Virginia Administrative Code › Title 12 - HEALTH › Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES › Chapter 105 - RULES AND REGULATIONS FOR LICENSING PROVIDERS BY THE DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES › Part VIII - Crisis Services › Section 12VAC35-105-1850 - Crisis assessment

Current through Register Vol. 40, No. 24, July 15, 2024
A. The provider
				  shall implement a written crisis assessment policy. The policy shall define how
				  crisis assessments will be conducted and documented.
B. The provider shall actively involve the
				  individual and the individual's authorized representative, if applicable, in
				  the preparation of crisis assessment. In the crisis assessment, the provider
				  shall consider the individual's needs, strengths, goals, preferences, and
				  abilities within the individual's cultural context.
C. The crisis assessment policy shall
				  designate appropriately qualified employees or contractors who are responsible
				  for conducting, obtaining, or updating assessments and medical screenings.
				  These employees or contractors shall have experience working with the needs of
				  individuals who are being assessed, with the crisis assessment tools being
				  utilized and with the provision of services that the individuals may require.
				  The crisis assessment policy shall include methods the provider will utilize to
				  identify other appropriate services to assist individuals who are not admitted
				  to the provider's service.
D.
				  Assessment is an ongoing activity. The provider shall make reasonable attempts
				  to obtain previous assessments or history relevant to the crisis. The provider
				  shall use the individual's previous assessments or other relevant history
				  within the course of treatment, if applicable, as noted within subsection F of
				  this section.
E. Providers shall
				  utilize standardized state-sanctioned or federally sanctioned crisis assessment
				  tools as approved by the department or utilize their own crisis assessment
				  tools that shall meet the requirements in subsection F of this
				  section.
F. A crisis assessment
				  shall be initiated prior to or at admission to the service. With the
				  participation of the individual and the individual's authorized representative,
				  if applicable, the provider shall complete or obtain information from other
				  qualified providers in order to complete a crisis assessment detailed enough to
				  (i) determine whether the individual qualifies for admission and (ii) initiate
				  a safety plan or crisis ISP as required by this chapter for those individuals
				  who are admitted to the service. The crisis assessment shall assess the
				  individual's service, health, and safety needs and, at a minimum, include:
1. For community-based crisis stabilization
				  providers providing the mobile crisis component of the service and crisis
				  receiving centers:
a. Diagnosis, including
				  current and past substance use or dependence and risk for intoxication or
				  substance withdrawal, and co-occurring mental illness or developmental
				  disability;
b. Risk of harm,
				  including elements that may make an individual a danger to self or
				  others;
c. Cognitive functional
				  status, including the individual's ability to protect from self-harm and
				  provide for the individual's basic human needs;
d. Precipitating issues, including recent
				  stressors or events;
e. Presenting
				  needs, including the individual's stated needs, psychiatric needs, support
				  needs, and the onset and duration of needs. The assessor shall record:
(1) Any physical reaction to the presenting
				  crisis if these issues are mentioned by the individual or observed during the
				  assessment. Examples include issues with sleep, appetite, or daily
				  activities;
(2) The individual's
				  housing arrangements and living situation if mentioned by the individual;
				  and
(3) Any trauma, such as sexual
				  abuse, physical abuse, or natural disaster, if appropriate, including if a
				  trauma is related to the current crisis or mentioned by the
				  individual;
f.
				  Additional current medical issues and symptoms, if applicable;
g. Current medications, including recent
				  changes to medications. The assessor shall review current medications to the
				  best of the individual's ability;
h. Barriers that will impact the individual's
				  ability to seek treatment or continue to participate in services, including the
				  individual's mood, ability, and willingness to engage in treatment, and access
				  to transportation;
i. The
				  individual's recovery environment and circle of support; and
j. Communication modality and language
				  preference.