New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 37A - LICENSED COMMUNITY RESIDENCES FOR ADULTS WITH MENTAL ILLNESSES › Subchapter 4 - CONSUMER SERVICES › Section 10:37A-4.3 - Comprehensive rehabilitation needs assessment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The PA
				shall complete a written comprehensive rehabilitation needs assessment for each
				consumer by the 14th day after admission.
1.
				The purpose of the comprehensive rehabilitation needs assessment is to provide
				a basis for the individualized rehabilitation plan by gathering all information
				required to determine the need for, scope of, and anticipated outcome of
				behavioral health and rehabilitation services, including, but not limited to,
				individual strengths, preferences, needs, abilities, psychiatric symptoms,
				medical history, and functional limitations.
2. The development of the written
				comprehensive rehabilitation needs assessment shall be a consumer-driven
				process, informed by a face-to-face evaluation and discussion with the
				consumer.
3. Family members,
				significant others, and other collateral service providers may participate
				and/or otherwise provide information, providing that their involvement is
				within the bounds of the confidentiality provisions of the policy and
				procedures manual and in conformance with State and Federal law.
4. The written comprehensive rehabilitation
				needs assessment shall include:
i.
				Identifying information (name, gender, date of birth, religion, race, and
				Social Security number), referral date, and source;
ii. Psychiatric history, current mental
				status, and multi-axial diagnosis, if such diagnosis can be obtained;
(1) Where a consumer's psychiatric diagnosis
				is obtained from a secondary source, the PA staff shall cite that
				source;
iii. Medication
				history, including current medication, dose, frequency, and name of prescribing
				physician;
iv. Current and prior
				involvement with other agencies/mental health services;
v. Legal information relevant to
				treatment;
vi. The name and phone
				number of an emergency contact person, and notation as to the existence of an
				advance directive for mental health care or living will. If an advance
				directive for mental health care or living will exists, a copy shall be
				included in the consumer's record;
vii. The consumer's aspirations, strengths,
				and goals related to improving his or her life, achieving valued life roles,
				and achieving wellness and recovery;
viii. Social and leisure functioning
				including, but not limited to, the ability to make friendships, communication
				skills, and hobbies;
ix. Social
				supports including, but not limited to, family, friends, social, and religious
				organizations;
x. Trauma and abuse
				history or lack thereof;
xi.
				Understanding of his or her illness(es) and coping mechanisms;
xii. Vocational and educational factors
				including, but not limited to, job and education history, learning
				disabilities/needs, task concentration, and motivation for work;
xiii. Activities of daily living including,
				but not limited to, self- preservation skills, fire safety (including fire
				prevention during activities such as cooking and smoking; and evacuation
				skills), transportation, self-care, and hygiene;
xiv. Previous living arrangements;
xv. Financial status and skills including
				budgeting, entitlements, and subsidies;
xvi. Substance abuse, including the
				substances used currently and in the past, triggers for use of each substance,
				efforts made to stop or reduce using, consequences of use (including violent
				behavior, health problems, and problems with relationships, finances, and law
				enforcement/courts/incarceration), substance abuse services received in the
				past and currently, the effectiveness of those services, community supports
				used to stop or reduce using, the effectiveness of those supports, and
				activities engaged in to avoid using;
xvii. Other important characteristics of the
				individual, such as special skills, talents, and abilities;
xviii. Characteristics and behaviors
				resulting in barriers to successful community integration; and
xix. Recommendations regarding
				rehabilitation, medical, and residential services to be provided.