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 12VAC35-105-1890 - Nursing assessment

Current through Register Vol. 40, No. 24, July 15, 2024
A. Crisis
				  receiving centers, crisis stabilization units, and REACH CTH providers shall
				  administer a nursing assessment within 24 hours of admission of an
				  individual.
B. Prior to admission,
				  each individual shall have a screening for communicable diseases, including
				  tuberculosis, as evidenced by the completion of a screening form containing, at
				  a minimum, the elements found on the Report of Tuberculosis Screening form
				  published by the Virginia Department of Health. The screening shall be no older
				  than 30 days. No screening shall be required for a new individual separated
				  from a service with another licensed provider with a break in service of six
				  months or less or who is transferred from another department-licensed
				  provider.
C. A staff member shall
				  conduct a nursing assessment. The nursing assessment shall collect information
				  about the nonpsychiatric medical or surgical condition of an individual to
				  determine whether there is a need for a medical assessment before a decision is
				  made regarding continued treatment within the provider's service or transfer to
				  a more intensive level of care. The nursing assessment shall determine if there
				  is a current medical crisis or underlying medical condition for the
				  individual's psychological crisis, such as any medical condition that affects
				  the individual's psychological state, presenting behavior, or ability to
				  receive the provider's service. The nursing assessment shall note the date of
				  examination and have the signature of a qualified practitioner.
D. Locations designated for nursing
				  assessments shall ensure individual privacy.
E. The provider shall review and follow up
				  with (i) the results of the nursing assessment, including any follow-up
				  diagnostic tests, treatments, or examinations, and (ii) documentation of the
				  arrangements for follow-up care in the individual's record.
F. Each individual's health record shall
				  include notations of any health or dental complaints mentioned by the
				  individual or any injuries and shall summarize symptoms and treatment
				  given.
G. Each individual's health
				  record shall include or document the facility's efforts to obtain treatment
				  summaries of ongoing psychiatric or other mental health treatment and
				  reports.
H. The provider shall
				  develop and implement written policies and procedures that include the use of
				  standard precautions and address communicable and contagious medical
				  conditions.
I. Community-based
				  crisis stabilization providers are not required to administer nursing
				  assessments. The provider may administer a nursing assessment if the provider
				  has the resources to do so or may obtain a medical history or relevant
				  information that would be a part of a medical history if the individual
				  receiving services provides it.
Statutory Authority: §§
												37.2-302 and
						37.2-400 of the Code of
						Virginia.