Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-19 - RULES AND REGULATIONS FOR DRUG ABUSE TREATMENT AND EDUCATION PROGRAMS
Rule 111-8-19-.13 - Client Referral, Intake, Assessment, and Admission

1. Physical Assessment. At the time of admission, a preliminary physical assessment shall be done, at a minimum, by a Registered Nurse or Licensed Practical Nurse under the supervision of a RN or physician and shall include documentation of vital signs, appropriate screening tests for STD and TB, urine drug screens, a determination of whether the client requires a physical or psychiatric examination by a physician according to established protocols, and laboratory tests as clinically indicated. Laboratory tests required upon admission for clients in each program modality, in addition to those tests required for all modalities, will be determined by the programs and documented in their policy and procedures as to the criteria used to determine and specify which minimum lab tests are to be done for each modality. Other lab tests may be required by the physician as clinically indicated. If an examination by a physician is indicated, arrangements shall be made for such an examination as appropriate. The assessment shall also include circumstances leading to admission, mental status, support system, psychiatric and medical history, risk assessment for HIV, history of use of drugs, including the age of onset, duration, patterns, and consequences of use, family history of drug use, route of administration and previous treatment. If a client has been referred for treatment from another facility, the results of a physical examination and laboratory tests from the other facility may be documented and used to assess physical status, provided that such physical examination was done within six months of admission, and there has been no significant change in the physical status of the client. Further assessments or laboratory tests may be required depending upon the modality of treatment needed or the client's changing condition.

2. Psycho-social assessment. At the time of admission or as soon as clinically appropriate (but no longer than ten working days), a comprehensive psycho-social assessment shall be done and shall document personal and social history, including current relationships, educational status, living arrangements, social habits, employment status, legal status and related areas.

1. Consent. Except as otherwise authorized by law, no person shall be admitted for treatment without written authorization from the client and parent, guardian, or responsible party, if applicable. The following information must be explained by a trained staff person to the client and other consenters, and documented in the client's file.

2. Orientation. The program shall provide orientation to clients admitted for treatment within 24 hours of admission or at such time that the client appears able to hear and respond to requests, but in no event later than 72 hours after admission. Orientation shall be done by a staff person who has been determined to be qualified by education, training, and experience to perform the task. The following information must be explained to the client, and documented in the client's file.