N.J. Admin. Code § 8:111-9.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:111-9.1 - Client assessment

(a) A residential substance use disorders treatment facility shall provide within 72 hours of admission, a comprehensive biopsychosocial assessment of all clients using the Addiction Severity Index or a similar standardized validated assessment instrument that assesses medical status, employment and support, tobacco, drug and alcohol use, legal status, family status/social status, psychiatric status, including diagnosis, as well as behavioral risk factors for HIV and Hepatitis. In order to ensure that the client is placed in the appropriate treatment facility, the client must be assessed for level of care determination based upon the ASAM PPC.

1. All client assessments shall document the result in a DSM diagnosis for alcohol, tobacco and other drug use, screening for other co-occurring disorders and ASAM level of care determination. Such documentation shall be included in the client record.

2. At the time of assessment, all clients must be screened for co-occurring disorders and, as appropriate, provided with or referred for full diagnosis and treatment planning. Such provision to a facility in which treatment staff are appropriately licensed to provide a full diagnosis of or referral for treatment planning shall be documented in the client's file.

3. If the biopsychosocial assessment indicates that the client should be referred to another treatment program or level of care, the facility shall coordinate the client's referral to another program. If transfer to another facility or level of care is indicated, interim services that are responsive at the client's current level of care shall be provided until the transfer is made.

4. If the physical examination and clearance is not conducted prior to admission, the client shall be assessed at admission by a registered professional nurse, licensed physician, or other licensed medical practitioner to ensure that the client does not exhibit potential symptoms of communicable disease, such as persistent coughing, fever, etc. The full physical examination shall be completed within 72 hours of admission, except as otherwise required for clients receiving detoxification services, or if conducted within 30 days pre-admission and waived pursuant to N.J.A.C. 8:111-7.1(b)1.

(b) In performing a bio-psychosocial assessment, the facility shall assess the following:

1. The client's medical, alcohol, tobacco, and drug history, and interventions, if any;

2. The results of the client's physical examination, which shall include a certification by the examining physician that the level of medical care needed by the client is available through the facility and the following laboratory tests and evaluations, subject to client's written consent:

i. Blood work for chronic, incurable and/or communicable diseases or conditions as indicated by the client's medical history and the physician's evaluation;

ii. Serologic tests for syphilis, smears and cultures for gonorrhea and other sexually transmitted diseases, as medically indicated;

iii. Routine urinalysis, including pregnancy testing for females;

iv. Human immunodeficiency virus antibody testing, as medically indicated, for which the facility shall obtain a separate written consent. All clients shall receive HIV pre-test counseling and post-test counseling if the client elects to be tested. If HIV testing is performed onsite, the facility is required to report positive results according to N.J.A.C. 8:57-2 and maintain client confidentiality according to 26:5C-7 et seq.;

v. All pregnant women shall be provided information on HIV and AIDS and offered testing for HIV infection. This information may be provided by the administrator or delegated to another healthcare professional, but such delegation of duties shall not relieve the administrator from the ultimate responsibility to see that this information is provided in accordance with 8:61-3.1;

vi. Hepatitis B and Hepatitis C, as medically indicated; and

vii. A Mantoux tuberculin skin test and tuberculosis screening and treatment in accordance with the Tuberculosis Surveillance Procedures for Substance Abuse Treatment Facilities, incorporated herein by reference as chapter Appendix A;

3. The client's history of psychological problems or psychiatric disorders and treatment received, including previous psychiatric admissions, history of suicidal or homicidal ideation and attempts, outpatient psychiatric treatment and psychotropic medications;

4. The client's family and relationships, including relationships evidencing co-dependency and the client's current living situation;

5. A social assessment including any legal proceedings involving the client;

6. A recreational assessment that includes the client's interests and physical abilities and limitations;

7. A vocational and educational assessment of the client's:

i. Current work or vocational skills, employment status and potential for improving those skills or developing new ones;

ii. Educational status and skills;

iii. Aptitudes, interests and motivation;

iv. Physical abilities, impairments or disabilities;

v. Relationships with co-workers and supervisors; and

vi. Current and prior work or school related problems including, but not limited to, those problems related to substance abuse;

8. Readiness to change;

9. Spiritual assessment; and

10. Assessment of housing needs.

N.J. Admin. Code § 8:111-9.1

Amended and recodified from 10:161A-9.1 53 N.J.R. 2208(a), effective 12/20/2021