N.J. Admin. Code § 10:37A-4.3 - Comprehensive rehabilitation needs assessment

(a) The PA shall complete a written comprehensive rehabilitation needs assessment for each consumer by the 14th day after admission.

1. The purpose of the comprehensive rehabilitation needs assessment is to provide a basis for the individualized rehabilitation plan by gathering all information required to determine the need for, scope of, and anticipated outcome of behavioral health and rehabilitation services, including, but not limited to, individual strengths, preferences, needs, abilities, psychiatric symptoms, medical history, and functional limitations.

2. The development of the written comprehensive rehabilitation needs assessment shall be a consumer-driven process, informed by a face-to-face evaluation and discussion with the consumer.

3. Family members, significant others, and other collateral service providers may participate and/or otherwise provide information, providing that their involvement is within the bounds of the confidentiality provisions of the policy and procedures manual and in conformance with State and Federal law.

4. The written comprehensive rehabilitation needs assessment shall include:

i. Identifying information (name, gender, date of birth, religion, race, and Social Security number), referral date, and source;

ii. Psychiatric history, current mental status, and multi-axial diagnosis, if such diagnosis can be obtained;

(1) Where a consumer's psychiatric diagnosis is obtained from a secondary source, the PA staff shall cite that source;

iii. Medication history, including current medication, dose, frequency, and name of prescribing physician;

iv. Current and prior involvement with other agencies/mental health services;

v. Legal information relevant to treatment;

vi. The name and phone number of an emergency contact person, and notation as to the existence of an advance directive for mental health care or living will. If an advance directive for mental health care or living will exists, a copy shall be included in the consumer's record;

vii. The consumer's aspirations, strengths, and goals related to improving his or her life, achieving valued life roles, and achieving wellness and recovery;

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

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

x. Trauma and abuse history or lack thereof;

xi. Understanding of his or her illness(es) and coping mechanisms;

xii. Vocational and educational factors including, but not limited to, job and education history, learning disabilities/needs, task concentration, and motivation for work;

xiii. Activities of daily living including, but not limited to, self- preservation skills, fire safety (including fire prevention during activities such as cooking and smoking; and evacuation skills), transportation, self-care, and hygiene;

xiv. Previous living arrangements;

xv. Financial status and skills including budgeting, entitlements, and subsidies;

xvi. Substance abuse, including the substances used currently and in the past, triggers for use of each substance, efforts made to stop or reduce using, consequences of use (including violent behavior, health problems, and problems with relationships, finances, and law enforcement/courts/incarceration), substance abuse services received in the past and currently, the effectiveness of those services, community supports used to stop or reduce using, the effectiveness of those supports, and activities engaged in to avoid using;

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

xviii. Characteristics and behaviors resulting in barriers to successful community integration; and

xix. Recommendations regarding rehabilitation, medical, and residential services to be provided.

Notes

N.J. Admin. Code § 10:37A-4.3

Adopted by 48 N.J.R. 1636(a), effective 8/15/2016