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RULE §448.803Assessment

(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. A facility that offers assessments through electronic means shall comply with the following requirements.

  (1) A counselor intern must have more than 2,000 hours of supervised work experience and must have passed the chemical dependency counselor licensing exam prior to conducting an assessment through electronic means.

  (2) An assessment conducted through electronic means shall comply with the requirements under §448.911 of this chapter (relating to Treatment Services Provided by Electronic Means).

  (3) The facility shall conduct an in-person and face-to-face assessment with an individual at the individual's request.

(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.

(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 and/or services 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.

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

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