Community Services Programs
Mental Health Agency Licensing Standards; Inpatient Service Standards - Assessment
A comprehensive assessment is conducted by an individual chosen or agreed to by client, with the client's participation, within 10 working days of the client's admission.
The comprehensive assessment minimally addresses the following:
- IN.2.A.1 the client's strengths and weaknesses;
- IN.2.A.2 the client's perception of his or her needs;
- IN.2.A.3 the family/guardian's input and perception of the client's needs when appropriate, and with the client's consent;
- IN.2.A.4 a personal, family, and social history;
- IN.2.A.5 emotional and psychological strengths and needs;
- IN.2.A.6 a psychiatric status and history, including, subject to the client's consent, records of previous psychiatric hospitalizations and services received by the client in the community, including crisis services;
- IN.2.A.7 a physical health status and history, including current prescription and over-the-counter medication use;
- IN.2.A.8 past and current drug/alcohol use;
- IN.2.A.9 a developmental history;
- IN.2.A.10 possible sources of assistance and support in meeting the needs expressed by the client or legally responsible party, including state and federal entitlement programs;
- IN.2.A.11 physical and environmental barriers that may impede the client and family's ability to obtain services;
- IN.2.A.12 history of physical and/or sexual abuse;
- IN.2.A.13 the vocational, educational, social, living, leisure/recreation and medical domains;
- IN.2.A.14 the signature of the person who performed the assessment.
Interpretive Guideline for IN.2.A.1 thru IN.2.A.14
The Division of Licensing recognizes that in some cases not all of the information requested in these standards will be able to be obtained. The Division also recognizes that the level of detail required will vary given a variety of factors (the client's level of cooperation, the integrity of information sources, the length of services or treatment, the condition being addressed, the practitioner's training, etc.). Although the Division will attempt to be sensitive to these factors and flexible in surveying this area, the agency should assure that assessments that do not address all these standards have accompanying documentation that justifies abbreviated or absent information.
The agency will establish policies and procedures establishing criteria for the performance of the following assessments:
a nutritional assessment;
a cognitive functioning assessment:
- Interpretive Guideline for IN.2.B.2
The client's cognitive functioning assessment should include assessment of the following functions: problem solving, decision making, organization, self-direction, system negotiation skills, concentration, and abstract reasoning. For individuals over 60 years of age, this assessment should also include memory, language, orientation, and visuo-spatial abilities.
an assessment of the client's capacity to make reasoned decisions;
a neurological assessment.
- Interpretive Guideline for IN.2.B thru IN.2.B.4
These assessments do not necessarily have to be performed in the agency or by agency staff. The intent of these standards are to assure that the agency has mechanisms by which to evaluate the need for these assessments and to perform or refer for assessment those clients whose symptomatology suggests the need for these assessments.
IN.2.C The assessment(s) shall be obtained from the client, legally responsible party, community service agencies, and to the extent possible, from other individuals in the community as authorized by the client or legally responsible party.
IN.2.C.1. In instances in which the client receives community support services and/or has an Individualized Support Plan, the agency will, subject to the client's consent, attempt to coordinate the assessment and subsequent treatment planning with the community support provider.
- IN.2.C.1.a. Services provided to these clients will be consistent with the targets and objectives of the Individualized Support Plan.
IN.2.D The client record contains a summary evaluation of the data collected in the comprehensive assessment.
IN.3 The agency has a documented policy and procedure on updating assessments that assures that assessments are current and in no case exceed annual updates.