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) An 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 medical assessment to determine the necessity of a medical evaluation; and a copy, where applicable, of the results of the medical evaluation; (d) A physical examination by a physician, physician assistant or nurse practitioner within twenty-four (24) hours of admission; and (e) A history prior to admission 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.