Policy Manual



Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

Printer Friendly Version: http://apps.comcareme.org/policymanual/default.aspx?code=3.MEP.19&nonav=yes

Supporting References: COA General Standards G.8.1.02/.03/, G8.2.01/.02/.03/.04/.05, G.8.3.01 Mental Health Regulations AS.1, CS.4, 5 et al, CS.7.B, OP.2, OP3, RS.2, RS.3, RS.4; Rights of Recipients of Mental Health Services Who are Children in Need of Treatment page 37-III.B/E; Program Standards for Tx Foster Care Section III.A/B pages 21, 24; and DBDS Residential Licensing Rule sections E.

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Management Team  2/04  N/A
Related Document Code Related Document Name Type

Procedure:  .

Community Care provides assessments for all persons served at specific junctures from Intake/Admission (as required by program specific licensing), throughout service provision, to discharge. An Initial Assessment is conducted within the first 14 to 30 days of placement (or as required by program specific licensing). A Comprehensive Assessment is conducted annually thereafter, from the date of admission.

1)      Assessments are tailored to unique individual needs and service objectives. In each type of Assessment, Community Care collects only that information as is necessary to provide the requested service, and as is required.

2)      Assessments will include the following information, as required, to provide the requested service:

i)                    Intake Assessment

A)    Identifying information, including name, date of birth, and social security number;

B)     Current residence;

C)    Emergency health needs;

D)    Emergency contacts;

E)     Imminent danger or risk of future harm, as appropriate for the service being provided;

F)     Guardian status; and

G)    Public assistance eligibility, if applicable.

ii)                   Basic Assessment (Initial Assessment)

A)    The elements in the Intake Assessment listed above;

B)     A preliminary evaluation of the request or need for service;

C)    Information about the person's past or current use of services from Community Care or other organizations;

D)    A family violence, abuse, or neglect screening;

E)     The need for a medical examination;

F)     Any dental problems;

G)    Medical care currently being provided;

H)    An alcohol and substance use screening;

I)       Need for on-going health care needs including dental and physical;

J)       Unique ethnic and/or cultural background and the need for any special approaches as a result;

K)    Insurance coverage; and

L)     Other information necessary to provide service.

iii)                 Comprehensive Assessment

A)    The elements listed above in the Intake and Basic Assessments

B)     The person's and/or family's strengths, resources, and existing formal and informal support systems;

C)    Psychiatric issues;

D)    A Mental status exam;

E)     Alcohol and substance abuse assessment;

F)     Assessment of non-substance addictive behaviors;

G)    Educational and vocational information;

H)    Family relationships and the legal status of minor persons served;

I)       Social and physical environments;

J)       Housing status and history;

K)    Legal status;

L)     The client's perception of his or her needs.

M)   Developmental status if the person served is a child, and

N)    Financial status, including eligibility for public assistance.

O)    The family/guardian's input and perception of the client's needs, so long as such input is appropriate and received with the client's permission.

iv)                 Additional Information that may be included in Assessments:

A)    A physical health history and current status including identification of any current used prescription and over the counter medications.

B)     Developmental history.

C)    Physical and environmental barriers that may impede the client and family's ability to obtain services.

D)    Status of vocational, educational, social, living, leisure/recreational and medical domains.

E)     Potential need for crisis intervention services.

F)     Status of the ISP if applicable.

G)    A review of the need for referral to a qualified individual for a nutritional assessment.

H)    A review of the need for referral to a qualified individual for a cognitive functioning assessment.�������

I)       A review of the need for referral to a qualified individual for a neurological assessment.

3)      All assessments, including the Comprehensive Assessment, must be signed by the individual completing the assessment, and the signature must include their title.

4)      The individual conducting the assessment must be a qualified, licensed individual possessing the skills necessary to recognize and assess persons with special needs, and make appropriate referrals for needed services if special needs exist.

5)      All assessments, including the Comprehensive Assessment, must be dated.

6)      All assessments must be placed in the client's case record.

7)      For programs where assessments are not part of the services provided by Community Care, a Basic Assessment will be conducted, as listed above, to ensure that appropriate services are provided to the client.