| (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 |
