Current through Register Vol. 56, No. 18, September 16, 2024
(a)
When documenting that a consumer is eligible for community support services,
the Division, its designee, or a referring entity, in consultation with the PA
and the consumer where feasible, shall develop a preliminary rehabilitation
needs assessment for that consumer, which may include information from any
prior service provider, any records of prior treatment accessible to the
Division or the PA, and records that identify community support needs
documented by a hospital, screening service, health care provider, or a
licensed PA.
(b) The PA shall
complete a written comprehensive rehabilitation needs assessment for each
consumer by the 14th day of admission, every six months for the first year
after the initial assessment, and annually thereafter.
(c) The development of the written
comprehensive rehabilitation needs assessment shall be a consumer-driven
process, informed by a face-to-face evaluation and discussion with the
consumer.
1. Family members, significant
others, and other collateral service providers, at the request of the consumer,
may participate and/or otherwise provide information, providing that their
involvement is within the bounds of the confidentiality provisions of
N.J.A.C. 10:37-6.79
.
(d) The
written comprehensive rehabilitation needs assessment shall include:
1. Identifying information (name, gender,
date of birth, religion, race, and Social Security number), referral date, and
source;
2. Psychiatric history,
current mental status, and diagnosis or diagnoses (any secondary source of a
consumer's psychiatric diagnosis shall be noted in the assessment);
3. Current health status and medical
history;
4. Medication history,
including current medication/dose/frequency and name of prescribing
physician(s);
5. Current and prior
involvement with other agencies/mental health and health care
services;
6. Legal information
relevant to treatment;
7. The name
and phone number of an emergency contact person and notation as to the
existence of an advance directive for mental health care or living will. If an
advance directive for mental health care or living will exists, a copy shall be
included in the consumer's record;
8. The valued life role the consumer wants to
achieve, as well as the consumer's aspirations, strengths, and goals related to
that valued life role, improving his or her life and achieving wellness and
pursuing recovery;
9. Precursors or
contributing factors to recent crises or increased distress and ways the
consumer has deescalated crises, such as relying on supports or accessing
mental health or health care services;
10. Social and leisure functioning,
including, but not limited to, ability to make friendships, communication
skills, and hobbies;
11. Social
supports, including, but not limited to, family, friends, social, and religious
organizations;
12. Trauma and abuse
history or lack thereof;
13. The
consumer's understanding of his or her mental health and health condition(s)
and coping mechanisms;
14.
Vocational and educational factors, including, but not limited to, employment
and education history, learning disabilities/needs, task concentration,
potential for self-employment, and motivation for work;
15. Activities of daily living, including,
but not limited to, self-preservation skills, fire safety (including fire
prevention during activities such as cooking and smoking) and evacuation
skills, transportation, self-care, and hygiene;
16. Previous, current, and desired living
arrangements;
17. Financial status;
current entitlements; amount, type, and date of eligibility for subsidies;
skills in and knowledge of budgeting, including any history of managing
entitlements and paying rent;
18.
Substance use, including any substances used currently and in the past,
triggers for use of each substance, efforts made to stop or reduce using,
consequences of use (including violent behavior, health issues, problems with
relationships and finances, and law enforcement/courts/incarceration events),
substance abuse services received in the past and currently, the effectiveness
of those services, community supports used to stop or reduce using, the
effectiveness of those supports, and activities engaged in to avoid
using;
19. Other important
characteristics of the individual, such as special skills, talents and
abilities;
20. Characteristics and
behaviors resulting in barriers to successful community integration;
21. Recommendations regarding rehabilitation
services to be provided; and
22.
Recommendations regarding housing arrangements.
