(10)First priority for services.
(a) A service shall prioritize admission in the following order:
1. First, pregnant women who inject drugs.
2. Second, pregnant women that use drugs or alcohol.
3. Third, persons who inject drugs.
4. All others.
(b) When a waitlist exists for services for pregnant women, the service shall either initiate interim services or notify the department within 2 business days.
(c) When a waitlist exists for services for individuals who inject drugs, the service shall either initiate interim services or notify the department within 14 business days.
(11)Clinical assessment.
(a) Clinical staff of a service, operating within the scope of their knowledge and practice, shall assess each patient through interviews, information obtained during intake, counselor observation, and collateral information.
(b) The service shall promote assessments that are trauma-informed.
(c) If a comprehensive clinical assessment has been conducted by a referring substance use treatment service and is less than 90 days old, the assessment may be utilized in lieu of conducting another one.
(d) Information for the assessment shall include the following:
1. The clinical staff’s evaluation of the patient, and documentation of psychological, social, and physiological signs and symptoms of substance use and/or mental health disorders, based on criteria in the DSM.
2. The summarized results of all psychometric, cognitive, vocational, and physical examinations provided as part of the assessment.
3. History of substance use that includes all of the following:
a. Substances used.
b. Duration of use for each substance.
c. Frequency and amount of use.
d. Method of administration.
e. Status of use immediately prior to entering into treatment.
f. Consequences and effects of use.
g. Withdrawal and overdose history.
4. Documentation about the current mental and physical health status of the patient.
5. Psychosocial history information shall include all of the following areas that relate to the patient’s presenting problem:
b. Significant relationships.
g. Employment.
h. Treatment history.
i. Other factors that appear to have a relationship to the patient’s substance use and physical and mental health.
6. The clinical assessment shall include any collateral information gathered during the clinical assessment. Collateral information may include one of more of the following:
a. Review of Wisconsin Prescription Drug Monitoring Program database.
b. Records of the patient’s legal history.
c. Information from referral sources.
d. Consultation with the patient’s physician or other medical or behavioral health provider.
e. Consultation with department of corrections or child protective services when applicable.
f. Information from the patient’s family or significant others.
g. Results of toxicology testing.
7. Level of care recommendation based on ASAM or other department-approved placement criteria.
(e) If no collateral information is obtained to inform the assessment, the service shall document the reason for not including collateral information.
(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.
(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.
(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.
(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.
(j) In the event that the assessed level of care is not available, a service shall:
1. Document accurately the level of care indicated by the clinical assessment.
2. Indicate on the treatment plan what alternative level of care is available or agreed upon.
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.
(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.
(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.
(12)Referral.
(a) A service shall have written policies and procedures for referring patients to other service providers and for coordinating care with other providers.
(b) Policies and procedures shall include a description of follow-up activities to be completed to support that recommended care is received.
(c) Follow-up shall occur within one week of the referral.
(13)Treatment plan.
(a) Clinical staff of a service shall develop a treatment plan for each patient.
(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.
(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.
(d) The treatment plan shall be signed by the patient, the primary counselor, and other behavioral health clinical staff, identified in the treatment plan.
(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.
(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.
(g) The treatment plan shall specify each intervention applied to reach the treatment goals.
(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.
(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.
(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.
(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.
(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.
(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.
(14)Clinical consultation.
(a) A service shall have a written policy and procedure that outlines the structure for clinical consultation.
(b) Clinical consultation applies to all clinical staff of a service.
(c) Clinical consultation shall be documented in the patient’s case record.
(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.
(e) Clinical consultation is required for any of the following:
1. When a patient’s substance use or mental health poses a significant risk to the individual, their family, or the community.
2. When a safety plan has been developed, per s. DHS 75.24 (4).
3. When an individual’s symptoms, pattern of substance use, risk level, or placement criteria indicate transfer to a higher level of care.
(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.
(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.
(15)Clinical staffing.
(a) A service shall have a written policy and procedure that outlines the structure for clinical staffing.
(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.
(c) For clinical staffing required under ss. DHS 75.49 to 75.59, the following shall apply:
1. Clinical staffing shall include the clinical supervisor of the service.
2. Clinical staffing shall include a patient’s prescriber or medical personnel, if applicable.
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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.