Assessment

(A) The Licensed or Approved Provider shall complete an assessment for each patient and resident that includes the following elements, as well as elements prescribed for each service type in 105 CMR 164.000: (1) Appropriateness of Licensed or Approved Provider's service type in relation to patient's or resident's treatment needs. A history of the use of alcohol, tobacco and other drugs, including age of onset, duration, patterns and consequences of use; history of overdose, including witnessing an overdose; use of alcohol, tobacco and other drugs by family members; and types of and responses to previous treatment. An assessment of the patient's or resident's psychological, social, health, economic, educational/vocational status; co-occurring mental health and/or physical health conditions; trauma history; and history of compulsive behaviors such as gambling. The assessment must be completed before a comprehensive treatment plan is developed for the patient. (4) An assessment of the patient's or resident's HIV risk status. (5) An assessment of the patient's or resident's TB risk status. (6) An assessment of the patient's or resident's cultural and linguistic needs. (B) Patient or resident treatment may begin prior to completing the assessment upon obtaining sufficient information to initiate treatment for the acute problem at the time of presentation and that the assessment is subsequently completed in a reasonable timeframe; provided that a Qualified Healthcare Professional must see such a patient or resident prior to initiating an FDA-approved medication for treatment of addiction. (C) When the assessment indicates a need for further evaluation, the program shall conduct necessary testing, physical examination and/or consultation by qualified professionals, or make appropriate referrals for such testing, physical examination and/or consultation by qualified professionals provided the program continues to provide treatment to the patient or resident in the interim. (D) The assessment shall be reviewed and signed by a Senior Clinician, Clinician, or Practitioner. If conducted by a Clinician, it must be approved in writing by a Senior Clinician or Practitioner. (E) The assessment shall conclude with: (1) a diagnosis of the status and nature of the patient's or resident's substance use disorder, using standardized definitions established by the American Psychiatric Association, or a mental or behavioral disorder due to use of psychoactive substances, as defined by the World Health Organization; and an offer to the patient or resident to initiate medication for treatment of addiction, including any FDA-approved medications for the treatment of addiction.