Wisconsin Law – DHS 83
The assessment is meant to comply with provisions of Wisconsin law under which SUD RECOVERY CENTERS are required to conduct both a psychiatric and a physical health an assessment of each client prior to admission, to wit:
[Note: All text is from the original Code. Highlighting in yellow has been supplied.]
DHS 83.35 Assessment, individual service plan and evaluations.
(a) Scope. The CBRF [i.e., SUD Recovery Centers] shall assess each resident’s needs, abilities, and physical and mental condition before admitting the person to the CBRF…The assessment shall include all areas listed under par. (c)…
(b) Information gathering. The CBRF shall base the assessment on the current diagnostic, medical and social history obtained from the person’s health care providers, case manager and other service providers. Other service providers may include a psychiatrist, psychologist, licensed therapist, counselor, occupational therapist, physical therapist, pharmacist or registered nurse. The administrator or designee shall hold a face-to-face interview with the person and the person’s legal representative, if any, and family members, as appropriate, to determine what the person views as his or her needs, abilities, interests, and expectations.
(c) Areas of assessment. The assessment, at a minimum, shall include all of the following areas applicable to the resident:
- Physical health, including identification of chronic, short-term and recurring illnesses, oral health, physical disabilities, mobility status and the need for any restorative or rehabilitative care.
- Medications the resident takes and the resident’s ability to control and self-administer medications.
- Presence and intensity of pain.
- Nursing procedures the resident needs and the number of hours per week of nursing care the resident needs.
- Mental and emotional health, including the resident’s self-concept, motivation and attitudes, symptoms of mental illness and participation in treatment and programming.
- Behavior patterns that are or may be harmful to the resident or other persons, including destruction of property.
- Risks, including, choking, falling, and elopement.
- Capacity for self-care, including the need for any personal care services, adaptive equipment or training.
- Capacity for self-direction, including the ability to make decisions, to act independently and to make wants or needs known.
- Social participation, including interpersonal relationships, communication skills, leisure time activities, family and community contacts and vocational needs.