N.J. Admin. Code § 10:37F-2.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:37F-2.3 - Assessment

(a) PA staff shall complete a written comprehensive assessment for each consumer prior to development of the individualized recovery plan. The comprehensive assessment provides the PA and consumer with an initial profile of the strengths and barriers related to community integration, achievement of chosen valued roles, and which issues or problems must be addressed in what priority.

1. The PA's written procedures shall require that every comprehensive assessment include at a minimum, the assessment of the consumer's skill and resource strengths, and barriers to attainment of the consumer's self-expressed goals related to community integration and living, learning, working and social role recovery in the following areas:

i. The consumer's interest in and strengths and goals related to participation in the program;

ii. Social and leisure functioning including, but not limited to, ability to make friendships, communication skills and hobbies;

iii. Emotional and psychological characteristics including, but not limited to, mental status, trauma and abuse history, if applicable, understanding of their own illness, and coping mechanisms;

iv. A review of medical systems including, but not limited to, applicable allergic and adverse medication reactions and screening for current physical, emotional, sexual abuse and/or neglect;

v. Vocational and educational factors including, but not limited to, job history, task concentration and motivation for work;

vi. Activities of daily living including, but not limited to, transportation, budgeting, self care and hygiene;

vii. Living arrangements including, but not limited to, housing, entitlements and subsidies;

viii. Social supports including, but not limited to, family, friends, social and religious organizations;

ix. Substance abuse; and

x. Other important characteristics of the individual such as special skills, talents and abilities.

2. The written comprehensive assessment shall clearly indicate justification for the need for PC services.

3. The written comprehensive assessment shall clearly indicate the consumer's interest or the situational urgency with which a barrier must be addressed in order to prioritize its intervention in the individualized recovery plan.

4. The written comprehensive assessment shall describe both the skills and resources needed to attain the consumer's expressed goals and values roles, including quality of life based upon, but not limited to, consumer interviews, direct observation and information obtained from family members and other collaterals.

5. The written comprehensive assessment shall be completed within one month after acceptance to the program and prior to development of the individualized recovery plan.

6. The written comprehensive assessment shall include a documented psychiatric evaluation completed within two weeks of admission which shall reflect consideration of the following:

i. Diagnosis in conformance with the DSM;

ii. Recommendations for treatment, including treatment modality;

iii. Medical history;

iv. Medication history and present regimen;

v. Mental status;

vi. Presenting psychiatric and non-psychiatric problems;

vii. Substance abuse history;

viii. Relevant legal issues (that is, legal issues with implications for treatment);

ix. Family psychiatric history; and

x. The consumer's expressed interests, preferences, strengths and goal(s) related to valued community roles and quality of life.

7. The PA shall make reasonable efforts to involve the family and significant others in the assessment process to the extent possible.

8. The PA shall continue to conduct functional and resource assessments of those areas, goals and objectives prioritized from the comprehensive assessment and selected for formulation in the individualized recovery plan. These on-going assessments shall be completed prior to the three-month review of the IRP and shall be documented in the clinical record.

N.J. Admin. Code § 10:37F-2.3

Recodified in part from N.J.A.C. 10:37F-2.2 and amended by R.2006 d.389, effective 11/6/2006.
See: 38 N.J.R. 1990(a), 38 N.J.R. 4694(b).
Section was "Assessment and service planning". Rewrote (a); recodified (b) through (d) as N.J.A.C. 10:37F-2.4. Former N.J.A.C. 10:37F-2.3, Services to be provided, recodified to N.J.A.C. 10:37F-2.5.

Amended by 53 N.J.R. 1842(a), effective 11/1/2021