South Carolina Code of Regulations › Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL › Subchapter 61-103 - Residential Treatment Facilities for Children and Adolescents › Sec2 61-103.700 - RESIDENT RECORDS › Section 61-103.700.703 - Comprehensive Assessment

Current through Register Vol. 48, No. 6, June 28, 2024
A. The
				facility shall describe the treatment modalities it provides, including
				content, methods, equipment, and personnel involved. Each treatment program
				shall conform to the stated purpose and objectives of the agency.
				(II)
B. Assessment. The facility is
				responsible for a comprehensive assessment of the resident by reliable
				professionals acceptable to the facility's staff. The complete assessment shall
				be signed and dated by all participants and shall include, but is not limited
				to, the following:
1. Psychiatric. The
				assessment includes direct evaluation and behavioral appraisal, evaluation of
				sensory, motor functioning, a mental status examination appropriate to the age
				of the resident and a psychodynamic appraisal. A history of any previous
				treatment for mental, emotional, or behavioral disturbances shall be obtained,
				including the nature, duration, and results of the treatment, and the reason
				for termination.
2. Psychological.
				The psychological assessment includes appropriate testing.
3. Developmental and Social.
a. The developmental assessment of the
				resident includes the prenatal period and from birth until present, the rate of
				progress, developmental milestones, developmental problems, and past
				experiences that may have affected the development. The assessment shall
				include an evaluation of the resident's strengths as well as problems.
				Consideration shall be given to the healthy developmental aspects of the
				resident, as well as to the pathological aspects, and the effects that each has
				on the other. There shall be an assessment of the resident's current
				age-appropriate developmental needs, which shall include a detailed appraisal
				of his peer and group relationships and activities.
b. The social assessment includes evaluation
				of the resident's relationships within the structure of the family and with the
				community at large, and evaluation of the characteristics of the social, peer
				group, and institutional settings from which the resident comes. Consideration
				shall be given to the resident's family circumstances, including the
				constellation of the family group, their current living situation, and all
				social, religious, ethnic, cultural, financial, emotional, and health factors.
				Other factors that shall be considered are past events and current problems
				that have affected the resident and family; potentialities of the family
				members meeting the resident's needs; and their accessibility to help in the
				treatment and rehabilitation of the resident. The expectations of the family
				regarding the resident's treatment, the degree to which they expect to be
				involved, and their expectations as to the length of time and type of treatment
				required shall be assessed.
4. Nursing. The nursing screening includes,
				but is not limited to, the evaluation of:
a.
				Self-care capabilities including bathing, sleeping, and eating;
b. Hygienic practices, such as routine dental
				and physical care and establishment of healthy toilet habits;
c. Nutritional habits including a balanced
				diet and appropriate fluid and caloric intake;
d. Responses to physical diseases, such as
				acceptance by the resident of a chronic illness as manifested by his compliance
				with prescribed treatment;
e.
				Responses to physical disabilities, such as the use of prosthesis or coping
				patterns used by the visually impaired; and
f. Responses to medications, such as
				allergies or dependence.
5. Educational and/or Vocational. Residents
				shall be evaluated using appropriate educational and vocational
				assessments.
6. Recreational. The
				resident's work and play experiences, activities, interests, and skills shall
				be evaluated in relation to planning appropriate recreational
				activities.