(a) A counselor or counselor intern shall conduct and
document a comprehensive psychosocial assessment with the client admitted
to the facility. The assessment shall document and elicit enough information
about the client's past and present status to provide a thorough understanding
of the following areas:
(1) presenting problems resulting in admission;
(2) alcohol and other drug use;
(3) psychiatric and chemical dependency treatment;
(4) medical history and current health status, to include
an assessment of Tuberculosis (TB), HIV and other sexually transmitted
disease (STD) risk behaviors as permitted by law;
(5) relationships with family;
(6) social and leisure activities;
(7) education and vocational training;
(8) employment history;
(9) legal problems;
(10) mental/emotional functioning; and
(11) strengths and weaknesses.
(b) The counselor or counselor intern may conduct the
assessment with a client in-person and face-to-face, or through electronic
means, as that term is defined by §448.911(a)(1) of this chapter
(relating to Treatment Services Provided by Electronic Means). A facility
offering assessments through electronic means shall comply with the
applicable requirements under §448.911 of this chapter and the
following requirements.
(1) Prior to conducting an assessment through electronic
means:
(A) a counselor intern, licensed professional counselor
assistant (LPC-A), or licensed master social worker (LMSW) must have
more than 2,000 hours of supervised work experience or have a supervised
work experience waiver under §140.408(b) of this title (relating
to Requirements for LCDC Licensure); and
(B) if the provider is a counselor intern, the intern
must have passed the chemical dependency counselor licensing exam.
(2) A counselor or counselor intern assessing a client
through electronic means shall use synchronous audiovisual technology,
as that term is defined by §448.911(a)(4) of this chapter, except
as provided under paragraph (3) of this subsection.
(3) To the extent allowed by federal law and only when
all the following criteria are met, the counselor or counselor intern
may assess a client using synchronous audio-only technology, as that
term is defined by §448.911(a)(3) of this chapter, when:
(A) the assessment occurs during a declared state of
disaster under Texas Government Code §418.014 (relating to Declaration
of State of Disaster) in the county in which the facility where the
client signed their consent for treatment form is located;
(B) the counselor or counselor intern determines and
documents a justification for their determination in the client's
record that assessing the client using synchronous audio-only technology
is safe and clinically appropriate for the client being assessed and
the reason why the counselor or counselor intern did not use synchronous
audiovisual technology to screen the individual; and
(C) the client being assessed agrees and provides verbal
consent, as that term is defined by §448.911(a)(5) of this chapter,
to participate in an assessment using synchronous audio-only technology.
(4) The counselor or counselor intern shall conduct
an in-person and face-to-face assessment with a client at the client's
request or if the client does not provide their verbal consent to
participate in an assessment through electronic means, as required
by §448.911(u) of this chapter.
(c) The assessment shall result in a comprehensive
listing of the client's problems, needs, and strengths.
(d) The assessment shall result in a comprehensive
diagnostic impression. The diagnostic impression shall correspond
to current Diagnostic and Statistical Manual of Mental Disorders (DSM)
standards. A licensed intern or other provider shall operate within
the scope of their license when conducting assessments.
(e) If the assessment identifies a potential mental
health problem, the facility shall obtain a mental health assessment
and seek appropriate mental health services when resources for mental
health assessments or services, or both, are available internally
or through referral at no additional cost to the program. These services
shall be provided by a facility or person authorized to provide such
services or a qualified professional as described in §448.901
of this chapter (relating to Requirements Applicable to all Treatment
Services).
(f) The assessment shall be signed by a QCC and filed
in the client record within three individual service days of admission.
(g) The program may accept an evaluation from an outside
source if:
(1) it meets the criteria set forth herein;
(2) it was completed during the 30 days preceding admission
or is received directly from a facility that is transferring the client;
and
(3) a counselor reviews the information with the client
and documents an update.
(h) For residential clients, a licensed health professional
shall conduct a health assessment of the client's physical health
status within 96 hours of admission. The facility may accept a health
assessment from an outside source completed no more than 30 days before
admission or received directly from a transferring facility. If the
client has any physical complaints or indications of medical problems,
the client shall be referred to a physician, physician assistant,
or nurse practitioner for a history and physical examination. The
examination, if needed, shall be completed within a reasonable time
frame and the results filed in the client record.
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Source Note: The provisions of this §448.803 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; amended to be effective February 22, 2024, 49 TexReg 871 |