South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-103 - Residential Treatment Facilities for Children and Adolescents
Sec2 61-103.700 - RESIDENT RECORDS
Section 61-103.700.703 - Comprehensive Assessment
Universal Citation: SC Code Regs 61-103.700.703
Current through Register Vol. 48, No. 9, September 27, 2024
A. The facility shall describe the treatment modalities it provides, including content, methods, equipment, and personnel involved. Each treatment program shall conform to the stated purpose and objectives of the agency. (II)
B. Assessment. The facility is responsible for a comprehensive assessment of the resident by reliable professionals acceptable to the facility's staff. The complete assessment shall be signed and dated by all participants and shall include, but is not limited to, the following:
1. Psychiatric. The
assessment includes direct evaluation and behavioral appraisal, evaluation of
sensory, motor functioning, a mental status examination appropriate to the age
of the resident and a psychodynamic appraisal. A history of any previous
treatment for mental, emotional, or behavioral disturbances shall be obtained,
including the nature, duration, and results of the treatment, and the reason
for termination.
2. Psychological.
The psychological assessment includes appropriate testing.
3. Developmental and Social.
a. The developmental assessment of the
resident includes the prenatal period and from birth until present, the rate of
progress, developmental milestones, developmental problems, and past
experiences that may have affected the development. The assessment shall
include an evaluation of the resident's strengths as well as problems.
Consideration shall be given to the healthy developmental aspects of the
resident, as well as to the pathological aspects, and the effects that each has
on the other. There shall be an assessment of the resident's current
age-appropriate developmental needs, which shall include a detailed appraisal
of his peer and group relationships and activities.
b. The social assessment includes evaluation
of the resident's relationships within the structure of the family and with the
community at large, and evaluation of the characteristics of the social, peer
group, and institutional settings from which the resident comes. Consideration
shall be given to the resident's family circumstances, including the
constellation of the family group, their current living situation, and all
social, religious, ethnic, cultural, financial, emotional, and health factors.
Other factors that shall be considered are past events and current problems
that have affected the resident and family; potentialities of the family
members meeting the resident's needs; and their accessibility to help in the
treatment and rehabilitation of the resident. The expectations of the family
regarding the resident's treatment, the degree to which they expect to be
involved, and their expectations as to the length of time and type of treatment
required shall be assessed.
4. Nursing. The nursing screening includes,
but is not limited to, the evaluation of:
a.
Self-care capabilities including bathing, sleeping, and eating;
b. Hygienic practices, such as routine dental
and physical care and establishment of healthy toilet habits;
c. Nutritional habits including a balanced
diet and appropriate fluid and caloric intake;
d. Responses to physical diseases, such as
acceptance by the resident of a chronic illness as manifested by his compliance
with prescribed treatment;
e.
Responses to physical disabilities, such as the use of prosthesis or coping
patterns used by the visually impaired; and
f. Responses to medications, such as
allergies or dependence.
5. Educational and/or Vocational. Residents
shall be evaluated using appropriate educational and vocational
assessments.
6. Recreational. The
resident's work and play experiences, activities, interests, and skills shall
be evaluated in relation to planning appropriate recreational
activities.
Disclaimer: These regulations may not be the most recent version. South Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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