SECTION 448.803. Assessment

(a) A counselor or counselor intern shall conduct and document a comprehensive psychosocial assessment with the client admitted to the facility. The assessment shall document and elicit enough information about the client's past and present status to provide a thorough understanding of the following areas:

(1) presenting problems resulting in admission;

(2) alcohol and other drug use;

(3) psychiatric and chemical dependency treatment;

(4) medical history and current health status, to include an assessment of Tuberculosis (TB), HIV and other sexually transmitted disease (STD) risk behaviors as permitted by law;

(5) relationships with family;

(6) social and leisure activities;

(7) education and vocational training;

(8) employment history;

(9) legal problems;

(10) mental/emotional functioning; and

(11) strengths and weaknesses.

(b) The counselor or counselor intern may conduct the assessment with a client in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1) of this chapter (relating to Treatment Services Provided by Electronic Means). A facility offering assessments through electronic means shall comply with the applicable requirements under §448.911 of this chapter and the following requirements.

(1) Prior to conducting an assessment through electronic means:

(A) a counselor intern, licensed professional counselor assistant (LPC-A), or licensed master social worker (LMSW) must have more than 2,000 hours of supervised work experience or have a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure); and

(B) if the provider is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam.

(2) A counselor or counselor intern assessing a client through electronic means shall use synchronous audiovisual technology, as that term is defined by §448.911(a)(4) of this chapter, except as provided under paragraph (3) of this subsection.

(3) To the extent allowed by federal law and only when all the following criteria are met, the counselor or counselor intern may assess a client using synchronous audio-only technology, as that term is defined by §448.911(a)(3) of this chapter, when:

(A) the assessment occurs during a declared state of disaster under Texas Government Code §418.014 (relating to Declaration of State of Disaster) in the county in which the facility where the client signed their consent for treatment form is located;

(B) the counselor or counselor intern determines and documents a justification for their determination in the client's record that assessing the client using synchronous audio-only technology is safe and clinically appropriate for the client being assessed and the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen the individual; and

(C) the client being assessed agrees and provides verbal consent, as that term is defined by §448.911(a)(5) of this chapter, to participate in an assessment using synchronous audio-only technology.

(4) The counselor or counselor intern shall conduct an in-person and face-to-face assessment with a client at the client's request or if the client does not provide their verbal consent to participate in an assessment through electronic means, as required by §448.911(u) of this chapter.

(c) The assessment shall result in a comprehensive listing of the client's problems, needs, and strengths.

(d) The assessment shall result in a comprehensive diagnostic impression. The diagnostic impression shall correspond to current Diagnostic and Statistical Manual of Mental Disorders (DSM) standards. A licensed intern or other provider shall operate within the scope of their license when conducting assessments.

(e) If the assessment identifies a potential mental health problem, the facility shall obtain a mental health assessment and seek appropriate mental health services when resources for mental health assessments or services, or both, are available internally or through referral at no additional cost to the program. These services shall be provided by a facility or person authorized to provide such services or a qualified professional as described in §448.901 of this chapter (relating to Requirements Applicable to all Treatment Services).

(f) The assessment shall be signed by a QCC and filed in the client record within three individual service days of admission.

(g) The program may accept an evaluation from an outside source if:

(1) it meets the criteria set forth herein;

(2) it was completed during the 30 days preceding admission or is received directly from a facility that is transferring the client; and

(3) a counselor reviews the information with the client and documents an update.

(h) For residential clients, a licensed health professional shall conduct a health assessment of the client's physical health status within 96 hours of admission. The facility may accept a health assessment from an outside source completed no more than 30 days before admission or received directly from a transferring facility. If the client has any physical complaints or indications of medical problems, the client shall be referred to a physician, physician assistant, or nurse practitioner for a history and physical examination. The examination, if needed, shall be completed within a reasonable time frame and the results filed in the client record.

Source Note: The provisions of this §448.803 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; amended to be effective February 22, 2024, 49 TexReg 871