DHS 75.24(11)(d)4.
4. Documentation about the current mental and physical health status of the patient.
DHS 75.24(11)(d)5.
5. Psychosocial history information shall include all of the following areas that relate to the patient's presenting problem:
DHS 75.24(11)(d)5.i.
i. Other factors that appear to have a relationship to the patient's substance use and physical and mental health.
DHS 75.24(11)(d)6.
6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following:
DHS 75.24(11)(d)6.d.
d. Consultation with the patient's physician or other medical or behavioral health provider.
DHS 75.24(11)(d)6.e.
e. Consultation with department of corrections or child protective services when applicable.
DHS 75.24(11)(d)7.
7. Level of care recommendation based on ASAM or other department-approved placement criteria.
DHS 75.24(11)(e)
(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
DHS 75.24(11)(f)
(f) The clinical staff's recommendations for treatment shall be included in a summary of the assessment that is consistent with diagnosis and level of care placement criteria.
DHS 75.24(11)(g)
(g) If an assessing substance abuse counselor identifies symptoms of a mental health disorder during the assessment process, the substance abuse counselor shall refer the individual to an appropriately credentialed provider for a comprehensive mental health assessment, unless the substance abuse counselor is also a licensed mental health professional.
DHS 75.24(11)(h)
(h) If the assessing clinical staff identifies symptoms of a physical health problem during the assessment process, the service shall refer the individual for a physical health assessment conducted by medical personnel.
DHS 75.24(11)(i)
(i) If the assessing clinical staff identifies that an individual is pregnant at the time of the assessment, the service shall make a referral for prenatal care or ensure that the patient is already receiving prenatal care, and document efforts to coordinate care with prenatal care providers.
DHS 75.24(11)(j)
(j) In the event that the assessed level of care is not available, a service shall:
DHS 75.24(11)(j)1.
1. Document accurately the level of care indicated by the clinical assessment.
DHS 75.24(11)(j)2.
2. Indicate on the treatment plan what alternative level of care is available or agreed upon.
DHS 75.24(11)(j)3.
3. Identify on the treatment plan what efforts will be made to access the appropriate level of care, additional services or supports that will be offered to bridge the gap in level of care, and ongoing assessment for clinical needs and level of care review.
DHS 75.24(11)(k)
(k) For assessments completed by a substance abuse counselor in-training or a graduate student QTT, the assessment and recommendations shall be reviewed and signed by the clinical supervisor within 7 days of the assessment date.
DHS 75.24(11)(L)
(L) For a patient receiving mental health services under s.
DHS 75.50 or
75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria is not required.
DHS 75.24(12)(a)(a) A service shall have written policies and procedures for referring patients to other service providers and for coordinating care with other providers.
DHS 75.24(12)(b)
(b) Policies and procedures shall include a description of follow-up activities to be completed to support that recommended care is received.
DHS 75.24(13)(a)(a) Clinical staff of a service shall develop a treatment plan for each patient.
DHS 75.24(13)(b)
(b) A patient's treatment plan shall represent an agreement between the service and the patient regarding needs identified in the clinical assessment, the patient's identified treatment goals, and treatment interventions and resources to be applied.
DHS 75.24(13)(c)
(c) When feasible, the treatment plan shall be developed in collaboration and with input from the patient's family or significant other, or other supportive persons identified by the patient.
DHS 75.24(13)(d)
(d) The treatment plan shall be signed by the patient, the primary counselor, and other behavioral health clinical staff, identified in the treatment plan.
DHS 75.24(13)(e)
(e) A treatment plan completed by a substance abuse counselor in-training or a graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the development of the plan or the next treatment plan review, whichever is earlier.
DHS 75.24(13)(f)
(f) The content of the treatment plan shall describe the identified needs and specify individualized treatment goals that are expressed in behavioral and measurable terms.
DHS 75.24(13)(g)
(g) The treatment plan shall specify each intervention applied to reach the treatment goals.
DHS 75.24(13)(h)
(h) The treatment plan shall be reviewed at the interval required by the patient's level of care or based on the patient's needs and clinical indication. The review shall be documented with a summary of progress and the signature of the patient and primary counselor.
DHS 75.24(13)(i)
(i) The treatment plan review shall include an updated level of care assessment which follows ASAM or other department-approved placement criteria and recommends continued stay, transfer, or discharge.
DHS 75.24(13)(j)
(j) An updated treatment plan shall be established during the review if there is a change in the patient's needs, goals, or interventions and resources to be applied. The updated treatment plan shall be signed by the patient, the primary counselor, and any other behavioral health clinical staff identified in the treatment plan.
DHS 75.24(13)(k)
(k) Treatment plan reviews and updates completed by a substance abuse counselor in-training or graduate student QTT shall be reviewed and signed by the clinical supervisor within 14 days of the review and update.
DHS 75.24(13)(L)
(L) For patients with co-occurring disorders receiving services under ss.
DHS 75.50,
75.51,
75.52,
75.54,
75.55,
75.56, and
75.59 service shall assign dually-credentialed clinicians whenever possible. When this is not possible, the service shall ensure that mental health needs and substance use needs are included in the treatment plan, and met by appropriately credentialed personnel.
DHS 75.24(13)(m)
(m) For a patient receiving mental health services under s.
DHS 75.50 or
75.56 who does not have a co-occurring substance use disorder, the requirement for ASAM or other department-approved level of care placement criteria and review is not required.
DHS 75.24(14)(a)(a) A service shall have a written policy and procedure that outlines the structure for clinical consultation.
DHS 75.24(14)(b)
(b) Clinical consultation applies to all clinical staff of a service.
DHS 75.24(14)(c)
(c) Clinical consultation shall be documented in the patient's case record.
DHS 75.24(14)(d)
(d) Clinical consultation for unlicensed staff shall be completed with a clinical supervisor and shall be documented with the clinical supervisor's signature. Clinical consultation for licensed professionals may occur with a clinical supervisor or another licensed professional who is a staff of the service.
DHS 75.24(14)(e)
(e) Clinical consultation is required for any of the following:
DHS 75.24(14)(e)1.
1. When a patient's substance use or mental health poses a significant risk to the individual, their family, or the community.
DHS 75.24(14)(e)3.
3. When an individual's symptoms, pattern of substance use, risk level, or placement criteria indicate transfer to a higher level of care.
DHS 75.24(14)(f)
(f) When a safety plan requires ongoing monitoring, clinical consultation shall be completed at clinically-determined intervals until the risk level is reduced or appropriately managed with services or collateral supports.
DHS 75.24(14)(g)
(g) When the recommended level of care cannot be determined, or is not available, or the individual has declined the recommended level of care, clinical consultation shall be completed at clinically-determined intervals until the appropriate level of care is determined, or obtained, or the individual's risk level decreases.
DHS 75.24(15)(a)(a) A service shall have a written policy and procedure that outlines the structure for clinical staffing.
DHS 75.24(15)(b)
(b) Clinical staffing applies to all clinical staff of a service, and includes the clinical supervisor and medical personnel. Clinical staffing is facilitated at intervals appropriate to the individual's needs and as prescribed based on the level of care.
DHS 75.24(15)(c)1.
1. Clinical staffing shall include the clinical supervisor of the service.
DHS 75.24(15)(c)2.
2. Clinical staffing shall include a patient's prescriber or medical personnel, if applicable.
DHS 75.24(15)(c)3.
3. Clinical staffing may be combined with treatment plan review and level of care review.
DHS 75.24(15)(c)4.
4. Clinical staffing shall be documented in the patient's clinical record.
DHS 75.24(16)(a)(a) A service shall document in the patient's record each contact the service has with a patient or with a collateral source.
DHS 75.24(16)(b)
(b) Notes shall be entered by the staff member providing the service to document the content of the contact with the patient or a collateral source; or, if notes are entered by a designee, this must be specified.
DHS 75.24(16)(c)
(c) Progress notes shall include chronological documentation of treatment that is directly related to the patient's treatment plan, and documentation of the patient's response to treatment.
DHS 75.24(16)(d)
(d) The person making the entry shall sign and date the note, and if a designee, shall indicate who provided the service.
DHS 75.24(17)(b)
(b) A service shall have written policies and procedures regarding group counseling that include, at minimum, the following:
DHS 75.24(17)(b)3.
3. Consideration of needs related to special populations or considerations for co-mingled groups.
DHS 75.24(17)(c)
(c) Each group therapy contact shall be documented as a progress note in each patient's case record.
DHS 75.24(18)(a)(a) When requested by a patient's affected family member or significant other, the service shall offer or refer for supportive services, such as counseling, support groups, or education.
