W. Va. Code R. § 69-7-33

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-7-33 - Comprehensive Bio-Psychosocial Evaluation

33.1. Within thirty days after admission, or when the patient is stable and able to fully participate, the program shall complete a full bio-psychosocial evaluation which shall be used to develop the long-term plan of care. The bio-psychosocial evaluation shall integrate information obtained in the comprehensive medical evaluation.

33.2. The bio-psychosocial evaluation shall include information obtained from:

33.2.a. The patient;

33.2.b. Family members, when applicable or permitted;

33.2.c. Friends and peers, when appropriate and permitted; and

33.2.d. Other appropriate and permitted collateral sources.

33.3. The bio-psychosocial evaluation shall include information about the person's:

33.3.a. Personal strengths;

33.3.b. Individualized needs;

33.3.c. Abilities and/or interests;

33.3.d. Presenting problems, including a thorough analysis of the individual's addictive behaviors such as, licit and illicit drugs used, including alcohol; amounts of drugs or alcohol used; frequency of use; duration of use; symptoms of physical addiction; history of treatment for addictive behaviors; adverse consequences of use; inappropriate use of prescribed substances; and urgent needs, including suicide risk;

33.3.e. Previous behavioral health services, including diagnostic information; treatment information; efficacy of current or previously used medication; physical health history and current status; diagnoses; mental status and current level of functioning;

33.3.f. Pertinent current and historical life situation information, including the patient's age; gender; employment history; involvement in legal proceedings; family history; history of abuse or neglect; and relationships, including natural supports;

33.3.g. Use of alcohol and tobacco;

33.3.h. Need for, and availability of, social supports;

33.3.i. Risk-taking behaviors;

33.3.j. Level of educational functioning;

33.3.k. Medications prescribed that are not a target of treatment or concern;

33.3.l. Medication allergies or adverse reactions to medications;

33.3.m. Adjustment to disabilities/disorders; and

33.3.n. Motivation for treatment.

33.4. The patient's counselor shall review the bio-psychosocial assessment and prepare a concise, interpretive multidisciplinary summary that:

33.4.a. Is based on the assessment data;

33.4.b. Describes and evaluates the level and severity of the individual's addictive behaviors;

33.4.c. Is used in the development of the individualized treatment plan of care; and

33.4.d. Identifies any co-occurring disabilities or disorders that should be addressed in the development of the individualized treatment plan of care.

W. Va. Code R. § 69-7-33