Section DHS 36.17 - Service planning and delivery processes(1) POLICIES AND PROCEDURES. The CCS shall implement policies and procedures that address the requirements under this section.(2) FACILITATION OF SERVICE PLANNING. (a) A written service plan shall be based upon the assessment and completed within 30 days of the consumer's application for services. The service plan shall include a description of all of the following:(b) The service planning process shall be explained to the consumer and, if appropriate, a legal representative or family member.(c) The service planning process shall be facilitated by the service facilitator in collaboration with the consumer and recovery team.(d) Service planning shall address the needs and recovery goals identified in the assessment.(2m) SERVICE PLAN DOCUMENTATION. (a) The service plan shall include a description of all of the following: 1. The service facilitation activities, that will be provided to the consumer or on the consumer's behalf.2. The psychosocial rehabilitation and treatment services, to be provided to or arranged for the consumer, including the schedules and frequency of services provided.3. The service providers and natural supports who are or will be responsible for providing the consumer's treatment, rehabilitation, or support services and the payment source for each.4. Measurable goals and type and frequency of data collection that will be used to measure progress toward desired outcomes.(b) An attendance roster shall include recovery team members in attendance at each service planning meeting. The roster shall include the date of the meeting and the name of each person attending the meeting. Each original, updated, and partially completed service plan shall be maintained in the consumer's service record as required in s. DHS 36.18.(c) The completed service plan shall be signed by the consumer, a mental health or substance abuse professional and the service facilitator.(d) Documentation of the service plan shall be available to all members of the recovery team.(3) SERVICE PLAN REVIEW. The service plan for each consumer shall be reviewed and updated as the needs of the consumer change or at least every 6 months. A service plan that is based on an abbreviated assessment shall be reviewed and updated upon the expiration of the abbreviated assessment or before that time if the needs of the consumer change. The review shall include an assessment of the progress toward goals and consumer satisfaction with services.(4) SERVICE DELIVERY. (a) Psychosocial rehabilitation and treatment services shall be provided in the most natural and least restrictive manner and most integrated settings practicable consistent with current legal standards, be delivered with reasonable promptness, and build upon the natural supports available in the community.(b) Services shall be provided with sufficient frequency to support achievement of goals identified in the service plan.(c) Documentation of the services shall be included in the service record of the consumer under the requirements in s. DHS 36.18.(5) DISCHARGE. (a) Discharge from the CCS shall be based on the discharge criteria in the service plan of the consumer unless any one of the following applies:1. The consumer no longer wants psychosocial rehabilitation services.2. The whereabouts of the consumer are unknown for at least 3 months despite diligent efforts to locate the consumer.3. The consumer refuses services from the CCS for at least 3 months despite diligent outreach efforts to engage the consumer.4. The consumer enters a long-term care facility for medical reasons and is unlikely to return to community living.5. The consumer is deceased.6. Psychosocial rehabilitation services are no longer needed.(am) When a consumer is discharged from the CCS program, the consumer shall be given written notice of the discharge. The notice shall include all of the following: 1. A copy of the discharge summary developed under par. (b).2. Written procedures on how to re-apply for CCS services.3. If a consumer is involuntarily discharged from the CCS program and the consumer receives Medical Assistance, the fair hearing procedures prescribed in s. DHS 104.01 (5). For all other consumers, information on how the consumer can submit a written request for a review of the discharge to the department. Note: A written request for review of the determination of need for psychosocial rehabilitation services should be addressed to the Bureau of Prevention, Treatment and Recovery, 1 W. Wilson Street, Room 850, P.O. Box 7851, Madison, WI 53707-7851.
(b) The CCS shall develop a written discharge summary for each consumer discharged from psychosocial rehabilitation services. The discharge summary shall include all of the following:1. The reasons for discharge.2. The consumer's status and condition at discharge including the consumer's progress toward the outcomes specified in the service plan.3. Documentation of the circumstances, as determined by the consumer and recovery team, that would suggest a renewed need for psychosocial rehabilitation services.4. For a planned discharge, the signature of the consumer, the service facilitator, and mental health professional or substance abuse professional. With the consumer's consent, this summary shall be shared with providers who will be providing subsequent services.Wis. Admin. Code Department of Health Services DHS 36.17
CR 04-025: cr. Register October 2004 No. 586, eff. 11-1-04; correction in (5) (am) 3. made under s. 13.92(4) (b) 7, Stats., Register November 2008 No. 635.Amended by, CR 23-053: am. (2m) (b) Register September 2023 No. 813, eff. 10/1/2023