Minnesota Administrative Rules

9530.6422 COMPREHENSIVE ASSESSMENT.

Subpart 1.

Comprehensive assessment of substance use disorder.

A comprehensive assessment of the client's substance use disorder must be coordinated by an alcohol and drug counselor and completed within three calendar days after service initiation for a residential program or three sessions of the client's initiation to services for all other programs. The alcohol and drug counselor may rely on current information provided by a referring agency or other sources as a supplement when information is available. Information gathered more than 45 days before the date of admission is not current. If the comprehensive assessment cannot be completed in the time specified, the treatment plan must indicate how and when it will be completed. The assessment must include sufficient information to complete the assessment summary according to subpart 2 and part 9530.6425. The comprehensive assessment must include information about the client's problems that relate to chemical use and personal strengths that support recovery, including:

A.

age, sex, cultural background, sexual orientation, living situation, economic status, and level of education;

B.

circumstances of service initiation;

C.

previous attempts at treatment for chemical use or dependency, compulsive gambling, or mental illness;

D.

chemical use history including amounts and types of chemicals used, frequency and duration of use, periods of abstinence, and circumstances of relapse, if any. For each chemical used within the previous 30 days, the information must include the date and time of the most recent use and any previous experience with withdrawal;

E.

specific problem behaviors exhibited by the client when under the influence of chemicals;

F.

current family status, family history, including history or presence of physical or sexual abuse, level of family support, and chemical use, abuse, or dependency among family members and significant others;

G.

physical concerns or diagnoses, the severity of the concerns, and whether or not the concerns are being addressed by a health care professional;

H.

mental health history and current psychiatric status, including symptoms, disability, current treatment supports, and psychotropic medication needed to maintain stability;

I.

arrests and legal interventions related to chemical use;

J.

ability to function appropriately in work and educational settings;

K.

ability to understand written treatment materials, including rules and client rights;

L.

risk-taking behavior, including behavior that puts the client at risk of exposure to blood borne or sexually transmitted diseases;

M.

social network in relation to expected support for recovery and leisure time activities that have been associated with chemical use;

N.

whether the client is pregnant and if so, the health of the unborn child and current involvement in prenatal care; and

O.

whether the client recognizes problems related to substance use and is willing to follow treatment recommendations.

Subp. 2.

Assessment summary.

An alcohol and drug counselor must prepare an assessment summary within three calendar days for a residential program or within three treatment sessions of service initiation. The narrative summary of the comprehensive assessment results must meet the requirements of items A and B:

A.

An assessment summary must be prepared by an alcohol and drug counselor and include:

(1)

a risk description according to part 9530.6622 for each dimension listed in item B;

(2)

narrative supporting the risk descriptions; and

(3)

a determination of whether the client meets the DSM criteria for a person with a substance use disorder.

B.

Contain information relevant to treatment planning and recorded in the dimensions in subitems (1) to (6):

(1)

Dimension 1, acute intoxication/withdrawal potential. The license holder must consider the client's ability to cope with withdrawal symptoms and current state of intoxication.

(2)

Dimension 2, biomedical conditions and complications. The license holder must consider the degree to which any physical disorder would interfere with treatment for substance abuse, and the client's ability to tolerate any related discomfort. The license holder must determine the impact of continued chemical use on the unborn child if the client is pregnant.

(3)

Dimension 3, emotional, behavioral, and cognitive conditions and complications. The license holder must determine the degree to which any condition or complications are likely to interfere with treatment for substance abuse or with functioning in significant life areas and the likelihood of risk of harm to self or others.

(4)

Dimension 4, readiness for change. The license holder must also consider the amount of support and encouragement necessary to keep the client involved in treatment.

(5)

Dimension 5, relapse, continued use, and continued problem potential. The license holder must consider the degree to which the client recognizes relapse issues and has the skills to prevent relapse of either substance use or mental health problems.

(6)

Dimension 6, recovery environment. The license holder must consider the degree to which key areas of the client's life are supportive of or antagonistic to treatment participation and recovery.

Statutory Authority:

MS s 241.021; 245A.03; 245A.09; 254A.03; 254B.03; 254B.04

History:

29 SR 129; 32 SR 2268

Published Electronically:

October 15, 2013