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, to be completed within 24 hours of admission, shall be to obtain whatever relevant information is necessary to develop an individualized patient-centered treatment/recovery plan. The initial evaluation shall comprise a written report of findings and conclusions and shall include the names of any staff or other persons participating in the evaluation.

5. (2) 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 plan. The initial services shall be based on goals the patient identifies for treatment.

   (c) Medical history.

6. (1) For those patients who do not have available a medical history and no physical examination has been performed within 12 months, within 3 days after admission the patient's medical history shall be recorded and placed in the patient's case record and the patient shall receive a physical examination by a physician, physician's assistant, or a nurse practitioner. The physical examination may include but shall not be limited to the investigation of, and if appropriate, screenings for infectious diseases; pulmonary, cardiac or liver abnormalities; and physical and/or mental limitations or disabilities which may require special services or attention during treatment. The physical examination shall also include the following laboratory tests:

   1. (i) complete blood count and differential;
   2. (ii) routine and microscopic urinalysis;
   3. (iii) if medically or clinically indicated, urine screening for drugs;
   4. (iv) intradermal PPD, given and interpreted by the medical staff unless the patient is known to be PPD positive;
   5. (v) or 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.
7. (2) If the patient has a medical history available and has had a physical examination performed within 12 months prior to admission, or if the patient is being admitted directly to the inpatient service 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 Part, provided that such documentation has been reviewed and determined to be current and accurate.

8. (3) 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.

   (d) Referral and connection.

9. (1) If the initial evaluation indicates that the individual needs services beyond the capacity of the inpatient 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 connections and the results of those referrals to identified program(s) shall be documented in the patient record.
10. (2) If a patient is referred directly to the inpatient program from another program certified by the office, or is readmitted to the same program within 60 days of discharge, the existing level of care determination and evaluation or treatment/recovery plan may be used, provided that documentation is maintained demonstrating a review and update.

(a) Post-admission.