N.J. Admin. Code § 10:161B-9.1 - Provision of nursing services

(a) An outpatient substance *[abuse]* *use disorder* treatment facility shall complete, within three visits of admission, a drug screen, and a comprehensive biopsychosocial assessment of all clients using an assessment instrument which assesses medical status, vocational/employment and support, alcohol, tobacco and other drug use, legal status, family/social status, psychiatric status, as well as behavioral risk factors for HIV and hepatitis. The client shall be placed in a treatment facility, the modality and underlying philosophy of which is consistent with the client's preferences and values and which is also consistent with the client's needs based on criteria defined in the ASAM *[Patient Placement]* Criteria *[2-R]* (see 10:161B-1.3.).
1. All client assessments shall result in a DSM diagnosis for alcohol, tobacco and other substance use, shall include screening for other identified co-occurring disorders, and shall document level of care determination using ASAM *[Patient Placement]* Criteria *[2-R]*.
2. If the biopsychosocial assessment indicates that the client should be referred to another treatment program or level of care, the program shall coordinate the client's referral to another program. If transfer to another program or level of care is indicated, interim services at the client's current level of care shall be provided until the transfer is effected.
(b) In performing a biopsychosocial assessment, the program shall include the following:
1. The client's medical, alcohol, tobacco, and drug history, and interventions;
2. Clients in outpatient detoxification and opioid treatment programs shall receive a physical exam, in accordance with 10:161B-11.6(c);
3. Clients in outpatient, intensive outpatient and partial care facilities shall complete a comprehensive health history and symptom review and be referred as appropriate for primary medical care services including voluntary HIV testing, hepatitis screening, tuberculosis (TB) testing, and mental health services;
i. No client seeking admission with potential symptoms of communicable diseases such as persistent coughing or fever shall be admitted to treatment without medical clearance;
4. The client's history of psychological and/or psychiatric treatment, which shall include previous admissions to psychiatric facilities, history of suicidal/homicidal ideation and attempts, outpatient psychiatric treatment, psychotropic medications; and assessments by a psychiatrist or other licensed mental health clinician for clients diagnosed with co-occurring mental health disorders;
5. The client's family and relationships, including relationships evidencing co-dependency and the client's current living situation;
6. A social assessment including any legal proceedings involving the client;
7. A recreational assessment that includes the client's interests and physical abilities and limitations; and
8. 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 and any handicaps 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 related to substance abuse.

Notes

N.J. Admin. Code § 10:161B-9.1
Amended by 48 N.J.R. 2791(a), effective 12/19/2016

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