6314

6315

6316

6317

6318

6319

6320

6321

6322

6324

6325

6326

6327

6328

6329

PROVIDER REQUIREMENT: INTAKE AND ASSESSMENT

6329.1 Intake and Assessment is a not a LOC but a core responsibility of all certified treatment providers. All certified treatment providers, with the exception of those certified at Level R only, shall provide an initial health screening and intake and assessment in accordance with this chapter. The intake and assessment shall include the following:

1. (a) Presenting problem;
2. (b) Substance use history;
3. (c) Immediate risks related to serious intoxication or withdrawal;
4. (d) Immediate risks for self-harm, suicide and violence;
5. (e) Past and present mental disorders, including posttraumatic stress disorder and other anxiety disorders, mood disorders, and eating disorders;
6. (f) Past and present history of violence and trauma, including sexual victimization and interpersonal violence;
7. (g) Legal history, including whether a client is court-ordered to treatment or under the supervision of the Department of Corrections;
8. (h) Employment and housing status;
9. (i) Once assessed, the provider shall refer the client to the appropriate LOC as

outlined by ASAM. The client has a choice about which provider will provide services at that LOC. If the client does not select the provider that conducted the initial assessment as the place to receive services, the provider shall make a referral, seek authorization of services, and arrange transportation to the chosen provider if the client selects same day services. The provider shall have a policy and procedure that clearly outlines an intake process and an emergency intake process, including a procedure to refer individuals who are not clinically appropriate for its program.

6329.2 All treatment providers shall provide the following services:

(a) Initial Assessment (if the client does not remain with assessing provider);

(b) SUD Counseling/Therapy;

(c) Crisis Intervention;

(d) Ongoing or Comprehensive Diagnostic Assessment (if the client remains at assessing provider);

(e) Drug Screening;

(f) CCC; and

(g) RSS.

6329.3 Treatment providers shall ensure appropriate staff is on duty to assess clients for acute withdrawal symptoms and to provide medical triage. Providers shall have proper infrastructure to conduct testing and screening and proper storage for testing kits.

6329.4 Medical triage is the process of determining the priority of a client's treatment needs via the following activities:

(a) Obtaining general medical history including co-occurring medical concerns; assessing medical stability and providing clearance for treatment;

(b) Checking vital signs including blood pressure, blood glucose, temperature, pulse, etc.;

(c) Assessing any urgent or emergent medical concerns and addressing as appropriate including but not limited to calling and engaging 911;

(d) Assessing for withdrawal symptoms/need for detox;

(e) Conducting medication review to ensure that medications match bottle

name and identified medical concern including physical health and psychiatric medications;

1. (f) Screening and assessing for emergent psychiatric concerns; determining current degree of mental health treatment;
2. (g) Urine pregnancy testing for all women of childbearing age and referral for pre-natal care if pregnant and has no provider;
3. (h) Conducting tuberculosis screens;
4. (i) Collecting urine for screening;
5. (j) Using ASAM criteria to make recommendations for medically necessary and clinically appropriate treatment;
6. (k) Collaborating with counselors regarding appropriate level of care; initiating the Treatment Assignment Protocol;
7. (l) Linking all clients that test positive to medical services via a warm transition; and
8. (m) Maintaining an updated list of HIV medical providers in the District.

6329.5 Providers shall screen all clients for RSS.

6329.6 Providers shall obtain client’s informed consent to treatment consistent with District laws and regulations.

SOURCE: Final Rulemaking published at 62 DCR 12056 (September 4, 2015); as amended by Final Rulemaking published at 67 DCR 011585 (October 9, 2020).