Service Recipient Assessment Requirements

(1) The facility must document that the following assessments are completed at the time of admission; re-admission assessments must document the following information from the date of last service: (a) Assessment of current functioning by trained staff according to presenting problem including addiction-focused history of the presenting problem; (b) Assessment of any special needs such as co-occurring psychiatric and medical conditions, physical limitations, cognitive impairments, and support system issues; (c) Basic medical history information and determination of the necessity of a medical evaluation and a copy, where applicable, of the results of the medical evaluation, as deemed necessary by the program physician; (d) A physical examination by a physician, physician assistant or nurse practitioner: within twenty-four (24) hours of admission if a facility is providing medically monitored detoxification; or as part of the initial assessment if a facility is providing clinically managed detoxification with the self-administration of detoxification medications; and (e) A history of prescribed medications, frequently used over-the-counter medications, and alcohol or other drugs, including patterns of specific usage for the past thirty (30) days prior to admission. (2) If the facility provides medically monitored detoxification services, then the facility must document that the following additional assessments are completed at the time of admission; MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND CHAPTER 0940-05-44 DRUG ABUSE RESIDENTIAL DETOXIFICATION TREATMENT FACILITIES re-admission assessments must document the following information from the date of last service: (a) An assessment on admission by a licensed nurse; (b) Appropriate laboratory and toxicology tests; and (c) If the medically monitored detoxification services are step-down services from medically managed detoxification in an acute care hospital (ASAM Level IV-D), an evaluation within twenty-four (24) hours of admission by a physician of records of a physical examination within the preceding seven (7) days.