community-based programs, within 30 calendar days following approval of the initial treatment plan and at least every 30 days thereafter. DHS 40.14(2)(a)2.2. In hospital-based programs, within 15 calendar days following approval of the initial treatment plan and at least every 15 days thereafter. DHS 40.14(2)(b)(b) In reviewing case progress, the interdisciplinary treatment team shall determine all of the following: DHS 40.14(2)(b)1.1. The degree to which the measurable objectives in the treatment plan have been met. DHS 40.14(2)(b)2.2. Any significant changes suggested or required in the treatment plan. DHS 40.14(2)(b)3.3. Whether any additional assessment of functional improvement is recommended as a result of information received or observations made during the course of treatment. DHS 40.14(2)(b)4.4. The youth’s assessment of functional improvement toward meeting treatment goals and suggestions for modification. DHS 40.14(2)(c)(c) As part of its review of case progress, the interdisciplinary treatment team shall prepare a written report which includes all of the following: DHS 40.14(2)(c)1.1. A description of the youth’s progress toward measurable objectives established in the treatment plan. DHS 40.14(2)(c)2.2. Documentation of clinical contacts with youth and interventions required as part of the treatment plan. DHS 40.14(2)(c)3.3. Identification of all days on which services were actually delivered to the client, and the amount of time the client spent in the program on those days. DHS 40.14(2)(e)(e) The written report shall be maintained as a permanent part of the youth’s record. DHS 40.14(2)(f)(f) A youth may continue to participate in a day treatment program as long as the review of the youth’s treatment plan under par. (b) indicates that the youth remains appropriate for the continued services being offered and services support the achievement of the measurable objectives identified in the treatment plan. DHS 40.14(3)(a)(a) Decision. Services provided to a youth under an individual treatment plan may be terminated by the program before the youth’s goals for discharge are attained under any of the following circumstances: DHS 40.14(3)(a)1.1. By agreement between the youth or legal representative, the program director, and the clinical coordinator. DHS 40.14(3)(a)2.2. By direction of the program director and the clinical coordinator acting upon recommendation of the interdisciplinary treatment team, if the team determines any of the following: DHS 40.14(3)(a)2.a.a. Further participation of the youth in the program is unlikely to provide any reasonable benefit to the youth. DHS 40.14(3)(a)2.b.b. The youth’s condition requires a greater or more restrictive level of care than can be provided by the program. DHS 40.14(3)(a)2.c.c. The youth’s behavior or condition is such that it creates a serious risk of harm to other clients in the program or to program staff members and no modifications of the program procedures or services are possible which will ensure the safety of other clients or staff members. DHS 40.14(3)(b)1.1. Unless the youth poses an immediate risk of harm to other clients or staff members or subd. 2. applies, the program shall provide the youth or legal representative and other agencies providing services to the client pursuant to the treatment plan with at least 7 days prior notice of the intent to terminate services. DHS 40.14(3)(b)2.2. When a youth has been placed in the program by order of a court under ch. 48, 51, 55, or 938, Stats., the program shall provide that court and the social worker responsible for supervising the implementation of the court order with 14 days prior notice of the intent to end services, unless the youth poses an immediate risk of harm to other clients or staff members, in order to permit the court to enter an alternative order regarding the care of the youth. DHS 40.14 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (3) (b) 2. made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: cr. (1) (b) 6m. Register September 2023 No. 813, eff. 10-1-23. DHS 40.15(1)(1) Location and format. Client records shall be managed in accordance with standard professional practices and any applicable legal requirements for the maintenance of client mental health records, and arranged in a format which provides for consistent recordkeeping within the program and which facilitates accurate and efficient record retrieval. DHS 40.15(2)(2) Elements. All entries in each client file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the staff member making the entry. An electronic representation of the staff member’s signature shall be used only by the staff member who makes the entry. The program shall possess a statement signed by the staff member, which certifies that only that staff member shall use the electronic representation via use of a personal password. DHS 40.15(4)(4) Consent. The treatment record shall document that the youth or legal representative were informed of the nature and policies of the program in their primary language and that the youth or legal representative understood and agreed to participation in the program. DHS 40.15(5)(5) Client treatment record. A treatment file or electronic record shall include all of the following: DHS 40.15(5)(b)(b) Notes and reports made while screening the youth for admission. DHS 40.15(5)(f)(f) Reports and other evaluations of the youth which were used in developing the assessment, and any necessary releases or authorizations for acquiring and using these reports and evaluations. DHS 40.15(5)(g)(g) Results of additional evaluations and other assessments performed while the youth is enrolled in the program. DHS 40.15(5)(i)(i) Descriptions of significant events that are related to the youth’s treatment plan and contribute to an overall understanding of the youth’s ongoing level and quality of functioning. DHS 40.15(5)(j)(j) Any recommended changes or improvements of the treatment plan resulting from clinical collaboration or clinical oversight. DHS 40.15(5)(k)(k) Written documentation of the services that have been provided to the youth or their legal representative as required under s. DHS 40.07 (4). DHS 40.15(5)(m)(m) Documentation of transition services and discharge planning, including involuntary discharge. DHS 40.15(5)(n)(n) Informed consent for treatment medication administration and medication records, if staff members dispense medications, including documentation of both over-the-counter and prescription medications dispensed to youth. Medication records shall contain documentation of ongoing monitoring of the administration of medications and detection of adverse drug reactions. All medication orders in the youth treatment record shall specify the name, type and purpose of the medication, and the dose, route of administration, frequency of administration, staff member administering, and name of the prescriber who prescribed the medication. DHS 40.15(5)(p)(p) Written consent, the court order, or county department authorization under s. DHS 40.12 (2) (a) to admission, and any consent for disclosure or authorization for release of information required under s. 51.30, Stats., and ch. DHS 92. DHS 40.15(5)(r)(r) Care coordination provided with the youth or legal representative. DHS 40.15(5)(s)(s) Any other information that is appropriate for the youth file. DHS 40.15(6)(a)(a) Programs may maintain treatment records electronically if the program has a written policy describing the records and the authentication and security policy. DHS 40.15(6)(b)(b) Electronic transmission of information from treatment records to information systems outside the program shall not occur without voluntary written consent for disclosure from the youth or legal representative per s. 51.30, Stats., or as otherwise provided by law. DHS 40.15(7)(7) Education records. Education records of a youth shall be kept separate from the youth’s treatment record, and shall comply with federal and state statutes and regulations relating to educational records. DHS 40.15 NoteNote: Federal and state statutes and regulations relating to educational records are found in 20 USC 1232g and 34 CFR Pt. 99, and s. 118.125, Stats. DHS 40.15(8)(8) Maintenance and security. The program director is responsible for the maintenance and security of client treatment records. DHS 40.15(9)(9) Disposition upon program closing. A program shall establish a written policy for maintenance and disposition of records, in accordance with s. DHS 92.12, in the event the program closes. DHS 40.15 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (3), (5) (k) made under s. 35.17, Stats., Register June 2020 No. 774. DHS 40.16DHS 40.16 Client rights. All programs shall comply with s. 51.61, Stats., and ch. DHS 94 on the rights of clients. DHS 40.16 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.
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