Service Recipient Assessment Requirements

(1) The facility must document that the following assessments are completed prior to development of the Individual Program Plan (IPP); re-admission assessments must document the following information from the date of last service: (a) Assessment of current functioning according to presenting problem, including history of the presenting problem; (b) Basic medical history, a determination of the necessity of a medical evaluation, and a copy, where applicable, of the results of the medical evaluation if deemed necessary by the program physician; (c) Screening to identify service recipients who are at high risk for infection with TB according to TB Guidelines, including documentation of the service recipient’s risk level and, if applicable, a tuberculin skin test or equivalent, the results of the tuberculin skin test, the date and result of a chest x-ray, and any drug treatment for TB; (d) Assessment information, including employment and educational skills; financial status; emotional and psychological health; community living skills and housing needs; and the impact of alcohol and/or drug abuse or dependency on each area of the service recipient’s life functioning; and (e) A six (6) month 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.