Person-centered care is demonstrated throughout the screening and / or assessment process.
The program demonstrates efforts to minimize the times between first contact, screening, and admission or referral.
The organization implements policies and written procedures that define:
- If / how screening is conducted.
- Eligibility for services.
- How admissions are:
- Prioritized, if necessary.
- Who is responsible for making admission decisions.
- Exclusionary or ineligibility criteria.
When screening is conducted by the organization, it:
- Is documented.
- Includes a review of each person’s eligibility for admission based on:
- Presenting problem(s).
- Identification and documentation of any urgent or critical needs of the person to be served.
- Legal eligibility criteria, when applicable.
- Availability of funding services.
- Whether the organization can provide the appropriate services needed.
- Alternate resources when services cannot be provided.
- An interview with the person to be served or referral source.
- When appropriate, a pre-admission on-site visit to the organization and its programs by the person to be served / legal guardian.
- Ensures that:
- Screening tools used are uniformly administered.
- Personnel are trained on use of tools prior to administration.
If the screening identifies an urgent and critical need, appropriate action is taken immediately.
If the screening identifies unsafe substance use:
- A brief intervention is conducted either directly, through referral, or as part of the treatment program.
- The individual is referred for a full assessment, if needed.
If a waiting list is maintained, the organization:
- Documents the person’s:
- Date of placement on the list.
- Identified needs.
- Maintains current waiting list information through:
- Ongoing review and updating of the list.
- Implementation of procedures for referral of persons in crisis to necessary care.
- Documents all contact with the persons on the waiting list.
- Responds to long-term waiting lists through:
- Strategic or community-based planning.
- Involvement of support services.
- Referral to available services / community supports.
Each person served receives an orientation that:
- Is provided in a timely manner based on:
- The person’s presenting condition.
- The type of service provided.
- Is understandable to the person served.
- Is documented.
- Includes, as applicable:
- An explanation of:
- The rights and responsibilities of the persons served.
- Complaint and appeal procedures.
- Ways in which input can be given.
- The organization’s:
- Confidentiality policies.
- Intent / consent to treat.
- Behavioral expectations of the persons served.
- Transition criteria and procedures.
- Discharge criteria
- Response to identification of potential risk to the person served
- Access to after-hour services
- Standards of professional conduct related to services
- Requirements for reporting and/or follow-up for the mandated person served, regardless of his or her discharge outcome
- Any and all financial obligations, fees, and financial arrangements for services provided by the organization
- The program’s health and safety policies regarding:
- The use of seclusion or restraint
- Use of tobacco products
- Illegal or legal substances brought into the program
- Prescription medication brought into the program
- Weapons brought into the program
- The program rules and expectations of the person served, which identifies the following:
- Any restrictions the program may place on the person served
- Events, behaviors, or attitudes and their likely consequences
- Means by which the person served may regain rights or privileges that have been restricted
- Familiarization with the premises, including emergency exits and/or shelters, fire suppression equipment, and first aid kits
- Education regarding advance directives, when indicated
- Identification of the purpose and process of the assessment
- A description of:
- How the person-centered plan will be developed
- The person’s participation in goal development and achievement
- The potential course of treatment/services
- How motivational incentives may be used
- Expectations for legally required appointments, sanctions, or court notifications
- Expectations for family involvement
- Identification of the person(s) responsible for service coordination
- An explanation of:
Assessments are conducted by qualified personnel:
- Knowledgeable to assess the specific needs of the persons served
- Trained in the use of applicable tools, tests, or instruments prior to administration
- Able to communicate with the persons served
When assessment results in diagnosis(es), the diagnosis is determined by a practitioner legally qualified to do so in accordance with all applicable laws and regulations.
The assessment process includes information obtained from:
- The person served
- Family members/legal guardian, when applicable and permitted
- Other collateral sources, when applicable and permitted
- External sources, when the needs for specified assessments not able to be provided by the organization is identified
- Focuses on the person’s specific needs
- Identifies the goals and expectations of the person served
- Is responsive to the changing needs of the person served
- Includes screening for suicide risk for all persons served age 12 and older using a standardized tool normed for the population served
- Includes provisions for communicating the results of the assessments to:
- The person served/legal guardian
- Applicable personnel
- Others as appropriate
- Provides the basis for legally required notification when applicable
- Occurs within timeframes established by the organization or external regulatory requirements
- Reflects significant life or status changes of the person served
The assessment process gathers and records sufficient information to develop a comprehensive person-centered plan for each person served, including information about the person’s:
- Presenting issues from the perspective of the person served
- Personal strengths
- Individual needs
- Abilities and/or interests
- Previous behavioral health services, including:
- Diagnostic history
- Treatment history
- Mental status
- Medication, including:
- Medication history and current use profile
- Efficacy of current or previously used medication
- Medication allergies or adverse reactions to medications
- Physical health issues, including:
- Health history
- Current health needs
- Current pregnancy and prenatal care
- Medical conditions
- Use of complementary health approaches
- Co-occurring disabilities and disorders
- Current level of functioning
- Pertinent current and historical life information, including his or her:
- Sexual orientation
- Gender identity
- Spiritual beliefs
- Education history
- Employment history
- Military history
- Living situation
- Legal involvement
- Family history
- Relationships, including families, friends, community members, and other interested parties
- History of trauma:
- That is:
- Sexual assault
- That is:
- Use of alcohol, tobacco, and/or other drugs, including:
- Current use
- Historical use
- Risk factors for:
- Other self-harm or risk-taking behaviors
- Violence toward others
- Literacy level
- Need for assistive technology in the provision of services
- Need for, and availability of, social supports
- Advance directives, when applicable
- Psychological and social adjustment to disabilities and/or disorders
- Resultant diagnosis(es), if identified
The assessment process includes the preparation of a written interpretive summary that:
- Is based on the assessment data
- Identifies any co-occurring disabilities, comorbidities, and/or disorders
- Is used in the development of the person-centered plan