DHS 35.19(2) (2)Approval of the treatment plan. As treatment services are rendered, the consumer or the consumer's legal representative must approve and sign the treatment plan and agree with staff on a course of treatment. If the consumer does not approve of the schedules, frequency, and nature of the services recommended, then appropriate notations regarding the consumer's refusal shall be made in the consumer file. The treatment plan under this subsection shall include a written statement immediately preceding the consumer's or legal representative's signature that the consumer or legal representative had an opportunity to be informed of the services in the treatment plan, and to participate in the planning of treatment or care, as required by s. 51.61 (1) (fm), Stats.
DHS 35.19(3) (3)Clinical review of the treatment plan.
DHS 35.19(3)(a)(a) Staff shall establish a process for a clinical review of the consumer's treatment plan and progress toward measurable outcomes. The review shall include the participation of the consumer and be an ongoing process. The results of each clinical review shall be clearly documented in the consumer file. Documentation shall address all of the following:
DHS 35.19(3)(a)1. 1. The degree to which the goals of treatment have been met.
DHS 35.19(3)(a)2. 2. Any significant changes suggested or required in the treatment plan.
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 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.20 DHS 35.20Medication management.
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(3) (3) All medications prescribed by the clinic shall be documented in the consumer file as required under s. DHS 35.23 (1) (a) 10.
DHS 35.20 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.21 DHS 35.21Treatment 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 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.215 DHS 35.215Group 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 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.22 DHS 35.22Discharge summary.
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)(a) (a) A description of the reasons for discharge.
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 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.23 DHS 35.23Consumer file.
DHS 35.23(1) (1)Records required.
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:
DHS 35.23(1)(a)1. 1. Results of each assessment conducted.
DHS 35.23(1)(a)2. 2. Initial and updated treatment plans.
DHS 35.23(1)(a)3. 3. The recommendation or prescription for psychotherapy.
DHS 35.23(1)(a)4. 4. For consumers who are diagnosed with substance abuse disorder, a completed copy of the most current approved placement criteria summary if required by s. DHS 35.16 (5).
DHS 35.23(1)(a)5. 5. Documentation of referrals of the consumer to outside resources.
DHS 35.23(1)(a)6. 6. Descriptions of significant events that are related to the consumer's treatment plan and contribute to an overall understanding of the consumer's ongoing level and quality of functioning.
DHS 35.23(1)(a)7. 7. Progress notes, which shall include documentation of therapeutic progress, functional status, treatment plan progress, symptom status, change in diagnosis, and general management of treatment.
DHS 35.23(1)(a)8. 8. Any recommended changes or improvement of the treatment plan resulting from clinical collaboration or clinical supervision.
DHS 35.23(1)(a)9. 9. Signed consent forms for disclosure of information and for medication administration and treatment, and court orders, if any.
DHS 35.23(1)(a)10. 10. A listing of medications prescribed by staff prescribers, and a medication administration record if staff dispenses or administers medications to the consumer.
DHS 35.23(1)(a)11. 11. Discharge summary and any related information.
DHS 35.23(1)(a)12. 12. Notice of involuntary discharge, if applicable.
DHS 35.23(1)(a)13. 13. Any other information that is appropriate for the consumer file.
DHS 35.23(1)(b) (b) Clinics may keep composite consumer files of a family in treatment as a unit. When information is released, provisions shall be made for individual confidentiality pursuant to s. 51.30, Stats., and ch. DHS 92.
DHS 35.23(2) (2)Confidentiality. Treatment records shall be kept confidential as required under s. 51.30, Stats., ch. DHS 92, and 45 CFR Parts 160, 162 and 164, and 42 CFR Part 2 in a designated place in each clinic office at which records are stored that is not accessible to consumers or the public but is accessible to appropriate staff members at all times.
DHS 35.23 Note Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b), Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b).
DHS 35.23(3) (3)Transferring treatment records. Upon written request of a consumer or former consumer or, if required, that person's legal representative, the clinic shall transfer to another licensed treatment professional, clinic or mental health program or facility the treatment records and all other information in the consumer file necessary for the other licensed treatment professional, clinic or mental health program or facility to provide further treatment to the consumer or former consumer.
DHS 35.23(4) (4)Retention and disposal.
DHS 35.23(4)(a)(a) The clinic shall implement a written policy governing the retention of treatment records that is in accordance with s. DHS 92.12 and any other applicable laws.
DHS 35.23(4)(b) (b) Upon termination of a staff member's association with the clinic, the treatment records for which the staff member was responsible shall remain in the custody of the clinic.
DHS 35.23(5) (5)Electronic record-keeping systems.
DHS 35.23(5)(a)(a) Clinics may maintain treatment records electronically if the clinic has a written policy describing the record and the authentication and security policy.
DHS 35.23(5)(b) (b) Electronic transmission of information from treatment records to information systems outside the outpatient mental health clinic may not occur without voluntary written consent of the consumer unless the release of confidential treatment information is permitted under s. 51.30, Stats., or other applicable law.
DHS 35.23 Note Note: Transmission of information must comply with 45 CFR parts 160, 162, and 164, s. 51.30, Stats., and ch. DHS 92.
DHS 35.23(5)(c) (c) If treatment records are kept electronically, the confidentiality of the treatment records shall be maintained as required under subs. (2) to (4). A clinic shall maintain a paper or electronic back-up system for any treatment records maintained electronically.
DHS 35.23 Note Note: If notes or records, recorded in any medium, maintained for personal use by an individual providing treatment services are available to others, the notes or records become part of the treatment records. See s. 51.30 (1) (b), Stats., and ss. DHS 92.02 (16) and 92.03 (1) (b).
DHS 35.23 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.24 DHS 35.24Consumer rights.
DHS 35.24(1) (1) A clinic shall implement written polices and procedures that are consistent with s. 51.61, Stats., and ch. DHS 94 to protect the rights of consumers.
DHS 35.24(2) (2) If a staff member no longer is employed by or contracts with the outpatient mental health clinic, the clinic shall offer consumers who had been served by that staff member options for ongoing services.
DHS 35.24(3)(a)(a) A consumer may be involuntarily discharged from treatment because of the consumer's inability to pay for services or for behavior that is reasonably a result of mental health symptoms only as provided in par. (b).
DHS 35.24(3)(b) (b) Before a clinic may involuntarily discharge a consumer under par. (a), the clinic shall notify the consumer in writing of the reasons for the discharge, the effective date of the discharge, sources for further treatment, and of the consumer's right to have the discharge reviewed, prior to the effective date of the discharge, by the subunit of the department that certifies clinics under this chapter, with the address of that subunit. A review under this paragraph is in addition to and is not a precondition for any other grievance or legal action the consumer may bring in connection with the discharge, including a grievance or action under s. 51.61, Stats. In deciding whether to uphold or overturn a discharge in a review under this paragraph, the department may consider:
DHS 35.24(3)(b)1. 1. Whether the discharge violates the consumer's rights under s. 51.61, Stats.
DHS 35.24(3)(b)2. 2. In cases of discharge for behavior that is reasonably a result of mental health symptoms, whether the consumer's needs can be met by the clinic, whether the safety of staff or other consumers of the clinic may be endangered by the consumer's behavior, and whether another provider has accepted a referral to serve the consumer.
DHS 35.24 Note Note: The address of the subunit of the department that certifies clinics under this chapter is Behavioral Health Certification Section, Division of Quality Assurance, PO Box 2969, Madison, WI 53701-2969.
DHS 35.24 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
DHS 35.25 DHS 35.25Death reporting. The clinic shall report the death of a consumer to the department if required under s. 51.64 (2), Stats.
DHS 35.25 History History: CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.