DHS 40.13(1)(b) (b) Notes and reports made while screening the client for admission;
DHS 40.13(1)(c) (c) A copy of the letter under s. DHS 40.08 (5) accepting or rejecting the referral;
DHS 40.13(1)(d) (d) The report under s. DHS 40.09 (3) of the multidisciplinary assessment of the client and his or her family;
DHS 40.13(1)(e) (e) Reports and other evaluations of the client and his or her family which were used in developing the initial assessment, and any necessary releases or authorizations for acquiring and using these reports and evaluations;
DHS 40.13(1)(f) (f) Results of additional evaluations and other assessments performed while the client is enrolled in the program;
DHS 40.13(1)(g) (g) The individual treatment plan for the client and his or her family and the signed approval of the treatment plan;
DHS 40.13(1)(h) (h) Written documentation of services provided to the client and client progress as required under s. DHS 40.10 (5) (c);
DHS 40.13(1)(i) (i) Written summaries of the reviews of the treatment plan pursuant to s. DHS 40.10 (5) (b) 4.;
DHS 40.13(1)(j) (j) Documentation of discharge planning and planned aftercare services;
DHS 40.13(1)(k) (k) Medication records, if program staff dispense medications, including documentation of both over-the-counter and prescription medications dispensed to clients. Medication records shall contain documentation of ongoing monitoring of the administration of medications and detection of adverse drug reactions. All medication orders in the client treatment record shall specify the name, type and purpose of the medication, and the dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication;
DHS 40.13(1)(L) (L) Records of referrals of the client and his or her family to outside resources;
DHS 40.13(1)(m) (m) Written consent or the court order or county department authorization under s. DHS 40.08 (8) to admission, and any consent for disclosure or authorization for release of information required under s. 51.30, Stats., and ch. DHS 92;
DHS 40.13(1)(n) (n) Records of any grievances lodged by the client, his or her family or other persons relating to the client's treatment, and documentation of the program's response to each grievance; and
DHS 40.13(1)(o) (o) Treatment plan case conference and consultation notes.
DHS 40.13(2) (2)Education records. Education records of a client shall be kept separate from the client's treatment record, and shall comply with federal and state statutes and regulations relating to educational records.
DHS 40.13 Note Note: Federal and state statutes and regulations relating to educational records are 20 USC 1232g and 34 CFR Pt. 99, and s. 118.125, Stats.
DHS 40.13(3) (3)Maintenance and security. The program director is responsible for the maintenance and security of client treatment records.
DHS 40.13(4) (4)Location and format. Client treatment records shall be kept in a central place, be managed in accordance with standard professional practices for the maintenance of patient 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 40.13(5) (5)Confidentiality and retention of records. Client treatment records shall be kept confidential and safeguarded and retained as required under s. 51.30, Stats., and ch. DHS 92.
DHS 40.13(6) (6)Disposition upon program closing. A program shall establish a plan for maintenance and disposition of records in the event the program closes.
DHS 40.13 History History: Cr. Register, August, 1996, No. 488, eff. 9-1-96; corrections in (1) (m) and (5) made under s. 13.93 (2m) (b) 7. Stats., Register January 2004 No. 577; corrections in (1) (m) and (5) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 40.14 DHS 40.14Client rights.
DHS 40.14(1) (1)Policies and procedures. All programs shall comply with s. 51.61, Stats., and ch. DHS 94 on the rights of clients.
DHS 40.14(2) (2)Case manager's duties. A client's case manager shall inform and assist the client and the client's parents or guardian in understanding and asserting their rights.
DHS 40.14(3) (3)Conflict resolution.
DHS 40.14(3)(a)(a) Clients and their parents shall be informed that they have the option of using either formal or informal procedures for resolving complaints and disagreements.
DHS 40.14(3)(b) (b) A program shall establish a process for informal management of concerns raised by clients, family members and other agencies involved in the care and treatment of clients.
DHS 40.14(3)(c) (c) A program shall establish a formal system for receiving and processing grievances which cannot be managed informally. The system shall provide for impartial review of complaints and shall include an option for mediation of disagreements.
DHS 40.14 History History: Cr. Register, August, 1996, No. 488, eff. 9-1-96; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
DHS 40.15 DHS 40.15Buildings, grounds and equipment.
DHS 40.15(1)(1)General requirements. All buildings used by a program to provide care and treatment for clients shall comply with the state building code, chs. SPS 361 to 365, and any applicable municipal building regulations.
DHS 40.15(2) (2)Food service. A program shall make food service available to any clients who are at the program's facility for 4 or more hours during a day. The food service shall comply with s. DHS 190.09.
DHS 40.15 History History: Cr. Register, August, 1996, No. 488, eff. 9-1-96; corrections made under s. 13.93 (2m) (b) 7., Stats., Register January 2004 No. 577; correction in (2) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register February 2012 No. 674.
DHS 40.16 DHS 40.16Program evaluation.
DHS 40.16(1) (1)Outcome.
DHS 40.16(1)(a)(a) Every program shall annually evaluate the effectiveness of services provided to its clients. The means used to carry out this outcome evaluation shall include:
DHS 40.16(1)(a)1. 1. A statement of the program's therapeutic, behavioral and skill-based outcome expectations for its clients stated in objectively measurable terms;
DHS 40.16(1)(a)2. 2. A process for obtaining and recording accurate information about changes in client performance to meet these outcome expectations during and following program participation;
DHS 40.16(1)(a)3. 3. A process for obtaining and recording honest and accurate statements of client, family and referral source satisfaction with program services; and
DHS 40.16(1)(a)4. 4. A method for collecting and analyzing the objective and subjective outcome data identified in subds. 1. to 3. in a manner which protects the confidentiality of clients and their families.
DHS 40.16(1)(b) (b) Every program shall send the annual report of client service outcomes to the department office which certified the program within 60 days after receiving notification of renewal of certification under s. DHS 40.04 (6) (b) and shall make it available for review as a public record maintained by the program. A form for this report will be supplied by the department.
DHS 40.16(2) (2)Operations.
DHS 40.16(2)(a)(a) In addition to the outcome evaluation under sub. (1), a program shall arrange for an annual review of its program operations to evaluate factors such as the appropriateness of admissions and clients' length of stay, the efficiency of procedures for conducting initial assessments and developing treatment plans, the effectiveness of discharge and aftercare services, the functionality of the program's interagency agreements and other factors that may contribute to effective use of the program's resources.
DHS 40.16(2)(b) (b) The review of program operations may be conducted by an advisory committee established by the program, by a committee of the board of directors of the organization operating the program or by any other appropriate and objective body.
DHS 40.16(2)(c) (c) A summary of the review of program operations shall be appended to the annual report prepared under sub. (1) (b).
DHS 40.16 History History: Cr. Register, August, 1996, No. 488, eff. 9-1-96.
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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.