1. (1) The goal of the comprehensive evaluation shall be to obtain that information necessary to develop an individual treatment plan.
2. (2) The comprehensive evaluation shall obtain that information necessary to determine whether a diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or another office-approved protocol is indicated.
3. (3) Each comprehensive evaluation shall be based, in part, on clinical interviews with the resident, and may also include interviews with significant others, if possible and appropriate.

4. (4) No later than 14 days after admission, staff shall complete the resident's comprehensive evaluation which shall include a written report of findings and conclusions addressing, at a minimum, the resident's:

   1. (i) chemical use, abuse and dependence history;
   2. (ii) history of previous attempts to abstain from chemicals and previous treatment experiences;

   3. (iii) comprehensive psychosocial history, including, but not limited to, the following:

      1. (a) legal involvements;
      2. (b) HIV and AIDS, tuberculosis, hepatitis or other communicable disease risk assessment;
      3. (c) relationships with, history of the use of chemicals by, and the impact of the use of chemicals on, significant others;
      4. (d) an assessment of the resident's individual, social and educational strengths and weaknesses, including, but not limited to, the resident's literacy level, daily living skills and use of leisure time;
      5. (e) the resident's medical history, mental health history, current status, and the resident's lethality (danger to himself/herself or to others) assessment; and
      6. (f) a specific diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or another office-approved protocol.

5. (5) The comprehensive evaluation shall bear the names of the staff members who participated in evaluating the individual and must be signed by the qualified health professional responsible for the evaluation.

   (b) Medical history.

6. (1) For those residents who do not have available a medical history and no physical examination has been performed within 12 months, within 45 days after admission the resident's medical history shall be recorded and placed in the resident's case record and the resident 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 resident 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 resident is being admitted directly to the residential 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) Resident records shall include a summary of the results of the physical examination and shall also demonstrate that appropriate medical care is recommended to any resident whose health status indicates the need for such care.

9. (c) After the comprehensive evaluation is completed, a resident shall be retained in such treatment only if the resident:

   1. (1) has a diagnosis of alcohol related or psychoactive substance related use disorder in accordance with the International Classification of Diseases, Ninth Revision or another office-approved protocol;
   2. (2) continues to meet the admission criteria in this Part;
   3. (3) is free of serious communicable diseases that can be transmitted through ordinary contact with other residents;
   4. (4) has no medical or surgical condition or mental disability requiring acute care in a general or psychiatric hospital;
   5. (5) is not in need of medically managed detoxification; and
   6. (6) can benefit from continued treatment in a residential service.
10. (d) If the comprehensive evaluation indicates that the individual needs services beyond the capacity of the residential service to provide either alone or in conjunction with another program, referral 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 resident record.
11. (e) If a resident is referred directly to the residential service from another service certified by the office, or is readmitted to the same service within 60 days of discharge, the existing level of care determination and comprehensive evaluation may be used, provided that documentation is maintained demonstrating a review and update.
12. (f) An initial treatment/service plan addressing the resident's individual needs must be developed within three days of admission, or readmission, to the chemical dependence residential service and shall be prepared in consultation with the resident, as documented by the resident's signature on the treatment/service plan. This initial treatment/service plan must contain a statement which documents that the individual is appropriate for this level of care, identifies the assignment of a named clinical staff member with the responsibility to provide orientation to the individual, and includes a preliminary schedule of activities, therapies and interventions.
13. (g) A comprehensive treatment/service plan (treatment/service plan), based on the admitting evaluation, shall be prepared within 30 days of development of the initial treatment/service plan to meet the identified needs of the resident, and shall take into account cultural and social factors as well as the particular characteristics, conditions and circumstances of each resident. For individuals moving directly from one chemical dependence service to another, an updated treatment/service plan shall be acceptable if it is in conformance with the requirements of this section.

14. (h) The treatment/service plan shall:

    1. (1) be developed in collaboration with the resident as evidenced by the resident's signature thereon;
    2. (2) be based on the admitting evaluations specified above and any additional evaluation(s) determined to be required;
    3. (3) specify goals for each problem identified;
    4. (4) specify the objectives to be achieved while the resident is receiving services which shall be used to measure progress toward attainment of goals;
    5. (5) include schedules for the provision of all services prescribed;
    6. (6) identify the single member of the clinical staff responsible for coordinating and managing the resident's care (the responsible clinical staff member);
    7. (7) include the diagnosis for which the resident is being treated; and
    8. (8) be signed by the responsible clinical staff member and approved and signed by the clinical staff member's supervisor or another supervising qualified health professional within seven days.

15. (i) Where a service is to be provided by any other service or facility off site, the treatment/service plan must contain a description of the nature of the service, a record that referral for such service has been made, the results of the referral, and procedures for ongoing coordination of care.

    (j) Treatment according to the treatment/service plan.

    The clinical staff member shall ensure that the treatment/service plan is included in the resident record and that all treatment is provided in accordance with the treatment/service plan.

16. (k) The case of any resident who is not responding to treatment, is not meeting goals defined in the comprehensive treatment/service plan, including educational and vocational goals, or who is disruptive to the service must be discussed at a case conference, or by the clinical supervisor and the clinical staff member in a supportive living service, and the treatment/service plan revised accordingly.

    1. (1) Progress notes shall be written, signed and dated by the responsible clinical staff member no less often than once every two weeks. All treatment plan life areas that are addressed in the two-week period must be documented in the applicable progress note.

    2. (2) Progress notes shall provide a chronology of the resident's progress related to the goals established in the treatment/service plan and be sufficient to delineate the course and results of treatment/services. The progress notes shall indicate the resident's participation in all significant services that are provided.

       (m) Discharge planning.

       Discharge planning shall begin as soon as the resident is admitted, be considered as part of the treatment/service planning process, and be provided by the responsible clinical staff member. The discharge plan shall be developed in collaboration with the resident and any significant other(s) the resident chooses to involve. If the resident is a minor, the discharge plan must also be developed in consultation with his or her parent or guardian, unless the minor is being treated without parental consent as authorized by section 22.11 of the Mental Hygiene Law.

    3. (1) The discharge plan shall be based on the individual's self-reported confidence in maintaining abstinence and following an individualized relapse prevention plan, an assessment of the resident's home environment, suitability of housing, vocational/educational/employment status, and relationships with significant others to establish the level of social resources available to the resident and the need for services to significant others. The discharge plan shall include but not be limited to:

       1. (i) identification of continuing chemical dependence services and any other treatment, rehabilitation, self-help and vocational, educational and employment services the resident will need after discharge;
       2. (ii) identification of specific providers of these needed services; and
       3. (iii) specific referrals and initial appointments for these needed services.

    (l) Documentation of service.

17. (n) No resident shall be discharged without a discharge plan which has been reviewed by the clinical supervisor or designee prior to the discharge of the resident. This does not apply to residents who leave the service without permission or otherwise fail to cooperate in the discharge planning process. A portion of the discharge plan which includes referrals for continuing care shall be given to the resident upon discharge.

    1. (1) the resident has accomplished the goals and objectives which were identified in the comprehensive treatment/service plan;
    2. (2) the resident refuses further care;
    3. (3) the resident has been referred to other appropriate treatment which cannot be provided in conjunction with the residential service;
    4. (4) the resident has been removed from the service by the criminal justice system or other legal process;
    5. (5) the resident has received maximum benefit from the service; and/or
    6. (6) the resident is disruptive to the service and/or fails to comply with the reasonably applied written behavioral standards of the facility.

    (o) Discharge criteria.

    A resident shall be appropriate for discharge from the residential service and shall be discharged when he or she meets one or more of the following criteria:

18. (p) A summary which includes the course and results of care must be prepared and included in each resident's record within 30 days of discharge.

(a) Comprehensive evaluation.