10A NCAC 27H .0104      PROCEDURE FOR ADMISSION

(a)  Any person voluntarily seeking admission to a residential treatment facility shall be examined and evaluated by a qualified physician within 24 hours of presenting himself for admission. In determining the appropriateness of the admission, the qualified physician shall consult with a qualified mental health professional (in programs for the mentally ill) or a qualified substance abuse, alcohol or drug abuse professional (in programs for intoxication). Such consultation shall not be required if the qualified physician comes within the definition of a qualified mental health, substance abuse, alcohol, or drug abuse professional as appropriate.

(b)  The qualified physician shall evaluate the client's condition, strengths, needs, and the resources to meet those needs in determining the appropriateness of the admission.

(c)  Should the minor or person adjudicated incompetent be diagnosed as mentally retarded as well as mentally ill or intoxicated, the qualified physician shall secure the consultation of a qualified mental retardation professional in determining the appropriateness of admission and evaluating the client's condition.

(d)  The residential treatment facility shall have written admission procedures which shall include at least an agreement between the residential facility and parents, guardians or persons standing in loco parentis, as appropriate, or guardians of persons adjudicated incompetent which shall delineate the responsibilities of all parties for the provision of medical and dental services, education and other needs.

(e)  These procedures shall delineate the standardized information required which at a minimum shall include:

(1)           the present condition of the applicant reported in objective, behavioral terms, and where possible a description of the applicant's condition by significant others;

(2)           social, educational and medical histories; and, if appropriate, vocational, developmental, psychological, psychiatric, legal and nutritional histories; and

(3)           determination of, and request for, additional referrals for special diagnostic tests, assessments or evaluations, if needed.

(f)  The residential treatment facility shall specify in writing any routine diagnostic tests, assessments and evaluations or medical examinations, as well as timeframes for their completion, which shall be completed for each client.

(g)  Client diagnoses shall be established using DSM‑III‑R or ICD‑9‑CM as required in Division Publication APSM 35‑1, 07/01/89 (STANDARDS FOR AREA PROGRAMS AND THEIR CONTRACT AGENCIES) adopted pursuant to G.S. 150B‑14(c).

History Note:        Authority G.S. 122C‑211; 122C‑212; 122C‑223; 143B‑147;

Eff. April 1, 1984;

Amended Eff. March 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. March 26, 2017.