Section DHS 36.16 - Assessment process(1) POLICIES AND PROCEDURES. The CCS shall implement policies and procedures that address the requirements under this section.(2) FACILITATION. All of the following shall occur concerning the assessment: (a) The assessment process and the assessment summary required under sub. (6) shall be completed within 30 days of receipt of an application for services. The assessment process shall be explained to the consumer and, if appropriate, a legal representative or family member.(b) The assessment process shall be facilitated by a service facilitator.(c) Substance use diagnoses shall be established by a substance abuse professional. An assessment of the consumer's substance use, strengths and treatment needs also shall be conducted by a substance abuse professional. (d) The assessment process shall incorporate, to the greatest extent possible, the consumer's unique perspective and own words about how he or she views his or her recovery, experience, challenges, strengths, resources and needs in each of the domains included in the assessment process.(3) ASSESSMENT CRITERIA. The assessment shall be comprehensive and accurate. The assessment shall be conducted within the context of the domains listed in sub. (4), and any other domains identified by the CCS, and shall be consistent with all of the following: (a) Be based upon known facts and recent information and evaluations and include assessment for co-existing mental health disorders, substance-use disorders, physical or mental impairments and medical problems.(b) Be updated as new information becomes available.(c) Address the strengths, needs, recovery goals, priorities, preferences, values and lifestyle of the consumer. (d) Address age and developmental factors that influence appropriate outcomes, goals and methods for addressing them.(e) Identify the cultural and environmental supports as they affect identified goals and desired outcomes and preferred methods for achieving the identified goals.(f) Identify the consumer's recovery goals and understanding of options for treatment, psychosocial rehabilitation services and self-help programs to address those goals.(4) ASSESSMENT DOMAINS. The assessment process shall address all of the following domains of functioning: (c) Social network and family involvement. In this paragraph "family involvement" means the activities of a family member to support a consumer receiving psychosocial rehabilitation services. Except where rights of visitation have been terminated, the family of a minor shall always be included. The family of an adult consumer may be involved only when the adult has given written permission. (d) Community living skills.(h) Finances and benefits.(L) Trauma and significant life stressors.(n) Crisis prevention and management.(p) Any other domain identified by the CCS.(5) ABBREVIATED ASSESSMENT. (a) The assessment in sub. (3) may be abbreviated if the consumer has signed an admission agreement and one of the following circumstances apply:1. The consumer's health or symptoms are such that only limited information can be obtained immediately.2. The consumer chooses not to provide information necessary to complete a comprehensive assessment at the time of application.3. The consumer is immediately interested in receiving only specified services that require limited information.(b) An assessment conducted under this subsection shall meet the requirements under sub. (3) to the extent possible within the context that precluded a comprehensive assessment.(c) The assessment summary required to be completed under sub. (6) shall include the specific reason for abbreviating the assessment. (d) An abbreviated assessment shall be valid for up to 3 months from the date of the application. Upon the expiration date, a comprehensive assessment shall be conducted to continue psychosocial rehabilitation services. If a comprehensive assessment cannot be conducted when the abbreviated assessment expires, the applicant shall be given notice of a determination that the consumer does not need psychosocial rehabilitation services pursuant to the requirements of s. DHS 36.14(3) (b).(6) ASSESSMENT SUMMARY. The assessment shall be documented in an assessment summary that shall be prepared by a member of the recovery team and shall include all of the following: (a) The period of time within which the assessment was conducted. Each meeting date shall be included.(b) The information on which outcomes and service recommendations are based.(c) Desired outcomes and measurable goals desired by the consumer. (d) The names and relationship to the consumer of all individuals who participated in the assessment process.(e) Significant differences of opinion, if any, which are not resolved among members of the recovery team.(f) Signatures of persons present at meetings being summarized.(7) RECOVERY TEAM. (a) The consumer shall be asked to participate in identifying members of the recovery team. (am) The recovery team shall include all of the following:2. A service facilitator.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.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.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.(b)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.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.Wis. Admin. Code Department of Health Services DHS 36.16
CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04.