Current through Register Vol. XLI, No. 38, September 20, 2024
33.1. Within thirty days after admission, or
when the patient is stable and able to fully participate, the program shall
complete a full bio-psychosocial evaluation which shall be used to develop the
long-term plan of care. The bio-psychosocial evaluation shall integrate
information obtained in the comprehensive medical evaluation.
33.2. The bio-psychosocial evaluation shall
include information obtained from:
33.2.a.
The patient;
33.2.b. Family
members, when applicable or permitted;
33.2.c. Friends and peers, when appropriate
and permitted; and
33.2.d. Other
appropriate and permitted collateral sources.
33.3. The bio-psychosocial evaluation shall
include information about the person's:
33.3.a. Personal strengths;
33.3.b. Individualized needs;
33.3.c. Abilities and/or interests;
33.3.d. Presenting problems, including a
thorough analysis of the individual's addictive behaviors such as, licit and
illicit drugs used, including alcohol; amounts of drugs or alcohol used;
frequency of use; duration of use; symptoms of physical addiction; history of
treatment for addictive behaviors; adverse consequences of use; inappropriate
use of prescribed substances; and urgent needs, including suicide
risk;
33.3.e. Previous behavioral
health services, including diagnostic information; treatment information;
efficacy of current or previously used medication; physical health history and
current status; diagnoses; mental status and current level of
functioning;
33.3.f. Pertinent
current and historical life situation information, including the patient's age;
gender; employment history; involvement in legal proceedings; family history;
history of abuse or neglect; and relationships, including natural
supports;
33.3.g. Use of alcohol
and tobacco;
33.3.h. Need for, and
availability of, social supports;
33.3.i. Risk-taking behaviors;
33.3.j. Level of educational
functioning;
33.3.k. Medications
prescribed that are not a target of treatment or concern;
33.3.l. Medication allergies or adverse
reactions to medications;
33.3.m.
Adjustment to disabilities/disorders; and
33.3.n. Motivation for treatment.
33.4. The patient's counselor
shall review the bio-psychosocial assessment and prepare a concise,
interpretive multidisciplinary summary that:
33.4.a. Is based on the assessment
data;
33.4.b. Describes and
evaluates the level and severity of the individual's addictive
behaviors;
33.4.c. Is used in the
development of the individualized treatment plan of care; and
33.4.d. Identifies any co-occurring
disabilities or disorders that should be addressed in the development of the
individualized treatment plan of care.
