1. (1) As soon as possible after admission, for all patients, all programs must:

   1. (i) offer viral hepatitis testing; testing may be done on site or by referral;
   2. (ii) offer HIV testing; testing may not be conducted without patient written informed consent except in situations specifically authorized by law; testing may be done on site or by referral; individuals on a regimen of pre- or post-exposure prophylaxis, must be permitted to continue the regimen until consultation with the prescribing professional occurs.

2. (2) If clinically indicated, all programs must:

   1. (i) conduct an intradermal skin or blood-based tuberculosis test; testing may be done on site or by referral with results as soon as possible after testing; for patients with a positive test result, refer the patient for further tuberculosis evaluation;
   2. (ii) offer testing for other sexually transmitted diseases; testing may be done on site or by referral;
   3. (iii) provide or recommend any other tests the examining physician or other medical staff member deems to be necessary including, but not limited to, an EKG, a chest X-ray, or a pregnancy test.

3. (3) As soon as possible after testing programs must explain any blood and skin test results to the patient.

   (b) Initial evaluation.

4. (1) The goal of the initial evaluation shall be to obtain information from such sources, including family members where appropriate, as necessary to develop an individualized patient-centered treatment/recovery plan.

5. (2) No later than three days after admission, staff shall complete the initial evaluation which shall include a written report of findings and conclusions and shall include the names of any staff participating in the evaluation and be signed by the qualified health professional responsible for the evaluation.

   (c) Initial services.

   The initial evaluation shall include an identification of initial services needed, and schedules of individuals and group counseling to address the needed services until the development of the treatment/recovery plan. The initial services shall be based on goals the patient identifies for treatment and shall include substance use and any other priority issues identified in the admission assessment and initial evaluation.

   (d) Medical history.

6. (1) For those patients who have not had a physical examination or mental health history taken within one year prior to admission, each such patient must either be assessed face-to-face by a member of the medical staff to ascertain the need for a physical examination or referred for a physical examination. For those patients who have had a physical examination within one year prior to admission, or for those patients being admitted directly to the outpatient program from another chemical dependence service authorized by the office, the existing medical history and physical examination documentation may be used to comply with the requirements of this subdivision, provided such documentation has been reviewed by a medical staff member and determined to be current. Notwithstanding the foregoing, the following shall be offered regardless of a documented history within the previous twelve months: HIV and viral hepatitis testing.

7. (2) Patient records shall include a summary of the results of the physical examination and shall also demonstrate that appropriate medical care is recommended to any patient whose health status indicates the need for such care.

   (e) Referral and connection.

8. (1) If the initial evaluation and medical history indicates that the individual needs services beyond the capacity of the program to provide either alone or in conjunction with another program, referral and connection to appropriate services shall be made. Identification of such referrals and the results of those referrals to identified program(s) shall be documented in the patient record.
9. (2) If a patient is referred directly to the program from another service provider certified by the office, or is readmitted to the same service provider within 60 days of discharge, the existing level of care determination and initial evaluation may be used, provided that documentation is maintained demonstrating a review and update.

(a) Post-admission.