Chapter DHS 63

DHS 63.12(3)(b)2. 2. Coordinate contracting for specialized assessment and diagnosis or treatment, rehabilitation and support services; and

DHS 63.12(3)(b)3. 3. Integrate other agency or service activities into the CSP treatment plan.

DHS 63.12(4) (4) Monitoring symptom status.

DHS 63.12(4)(a) (a) The case manager shall assess, on a consistent basis, the client’s symptom status. Changes in status shall be documented in the client’s treatment record to measure progress or decompensation.

DHS 63.12(4)(b) (b) The case manager shall keep the CSP program director and clinical coordinator informed of all changes in symptom status by signed notation in the client’s treatment record.

DHS 63.12(4)(c) (c) The case manager shall coordinate the provision of emergency services when a client is in crisis and shall provide documentation in the client’s treatment record of emergency services provided.

DHS 63.12(5) (5) Supportive psychotherapy and education. The case manager shall coordinate the provision of or provide supportive psychotherapy and education in symptom and illness management to the client.

DHS 63.12(6) (6) Advocacy.

DHS 63.12(6)(a) (a) The case manager shall advocate for and help his or her clients obtain needed benefits and services, including general relief, supplemental security income, housing subsidies, food stamps, medical assistance and legal services.

DHS 63.12(6)(b) (b) The case manager shall work with existing community agencies to develop needed CSP resources, including housing, employment options and income assistance.

DHS 63.12(7) (7) Education, support and consultation to clients’ families and other major supports.

DHS 63.12(7)(a) (a) The case manager shall determine what support, consultation and education the client’s family may need from the CSP to manage the symptoms and illness of the client family member.

DHS 63.12(7)(b) (b) The case manager shall coordinate support and consult with the client’s family at time intervals as specified in the client’s treatment plan.

DHS 63.12(7)(c) (c) The case manager shall provide the client’s other support systems with education and information about chronic mental illness and community support program treatment.

DHS 63.12 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.13 DHS 63.13 Client rights. A CSP shall have policies and procedures that ensure that client rights are protected in accordance with s. 51.61, Stats., and ch. DHS 94. The CSP shall require all case managers to assist clients in asserting their rights under s. 51.61, Stats., and ch. DHS 94.

DHS 63.13 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89; corrections made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 63.14 DHS 63.14 Complaints. A CSP shall have procedures for reporting and investigating alleged unethical, illegal or grossly negligent acts affecting clients and violation of written policies and procedures. The procedures shall also address both client and staff reporting of complaints regarding program procedures, staff and services.

DHS 63.14 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.15 DHS 63.15 Client records.

DHS 63.15(1) (1) A CSP shall maintain a treatment record for each client. The record shall include information that is sufficiently detailed to enable a person not familiar with the CSP to identify the types of services the client has received.

DHS 63.15(2) (2) The CSP director is responsible for the maintenance and security of client treatment records.

DHS 63.15(3) (3) Client treatment records shall be maintained in a central location.

DHS 63.15(4) (4) Client treatment records shall be kept confidential and safeguarded as required under s. 51.30, Stats., and ch. DHS 92.

DHS 63.15(5) (5) The treatment recordkeeping format shall provide for consistency within the CSP and shall facilitate information retrieval. Treatment records shall include:

DHS 63.15(5)(a) (a) Results of all examinations, tests and other assessment information;

DHS 63.15(5)(b) (b) Reports from referring sources;

DHS 63.15(5)(c) (c) Treatment and service plans, except for records of hospital emergency services;

DHS 63.15(5)(d) (d) Medication records, which shall document ongoing monitoring of administration of medications and the detection of adverse drug reactions. All medication orders in the client treatment record shall specify the name of the medication, dose, route of administration, frequency of administration, person administering and name of the physician who prescribed the medication;

DHS 63.15(5)(e) (e) Records of referrals of the client to outside resources;

DHS 63.15(5)(f) (f) Reports from outside resources;

DHS 63.15(5)(g) (g) Multidisciplinary case conference and consultation notes;

DHS 63.15(5)(h) (h) Consent for disclosure of information release forms;

DHS 63.15(5)(i) (i) Progress notes which shall document the location where the service was provided; and

DHS 63.15(5)(j) (j) Discharge documentation.

DHS 63.15(6) (6) There shall be a policy governing the disposal of client records.

DHS 63.15(7) (7) There shall be a policy concerning the disposition of client records in the event of the CSP closing.

DHS 63.15 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89; correction in (4) made under s. 13.93 (2m) (b) 7., Stats., Register December 2004 No. 588; correction in (4) made under s. 13.92 (4) (b) 7., Stats., Register November 2008 No. 635.

DHS 63.16 DHS 63.16 Discharge. Documentation by the client’s case manager, clinical coordinator and psychiatrist of a client’s discharge from a CSP shall be entered in the client’s treatment record within one week after termination of treatment or services. Documentation of discharge shall include:

DHS 63.16(1) (1) The reasons for discharge;

DHS 63.16(2) (2) The client’s status and condition at discharge;

DHS 63.16(3) (3) A written final evaluation summary of the client’s progress toward the goals set forth in the treatment plan;

DHS 63.16(4) (4) A plan developed, in conjunction with the client, for care after discharge and for follow-up; and

DHS 63.16(5) (5) The signature of the case manager, clinical coordinator and psychiatrist.

DHS 63.16 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.

DHS 63.17 DHS 63.17 Program evaluation.

DHS 63.17(1) (1) Each CSP shall have an evaluation plan, which shall include:

DHS 63.17(1)(a) (a) A statement of the program’s objectives. The objectives shall relate directly to the program’s clients or target population;

DHS 63.17(1)(b) (b) Measurable criteria to be applied in determining whether or not the objectives under par. (a) are achieved;

DHS 63.17(1)(c) (c) Methods for documenting achievements not related to the program’s stated objectives; and

DHS 63.17(1)(d) (d) Methods for assessing the effective utilization of staff and resources toward the attainment of the objectives.

DHS 63.17(2) (2) In addition to the evaluation plan required under sub. (1), a CSP shall have a system for regular review that is designed to evaluate the appropriateness of admissions to the program, length of stay, treatment or service plans, discharge practices and other factors that may contribute to effective use of the program’s resources.

DHS 63.17(3) (3) An annual report on the program’s progress in meeting its objectives shall be prepared, distributed to interested persons and made available to the department upon request.

DHS 63.17(4) (4) The CSP’s governing body or appropriate authority shall review the annual report.

DHS 63.17 History History: Cr. Register, April, 1989, No. 400, eff. 5-1-89.