N.J. Admin. Code § 10:52A-4.9 - Comprehensive written assessment

Current through Register Vol. 54, No. 7, April 4, 2022

(a) The provider shall develop written procedures that require that every beneficiary receive a comprehensive written assessment, which includes, at a minimum, the assessment of the beneficiary's acute symptomatology, skill and resource strengths and barriers to attainment of the beneficiary's self-expressed goals related to community integration and living, learning, working and social role recovery.
(b) Within 14 business days of the admission of a beneficiary to the APH program, and within 30 days of admission of a beneficiary to the PH program, a comprehensive written assessment shall be completed for the purpose of developing an Individualized Recovery Plan. The comprehensive assessment shall include, at a minimum, the following:
1. Acute symptomatology that requires treatment interventions in order to return the beneficiary to a pre-morbid level of functioning;
2. The beneficiary's interest in, and strengths and goals related to, participation in the program;
3. The beneficiary's functioning including, but not limited to, the ability to make friends and communicate;
4. The beneficiary's emotional and psychological characteristics including, but not limited to, mental status, trauma and abuse history, if applicable, understanding of his or her own illness and coping mechanisms;
5. A review of medical history including, but not limited to, applicable allergic and adverse medication reactions and screening for current physical, emotional, sexual abuse or neglect. If abuse or neglect is identified, staff shall refer the matter to the appropriate authorities, as required by law;
6. The beneficiary's expressed interests, preferences, strengths and goal(s) related to community roles and quality of life;
7. Identification of the beneficiary's strengths and barriers to goal attainment;
8. A social (family) history;
9. A nutritional screening to identify potential health complications and a need for nutritional education;
10. An assessment of cultural preferences;
11. An assessment of spiritual preferences;
12. A legal assessment, if applicable, assessing the beneficiary's legal history and any current relevant legal issues relating to the beneficiary;
13. An assessment of educational and vocational issues or needs, if applicable;
14. Community resources needed to help the beneficiary achieve the identified goals and objectives. Staff members shall document alternative services identified and not provided by the psychiatric acute partial hospital program and shall refer the beneficiary to the appropriate service(s);
15. An assessment of the beneficiary's emotional and psychological functioning including, but not limited to, mental status and understanding of his or her own illness, and coping mechanisms;
16. An assessment of activities of daily living including, but not limited to, transportation, budgeting, self-medication and hygiene; and
17. Living arrangements, including housing, entitlements and subsidies.
(c) Assigned staff shall sign, date and maintain all assessment and evaluation documentation in the beneficiary's file.
(d) Assigned staff from the interdisciplinary treatment team shall make reasonable efforts to involve the family and significant others in the assessment process to the extent possible.

Notes

N.J. Admin. Code § 10:52A-4.9

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