DHS 36.17(1)(1) Policies and procedures. The CCS shall implement policies and procedures that address the requirements under this section.

DHS 36.17(2)(2) Facilitation of service planning.

DHS 36.17(2)(a)(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:

DHS 36.17(2)(b)(b) The service planning process shall be explained to the consumer and, if appropriate, a legal representative or family member.

DHS 36.17(2)(c)(c) The service planning process shall be facilitated by the service facilitator in collaboration with the consumer and recovery team.

DHS 36.17(2)(d)(d) Service planning shall address the needs and recovery goals identified in the assessment.

DHS 36.17(2m)(2m) Service plan documentation.

DHS 36.17(2m)(a)1.1. The service facilitation activities, that will be provided to the consumer or on the consumer’s behalf.

DHS 36.17(2m)(a)2.2. The psychosocial rehabilitation and treatment services, to be provided to or arranged for the consumer, including the schedules and frequency of services provided.

DHS 36.17(2m)(a)3.3. 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.

DHS 36.17(2m)(a)4.4. Measurable goals and type and frequency of data collection that will be used to measure progress toward desired outcomes.

DHS 36.17(2m)(b)(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.

DHS 36.17(2m)(c)(c) The completed service plan shall be signed by the consumer, a mental health or substance abuse professional and the service facilitator.

DHS 36.17(2m)(d)(d) Documentation of the service plan shall be available to all members of the recovery team.

DHS 36.17(3)(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.

DHS 36.17(4)(4) Service delivery.

DHS 36.17(4)(a)(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.

DHS 36.17(4)(b)(b) Services shall be provided with sufficient frequency to support achievement of goals identified in the service plan.

DHS 36.17(4)(c)(c) Documentation of the services shall be included in the service record of the consumer under the requirements in s. DHS 36.18.

DHS 36.17(5)(5) Discharge.

DHS 36.17(5)(a)(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:

DHS 36.17(5)(a)2.2. The whereabouts of the consumer are unknown for at least 3 months despite diligent efforts to locate the consumer.

DHS 36.17(5)(a)3.3. The consumer refuses services from the CCS for at least 3 months despite diligent outreach efforts to engage the consumer.

DHS 36.17(5)(a)4.4. The consumer enters a long-term care facility for medical reasons and is unlikely to return to community living.