Section 63.10. Assessment and treatment planning.

 

(1)   Assessment.

(a) An initial assessment shall be done at the time of the client's admission to the CSP, and an in-depth assessment shall be completed within one month after a client's admission. The physician shall make a psychiatric assessment of the client's need for CSP care and appropriate professional personal shall make a psychiatric and psychosocial assessment of the client's need for CSP care.

(b) The assessments shall:

1. Be clearly explained to the client or guardian, if any, and, when appropriate, to the client's family;

2. Include available information on the client's family and the client's legal, social, vocational and educational history; and

3. Be incorporated into review and revisions of the client's treatment plan under sub. (2) .

(c) A clinical coordinator shall include a signed statement in the client's treatment record that the assessments under par. (a) were performed by appropriate professional personnel specified under s. DHS 63.06 (4) (a) 1. to 8.

(d) The in-depth assessment shall include evaluation of the client's:

1. Psychiatric symptomatology and mental status, by a psychiatrist and by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) . Utilizing information derived from the evaluation required under this subdivision, a psychiatrist or a clinical psychologist shall make a psychiatric diagnosis;

2. Use of drugs or alcohol, or both, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) ;

3. Vocational and educational functioning, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) ;

4. Social functioning, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) ;

5. Self-care and independent living capacity, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) ;

6. Relationship with his or her family, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) ;

7. Medical health, by a psychiatrist or physician. A registered nurse may collect health-related information and history and perform partial examinations under supervision of a physician;

8. Dental health information and history may be collected by a psychiatrist, a physician or a CSP professional under the supervision of a physician; and

9. Other specified problems and needs, by a CSP professional supervised by the clinical coordinator or a designated staff member meeting qualifications under s. DHS 63.06 (2) (c) .

(e) Evidence that a service is medically necessary shall be indicated through the signature of a psychiatrist on the client's treatment record following the psychiatrist's review and approval of the service.

(2)   Treatment planning.

(a) The case manager assigned to a client under s. DHS 63.12 (1) shall ensure that an initial written treatment plan is developed at the time of the client's admission to the CSP and that a comprehensive treatment plan is developed and written within one month after admission and is reviewed and updated in writing at least once every 6 months.

(b) The treatment plan shall:

1. Be based on the initial assessment required under sub. (1) (a) and, when appropriate, on the in-depth assessment required under sub. (1) (a) and (d) ;

2. Be developed in collaboration with other CSP professional and paraprofessional staff, service provider staff, the client or guardian, if any, and, when feasible, the client's family. The client's participation in the development of treatment or service goals shall be documented;

3. Specify treatment goals along with the treatment, rehabilitation and service actions necessary to accomplish the goals. The goals shall be developed with both short-range and long-range expectations and shall be written in measurable terms;

4. Identify the expected outcomes and the staff or agencies responsible for providing the client's treatment, rehabilitation and support services;

5. Describe criteria for termination of treatment, rehabilitation and support services; and

6. Be reviewed, approved and signed by the CSP's psychiatrist and clinical coordinator and be included in the client's treatment record.

(c) Treatment or provision of services may begin before the treatment plans are completed.

(d) The client's progress and current status in meeting the goals set forth in the plan shall be reviewed by the staff working with the client at regularly scheduled case conferences at least every 6 months and shall be recorded in the client's treatment record as follows:

1. The date and results of the review and any changes in the plan shall be recorded; and

2. The names of participants in the case conference shall be recorded.

(e) The case manager shall discuss the results of the review required under par. (d) with the client or guardian, if any, and, if appropriate, the client's parent and shall record the client's or guardian's acknowledgement of any changes in the plan.

(3)   Place of treatment. Each CSP shall set a goal of providing over 50% of service contacts in the community, in non-office based or non-facility based settings. For a period of 2 years following the effective date of this chapter, a CSP shall submit to the department records of the places where treatment and services are provided to each client. The records shall cover time periods specified by the department.

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