Assessment

(A) Licensed or Approved Providers that directly provide services shall complete an assessment for each patient and resident that includes the following elements, as well as applicable elements prescribed for each applicable level or levels of service provided pursuant to 105 CMR 164.100 through 164.400: Part Two: 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 service plan is developed for the patient. (B) Patient or resident treatment may begin prior to completing the assessment, provided that sufficient information to initiate treatment for the presenting complaint or problem on that day of services is obtained and that the assessment is completed in a reasonable timeframe. (C) When the assessments 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 (2) an offer to the patient or resident to initiate any FDA-approved medication for addiction treatment.