Wisconsin Legislature: DHS 63.16(1)

(7) Education, support and consultation to clients’ families and other major supports.

(a) The case manager shall determine what support, consultation and education the client’s family may need from the CSP to manage the symptoms and illness of the client family member.

(b) The case manager shall coordinate support and consult with the client’s family at time intervals as specified in the client’s treatment plan.

(c) The case manager shall provide the client’s other support systems with education and information about chronic mental illness and community support program treatment.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.13 Client rights. A CSP shall have policies and procedures that ensure that client rights are protected in accordance with s. 51.61, Stats., and ch. DHS 94. The CSP shall require all case managers to assist clients in asserting their rights under s. 51.61, Stats., and ch. DHS 94.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89; corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 63.14 Complaints. A CSP shall have procedures for reporting and investigating alleged unethical, illegal or grossly negligent acts affecting clients and violation of written policies and procedures. The procedures shall also address both client and staff reporting of complaints regarding program procedures, staff and services.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.15 Client records.

(1) A CSP shall maintain a treatment record for each client. The record shall include information that is sufficiently detailed to enable a person not familiar with the CSP to identify the types of services the client has received.

(2) The CSP director is responsible for the maintenance and security of client treatment records.

(3) Client treatment records shall be maintained in a central location.

(4) Client treatment records shall be kept confidential and safeguarded as required under s. 51.30, Stats., and ch. DHS 92.

(5) The treatment recordkeeping format shall provide for consistency within the CSP and shall facilitate information retrieval. Treatment records shall include:

(a) Results of all examinations, tests and other assessment information;

(b) Reports from referring sources;

(d) Medication records, which shall document ongoing monitoring of administration of medications and the detection of adverse drug reactions. All medication orders in the client treatment record shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication;

(e) Records of referrals of the client to outside resources;

(f) Reports from outside resources;

(g) Multidisciplinary case conference and consultation notes;

(h) Consent for disclosure of information release forms;

(i) Progress notes which shall document the location where the service was provided; and

(j) Discharge documentation.

(6) There shall be a policy governing the disposal of client records.

(7) There shall be a policy concerning the disposition of client records in the event of the CSP closing.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89; correction in (4) made under s. 13.93 (2m) (b) 7., Stats., Register December 2004 No. 588; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 63.16 Discharge. Documentation by the client’s case manager, clinical coordinator and psychiatrist of a client’s discharge from a CSP shall be entered in the client’s treatment record within one week after termination of treatment or services. Documentation of discharge shall include:

(1) The reasons for discharge;

(2) The client’s status and condition at discharge;

(3) A written final evaluation summary of the client’s progress toward the goals set forth in the treatment plan;

(4) A plan developed, in conjunction with the client, for care after discharge and for follow-up; and

(5) The signature of the case manager, clinical coordinator and psychiatrist.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.17 Program evaluation.

(1) Each CSP shall have an evaluation plan, which shall include:

(a) A statement of the program’s objectives. The objectives shall relate directly to the program’s clients or target population;

(b) Measurable criteria to be applied in determining whether or not the objectives under par. (a) are achieved;

(d) Methods for assessing the effective utilization of staff and resources toward the attainment of the objectives.

(2) In addition to the evaluation plan required under sub. (1), a CSP shall have a system for regular review that is designed to evaluate the appropriateness of admissions to the program, length of stay, treatment or service plans, discharge practices and other factors that may contribute to effective use of the program’s resources.

(3) An annual report on the program’s progress in meeting its objectives shall be prepared, distributed to interested persons and made available to the department upon request.

(4) The CSP’s governing body or appropriate authority shall review the annual report.

History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.