West Virginia Code of State Rules
Agency 69 - Health And Human Resources
Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Series 69-11 - Medication-Assisted Treatment - Opioid Treatment Programs
Section 69-11-28 - Physical and Biopsychosocial Assessments

Universal Citation: 69 WV Code of State Rules 69-11-28

Current through Register Vol. XLI, No. 38, September 20, 2024

28.1. The program shall complete a physical and biopsychosocial evaluation, which shall be used to develop the long-term individualized treatment plan of care. The physical and biopsychosocial evaluations shall integrate information obtained in all treatment of the patient at the MAT program.

28.2. The physical and biopsychosocial evaluations shall include information obtained from:

28.2.a. The patient;

28.2.b. Family members, when applicable and permitted;

28.2.c. Friends and peers, when appropriate and permitted; and

28.2.d. Other appropriate and permitted collateral sources.

28.3. The physical assessment shall include information regarding the following:

28.3.a. A physical assessment;

28.3.b. An update to any immediate relevant history, including, but not limited to, the determination of chronic or acute medical conditions such as diabetes, renal disease, hepatitis, sickle cell anemia, tuberculosis, HIV exposure, sexually transmitted disease, chronic cardiopulmonary disease and pregnancy;

28.3.c. A determination of currently prescribed medications or utilized over-the-counter substances;

28.3.d. Medications prescribed that are not a target of treatment or concern;

28.3.e. Medication allergies or adverse reactions to medications;

28.3.f. A determination and evaluation of the patient's use of other substances of abuse and alcohol;

28.3.g. A drug screen;

28.3.h. An inquiry to and report from the Controlled Substances Monitoring Program database;

28.3.i. An inquiry whether the patient is enrolled in any other MAT program; and

28.3.j. Screen for communicable diseases and address them as needed with treatment or referral and evaluate patient's level of physical, psychological and social functioning or impairment.

28.4. The biopsychosocial assessment shall include information about the patient's:

28.4.a. Personal strengths;

28.4.b. Individualized needs;

28.4.c. Abilities or interests;

28.4.d. Presenting problems, including a thorough analysis of the individual's substance use disorders 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 substance use disorder; adverse consequences of use; inappropriate use of prescribed substances; and urgent needs, including suicide risk;

28.4.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;

28.4.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;

28.4.g. Assessment of the individual's access to social supports, family, friends, employment, housing, finances and whether any legal problems exist;

28.4.h. Use of alcohol and tobacco;

28.4.i. Need for, and availability of, social supports;

28.4.j. Risk-taking behaviors;

28.4.k. Level of educational functioning;

28.4.l. Adjustment to disabilities or disorders; and

28.4.m. Motivation for treatment.

28.5. The patient's primary counselor shall review the biopsychosocial assessment and prepare a concise, interpretive multidisciplinary summary that:

28.5.a. Is based on the assessment data;

28.5.b. Describes and evaluates the level and severity of the individual's substance use disorder behaviors;

28.5.c. Is used in the development of the individualized treatment plan of care; and

28.5.d. Identifies any co-occurring disabilities or disorders that should be addressed in the development of the individualized treatment plan of care.

Disclaimer: These regulations may not be the most recent version. West Virginia 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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.