Section DHS 35.19 - Treatment plan(1) DEVELOPMENT OF THE TREATMENT PLAN. (a) A licensed treatment professional, mental health practitioner, or recognized psychotherapy practitioner, shall develop an initial treatment plan upon completion of the comprehensive assessment required under s. DHS 35.17(1) (b). The treatment plan shall be based upon the diagnosis and symptoms of the consumer and describe all of the following: 1. The consumer's strengths and how they will be used to develop the methods and expected measurable outcomes that will be accomplished.2. The method to reduce or eliminate the symptoms causing the consumer's problems or inability to function in day to day living, and to increase the consumer's ability to function as independently as possible.3. For a child or adolescent, a consideration of the child's or adolescent's development needs as well as the demands of the illness.4. The schedules, frequency, and nature of services recommended to support the achievement of the consumer's recovery goals, irrespective of the availability of services and funding. Note: Nothing in this chapter is intended to interfere with the right of providers under s. 51.61(6), Stats., to use customary and usual treatment techniques and procedures in a reasonable and appropriate manner in the treatment of patients who are receiving services under the mental health system, for the purpose of ameliorating the conditions for which the patients were admitted to the system.
(b) The treatment plan shall reflect the current needs and goals of the consumer as indicated by progress notes and by reviewing and updating the assessment as necessary.(2) APPROVAL OF THE TREATMENT PLAN. As treatment services are rendered, the consumer or the consumer's legal representative must approve and sign the treatment plan and agree with staff on a course of treatment. If the consumer does not approve of the schedules, frequency, and nature of the services recommended, then appropriate notations regarding the consumer's refusal shall be made in the consumer file. The treatment plan under this subsection shall include a written statement immediately preceding the consumer's or legal representative's signature that the consumer or legal representative had an opportunity to be informed of the services in the treatment plan, and to participate in the planning of treatment or care, as required by s. 51.61(1) (fm), Stats.(3) CLINICAL REVIEW OF THE TREATMENT PLAN. (a) Staff shall establish a process for a clinical review of the consumer's treatment plan and progress toward measurable outcomes. The review shall include the participation of the consumer and be an ongoing process. The results of each clinical review shall be clearly documented in the consumer file. Documentation shall address all of the following: 1. The degree to which the goals of treatment have been met.2. Any significant changes suggested or required in the treatment plan.3. Whether any additional assessment or evaluation is recommended as a result of information received or observations made during the course of treatment.4. The consumer's assessment of functional improvement toward meeting treatment goals and suggestions for modification.(b) A mental health professional shall conduct a clinical review of the treatment plan with the consumer as described in par. (a) at least every 90 days or 6 treatment sessions, whichever covers a longer period of time. (4) The clinic shall develop and implement written policies and procedures for referring consumers to other community service providers for services that the clinic does not or is unable to provide to meet the consumer's needs as identified in the comprehensive assessment required under s. DHS 35.17(1) (b). The policies shall identify community services providers to which the clinic reasonably determines it will be able to refer consumers for services the clinic does not or cannot provide.Wis. Admin. Code Department of Health Services § DHS 35.19
CR 06-080: cr. Register May 2009 No. 641, eff. 6-1-09.