DHS 36.16(6)(c)(c) Desired outcomes and measurable goals desired by the consumer. DHS 36.16(6)(d)(d) The names and relationship to the consumer of all individuals who participated in the assessment process. DHS 36.16(6)(e)(e) Significant differences of opinion, if any, which are not resolved among members of the recovery team. DHS 36.16(6)(f)(f) Signatures of persons present at meetings being summarized. DHS 36.16(7)(a)(a) The consumer shall be asked to participate in identifying members of the recovery team. DHS 36.16(7)(am)3.3. A mental health professional or substance abuse professional. If the consumer has or is believed to have a co-occurring condition, the recovery team shall consult with an individual who has the qualifications of a mental health professional and substance abuse professional or shall include both a mental health professional and substance abuse professional or a person who has the qualifications of both a mental health professional and substance abuse professional on the recovery team. DHS 36.16(7)(am)4.4. Service providers, family members, natural supports and advocates shall be included on the recovery team, with the consumer’s consent, unless their participation is unobtainable or inappropriate. DHS 36.16(7)(am)5.5. If the consumer is a minor or is incompetent or incapacitated, a parent or legal representative of the consumer, as applicable, shall be included on the recovery team. DHS 36.16(7)(b)1.1. The recovery team shall participate in the assessment process and in service planning. The role of each team member shall be guided by the nature of team member’s relationship to the consumer and the scope of the team member’s practice. DHS 36.16(7)(b)2.2. Team members shall provide information, evaluate input from various sources, and make collaborative recommendations regarding outcomes, psychosocial rehabilitation services and supportive activities. This partnership shall be built upon the cultural norms of the consumer. DHS 36.16 HistoryHistory: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04. DHS 36.17DHS 36.17 Service planning and delivery processes. 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)(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)(a)(a) The service plan shall include a description of all of the following: 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)(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)(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)1.1. The consumer no longer wants psychosocial rehabilitation services. 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. DHS 36.17(5)(am)(am) When a consumer is discharged from the CCS program, the consumer shall be given written notice of the discharge. The notice shall include all of the following: DHS 36.17(5)(am)3.3. If a consumer is involuntarily discharged from the CCS program and the consumer receives Medical Assistance, the fair hearing procedures prescribed in s. DHS 104.01 (5). For all other consumers, information on how the consumer can submit a written request for a review of the discharge to the department. DHS 36.17 NoteNote: A written request for review of the determination of need for psychosocial rehabilitation services should be addressed to the Bureau of Prevention, Treatment and Recovery, 1 W. Wilson Street, Room 850, P.O. Box 7851, Madison, WI 53707-7851.
DHS 36.17(5)(b)(b) The CCS shall develop a written discharge summary for each consumer discharged from psychosocial rehabilitation services. The discharge summary shall include all of the following: DHS 36.17(5)(b)2.2. The consumer’s status and condition at discharge including the consumer’s progress toward the outcomes specified in the service plan. DHS 36.17(5)(b)3.3. Documentation of the circumstances, as determined by the consumer and recovery team, that would suggest a renewed need for psychosocial rehabilitation services. DHS 36.17(5)(b)4.4. For a planned discharge, the signature of the consumer, the service facilitator, and mental health professional or substance abuse professional. With the consumer’s consent, this summary shall be shared with providers who will be providing subsequent services. DHS 36.17 HistoryHistory: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (5) (am) 3. made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635; CR 23-053: am. (2m) (b) Register September 2023 No. 813, eff. 10-1-23. DHS 36.18(1)(1) Each consumer service record shall be maintained pursuant to the confidentiality requirements under HIPAA, s. 51.30, Stats., ch. DHS 92 and, if applicable, 42 CFR Part 2. Electronic records and electronic signatures shall meet the HIPAA requirements in 45 CFR 164, Subpart C. DHS 36.18(2)(2) The CCS shall maintain in a central location a service record for each consumer. Each record shall include sufficient information to demonstrate that the CCS has an accurate understanding of the consumer, the consumer’s needs, desired outcomes and progress toward goals. Entries shall be legible, dated and signed. DHS 36.18(3)(3) Each consumer record shall be organized in a consistent format and include a legend to explain any symbol or abbreviation used. All of the following information shall be included in the consumer’s record: DHS 36.18(3)(b)(b) Initial and updated service plans, including attendance rosters from service planning sessions. DHS 36.18(3)(d)(d) Any request by the consumer for a change in services or service provider and the response by the CCS to such a request. DHS 36.18(3)(e)(e) Service delivery information, including all of the following: DHS 36.18(3)(e)3.3. Descriptions of significant events that are related to the consumer’s service plan and contribute to an overall understanding of the consumer’s ongoing level and quality of functioning. DHS 36.18(3)(e)4.4. Evidence of the consumer’s progress, including response to services, changes in condition and changes in services provided. DHS 36.18(3)(e)5.5. Observation of changes in activity level or in physical, cognitive or emotional status and details of any related referrals. DHS 36.18(3)(e)7.7. Service provider notes in accordance with standard professional documentation practices. DHS 36.18(3)(e)8.8. Reports of treatment, or other activities from outside resources that may be influential in the CCS’s service planning. DHS 36.18(3)(f)(f) A list of current prescription medication and regularly taken over the counter medications. Documentation of each prescribed medication shall include all of the following: DHS 36.18(3)(f)6.6. Name of the prescriber. The signature of prescriber is also required if the CCS prescribes medication as a service. DHS 36.18(3)(f)7.7. Activities related to the monitoring of medication including monitoring for desired responses and possible adverse drug reactions, as well as an assessment of the consumer’s ability to self-administer medication. DHS 36.18(3)(f)7m.7m. Medications may be administered only by a physician, nurse, a practitioner, a person who has completed training in a drug administration course approved by the department, or by the consumer. DHS 36.18(3)(f)8.8. If a CCS staff member administers medications, each medication administered shall be documented on the consumer’s individual medication administration record (MAR) including, the time the medication was administered and by whom and observation of adverse drug reactions, including a description of the adverse drug reaction, the time of the observation and the date and time the prescriber of the medication was notified. If a medication was missed or refused by the consumer, the record shall explicitly state the time that it was scheduled and the reason it was missed or refused. DHS 36.18(3)(g)(g) Signed consent forms for disclosure of information and for medication administration and treatment. DHS 36.18(3)(h)(h) Legal documents addressing commitment, guardianship, and advance directives. DHS 36.18(3)(j)(j) Any other information that is appropriate for the consumer service record. DHS 36.18 HistoryHistory: CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (1) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.
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