(a)  An assessment shall be completed for a client, according to governing body policy, prior to the delivery of services, and shall include, but not be limited to:

(1)           the client's presenting problem;

(2)           the client's needs and strengths;

(3)           a provisional or admitting diagnosis with an established diagnosis determined within 30 days of admission, except that a client admitted to a detoxification or other 24-hour medical program shall have an established diagnosis upon admission;

(4)           a pertinent social, family, and medical history; and

(5)           evaluations or assessments, such as psychiatric, substance abuse, medical, and vocational, as appropriate to the client's needs.

(b)  When services are provided prior to the establishment and implementation of the treatment/habilitation or service plan, hereafter referred to as the "plan," strategies to address the client's presenting problem shall be documented.

(c)  The plan shall be developed based on the assessment, and in partnership with the client or legally responsible person or both, within 30 days of admission for clients who are expected to receive services beyond 30 days.

(d)  The plan shall include:

(1)           client outcome(s) that are anticipated to be achieved by provision of the service and a projected date of achievement;

(2)           strategies;

(3)           staff responsible;

(4)           a schedule for review of the plan at least annually in consultation with the client or legally responsible person or both;

(5)           basis for evaluation or assessment of outcome achievement; and

(6)           written consent or agreement by the client or responsible party, or a written statement by the provider stating why such consent could not be obtained.


History Note:        Authority G.S. 122C‑26; 130A‑144; 130A‑152; 143B‑147;

Eff. May 1, 1996;

Recodified from 10 NCAC 14V .0203 to 10 NCAC 14V .0205 Eff. January 3, 2001.