DHS 35.19(3)(a)3.3. Whether any additional assessment or evaluation is recommended as a result of information received or observations made during the course of treatment. DHS 35.19(3)(a)4.4. The consumer’s assessment of functional improvement toward meeting treatment goals and suggestions for modification. DHS 35.19(3)(b)(b) A mental health professional shall conduct a clinical review of the treatment plan with the consumer as described in par. (a) at least every 90 days or 6 treatment sessions, whichever covers a longer period of time. DHS 35.19(4)(4) The clinic shall develop and implement written policies and procedures for referring consumers to other community service providers for services that the clinic does not or is unable to provide to meet the consumer’s needs as identified in the comprehensive assessment required under s. DHS 35.17 (1) (b). The policies shall identify community services providers to which the clinic reasonably determines it will be able to refer consumers for services the clinic does not or cannot provide. DHS 35.19 HistoryHistory: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.20(1)(1) A clinic may choose whether to provide medication management as part of its services. DHS 35.20(2)(2) Consumers receiving only medication management from a clinic shall be referred by the clinic’s prescriber for psychotherapy when appropriate to the consumer’s needs and recovery. DHS 35.20 HistoryHistory: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.21DHS 35.21 Treatment approaches and services. DHS 35.21(1)(1) The clinic shall have and implement a written policy that identifies the selection of treatment approaches and the role of clinical supervision and clinical collaboration in treatment approaches. The treatment approaches shall be based on guidelines published by a professional organization or peer-reviewed journal. The final decision on the selection of treatment approaches for a specific consumer shall be made by the consumer’s therapist in accordance with the clinic’s written policy. DHS 35.21(2)(2) The clinic shall make reasonable efforts to ensure that each consumer receives the recommended interventions and services identified in the consumer’s treatment plan or revision of the treatment plan that is created under s. DHS 35.19 (1), that the consumer is willing to receive as communicated by an informed consent for treatment. DHS 35.21 HistoryHistory: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.215DHS 35.215 Group therapy. The maximum number of consumers receiving services in a single group therapy session is 16, and the minimum staff to consumer ratio in group therapy is one to 8. If different limits are justified based on guidelines published by a governmental entity, professional organization or peer-reviewed journal indicate, the clinic may request a variance of either the limit of group size or the minimum staff to consumer ratio. DHS 35.215 HistoryHistory: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.22(1)(1) Within 30 days after a consumer’s date of discharge, the licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner who was primarily responsible for providing outpatient mental health services for the consumer shall prepare a discharge summary and enter it into the consumer file. The discharge summary shall include all of the following: DHS 35.22(1)(b)(b) A summary of the outpatient mental health services provided by the clinic, including any medications. DHS 35.22(1)(c)(c) A final evaluation of the consumer’s progress toward the goals of the treatment plan. DHS 35.22(1)(d)(d) Any remaining consumer needs at the time of discharge and the recommendations for meeting those needs, which may include the names and addresses of any facilities, persons or programs to which the consumer was referred for additional services following discharge. DHS 35.22(2)(2) The discharge summary shall be signed and dated by the licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner who was primarily responsible for providing services to the consumer. DHS 35.22 HistoryHistory: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09. DHS 35.23(1)(a)(a) The clinic shall maintain a consumer file for each consumer who receives outpatient mental health services. Each consumer file shall be arranged in a format that provides for consistent recordkeeping that facilitates accurate and efficient retrieval of record information. All entries in the consumer file shall be factual, accurate, legible, permanently recorded, dated, and authenticated with the signature and license or title of the person making the entry. Treatment records contained in a consumer file are confidential to the extent required under s. 51.30, Stats. An electronic representation of a person’s signature may be used only by the person who makes the entry. The clinic shall possess a statement signed by the person, which certifies that only that person shall use the electronic representation via use of a personal password. Each consumer file shall include accurate documentation of all outpatient mental health services received including all of the following: