Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-19 - RULES AND REGULATIONS FOR DRUG ABUSE TREATMENT AND EDUCATION PROGRAMS › Rule 111-8-19-.13 - Client Referral, Intake, Assessment, and Admission

Current through Rules and Regulations filed through June 27, 2024
(1) A program shall
				only accept referrals and shall only admit and retain clients whose known needs
				can be met by the program in accordance with its program purpose and
				description. Written policies and procedures for client referral, intake,
				assessment, and admission shall be established and implemented and shall
				include the following:
(a) Screening. All
				persons referred to the program or who present themselves for services shall be
				initially screened to determine if the prospective client appears to meet the
				program's admission criteria. Such screenings shall be done by a staff person
				who has been determined to be qualified by education, training, experience, and
				who are licensed/certified if required by state practice acts to perform such
				screenings. Screenings shall constitute an initial appraisal of the clients'
				dysfunctions and the types of services that appear needed. Persons whose needs
				cannot be met by the program shall not be admitted and should be referred to
				other programs that provide appropriate services. A record (log) will be kept
				of persons not admitted and reason(s) for not admitting. The program has the
				discretion to use information on clinical evaluations done within thirty
				days.
(b) Assessment. All clients
				admitted to the program shall be evaluated by a staff person who has been
				determined to be qualified by education, training, and experience and who are
				licensed/certified if required by state practice acts to perform or coordinate
				the provision of such assessments. Such evaluations shall include a
				comprehensive assessment of the client's physical, emotional, behavioral,
				social, recreational, and educational status and needs. The program has the
				discretion to use current clinical information concerning a transitioning
				client from another licensed program, licensed hospital, or a state or federal
				agency, if there has not been a discontinuance in treatment.
1. Physical Assessment. At the time of
				admission, a preliminary physical assessment shall be done, at a minimum, by a
				Registered Nurse or Licensed Practical Nurse under the supervision of a RN or
				physician and shall include documentation of vital signs, appropriate screening
				tests for STD and TB, urine drug screens, a determination of whether the client
				requires a physical or psychiatric examination by a physician according to
				established protocols, and laboratory tests as clinically indicated. Laboratory
				tests required upon admission for clients in each program modality, in addition
				to those tests required for all modalities, will be determined by the programs
				and documented in their policy and procedures as to the criteria used to
				determine and specify which minimum lab tests are to be done for each modality.
				Other lab tests may be required by the physician as clinically indicated. If an
				examination by a physician is indicated, arrangements shall be made for such an
				examination as appropriate. The assessment shall also include circumstances
				leading to admission, mental status, support system, psychiatric and medical
				history, risk assessment for HIV, history of use of drugs, including the age of
				onset, duration, patterns, and consequences of use, family history of drug use,
				route of administration and previous treatment. If a client has been referred
				for treatment from another facility, the results of a physical examination and
				laboratory tests from the other facility may be documented and used to assess
				physical status, provided that such physical examination was done within six
				months of admission, and there has been no significant change in the physical
				status of the client. Further assessments or laboratory tests may be required
				depending upon the modality of treatment needed or the client's changing
				condition.
2. Psycho-social
				assessment. At the time of admission or as soon as clinically appropriate (but
				no longer than ten working days), a comprehensive psycho-social assessment
				shall be done and shall document personal and social history, including current
				relationships, educational status, living arrangements, social habits,
				employment status, legal status and related areas.
(c) Admission.
1. Consent. Except as otherwise authorized by
				law, no person shall be admitted for treatment without written authorization
				from the client and parent, guardian, or responsible party, if applicable. The
				following information must be explained by a trained staff person to the client
				and other consenters, and documented in the client's file.
(i) The program's services and
				treatment;
(ii) The specific
				condition that will be treated;
(iii) The expected charges for services
				including any charges that might be billed separately;
(iv) The Client's Rights and
				Responsibilities;
(v) The rights of
				consenters to obtain information about the client's treatment, etc.;
				and
(vi) The procedures for
				complaint and question resolution.
2. Orientation. The program shall provide
				orientation to clients admitted for treatment within 24 hours of admission or
				at such time that the client appears able to hear and respond to requests, but
				in no event later than 72 hours after admission. Orientation shall be done by a
				staff person who has been determined to be qualified by education, training,
				and experience to perform the task. The following information must be explained
				to the client, and documented in the client's file.
(i) The expected benefits of the treatment
				that the client is expected to receive;
(ii) An explanation of individualized
				treatment planning;
(iii) The
				client's responsibilities for adhering to the treatment plan and the
				consequences of non-adherence;
(iv)
				The identification of the staff person that is expected to provide treatment or
				coordinate the treatment;
(v)
				Program rules including requirements for conduct and the consequences of
				infractions;
(vi) Client's Rights,
				Responsibilities, and Complaints;
(vii) The program's policies for use of
				behavior management and emergency safety interventions when necessary;
				and
(viii) Policies and procedures
				for visiting hours and communications with persons outside the program, if a
				residential program.