Chapter DHS 40

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)(d) (d) The written report shall be prepared as follows:

DHS 40.14(2)(d)1. 1. At least every 30 days in community-based programs.

DHS 40.14(2)(d)2. 2. At least every 15 days in hospital-based programs.

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) (3) Termination of services.

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) (b) Notice.

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 History History: 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 DHS 40.15 Client records.

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(3) (3) Confidentiality and retention of records. Client records shall be kept confidential and safeguarded and retained as required under 42 CFR part 2, 45 CFR parts 160, 162, 164, and s. 51.30, Stats., ch. DHS 92, and any other applicable law.

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)(a) (a) Initial referral materials.

DHS 40.15(5)(b) (b) Notes and reports made while screening the youth for admission.

DHS 40.15(5)(c) (c) A copy of the screening summary under s. DHS 40.11 (3).

DHS 40.15(5)(d) (d) The safety plan under s. DHS 40.12 (4).

DHS 40.15(5)(e) (e) The written, signed assessment under s. DHS 40.13 (2).

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)(h) (h) The initial, signed individual treatment plan.

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)(L) (L) Written summaries of the reviews of the treatment plan pursuant to s. DHS 40.14 (2) (c).

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)(o) (o) Records of referrals of the youth to outside resources.

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)(q) (q) Treatment plan case reviews and consultation notes.

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) (6) Electronic treatment records.

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 Note Note: 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 History History: 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 40.16 DHS 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 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.

DHS 40.17 DHS 40.17 Program evaluation.

DHS 40.17(1) (1) Outcomes. A program shall at least annually evaluate the effectiveness of services provided to its clients by doing all of the following:

DHS 40.17(1)(a) (a) Preparing a statement of the program’s clinical and support services outcomes for youth stated in objectively measurable terms.

DHS 40.17(1)(b) (b) Preparing and making available to the public an annual report of youth service outcomes.

DHS 40.17(2) (2) Operations.

DHS 40.17(2)(a) (a) In addition to the outcome evaluation under sub. (1), a program shall arrange for an annual review of its program operations, including all of the following:

DHS 40.17(2)(a)1. 1. Appropriateness of referrals, admissions, and clients’ length of stay.

DHS 40.17(2)(a)2. 2. Efficiency of procedures for conducting assessments and developing treatment plans.

DHS 40.17(2)(a)3. 3. Use of a supportive and trauma-informed treatment milieu, and improving quality of care and safety of youth.

DHS 40.17(2)(a)4. 4. The use of emergency safety interventions, including an aggregate review of all incidents of seclusion and physical restraint, to assure that the wellbeing of youth is safeguarded and that youth rights are protected.

DHS 40.17(2)(a)5. 5. Effectiveness of transition planning and discharge.

DHS 40.17(2)(a)6. 6. Functionality of care coordination and integration with other services.

DHS 40.17(2)(b) (b) The review of program operations may be conducted by an advisory committee established by the program, an already established quality assurance and performance improvement committee, by a committee of the board of directors of the facility operating the program, or by any other appropriate and objective body. The committee shall include the program director and clinical coordinator, additional program staff members as appropriate, and whenever possible include parents and community members.

DHS 40.17(2)(c) (c) A summary of the review of program operations shall be appended to the annual report prepared under sub. (1) (b) and made available to department staff upon request.

DHS 40.17 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (2) (c) made under s. 13.92 (4) (b) 7., Stats., Register January 2021 No. 781.

DHS 40.18 DHS 40.18 Death Reporting. Each program shall adopt written policies and procedures for reporting to the department deaths of youth no later than 24 hours after a death due to suicide, psychotropic medications, or use of physical restraints, as required by s. 51.64 (2), Stats.

DHS 40.18 Note Note: Copies of the form for reporting these deaths can be obtained from https://www.dhs.wisconsin.gov/regulations/report-death/proc-reportingdeath.htm.

DHS 40.18 History History: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20.