ADMISSION ASSESSMENT/PRE-SCREENING

ADMISSION ASSESSMENT/PRE-SCREENING

Pre-screening Admission Assessments will be completed by the Qualified Professional with information gathered from the client’s referring agency and the consumer and/or consumer’s parent(s) / legal guardian(s). This pre-screening assessment will be done prior to the admission, within 24 hours of admission, and documented in the client’s record. Assessments for clients will include, but are not limited, to the following: (STR or The Ship Group Community Services Care specific pre-screening assessment tool, SAR/TAR, Treatment Plan, LME/MCO admission form, target population, etc.)

• Client’s presenting problem/reason for admission

• Client’s needs and strengths

• Preferences

• Where appropriate, the strength and needs of family members that may provide support to the client

• A provisional or admitting diagnosis with an established diagnosis determined within 30 days of admission

• A description of the current status including the following, when appropriate:

▪ Mental status, including suicidal or homicidal potential

▪ Developmental condition or impairment

▪ Substance use or abuse

▪ Legal status or circumstance

▪ Medical condition (Diagnosis according to the newest DSM)

▪ Family and other support systems

▪ A description of the client’s conditions from family or significant others, when available

▪ The disposition, including referrals and recommendations

▪ Initial treatment goals, primary treatment plan

If a client is expected to receive services for more than 30 days, the assessment will include the following within the 30 day admission:

• A social and family history

• A medical history

• When appropriate, histories and assessment as follows:

▪ Psychiatric, including previous treatment

▪ Substance Abuse, including previous treatment

▪ Developmental, including previous services received

▪ Educational

▪ Auditory and Visual

▪ Nutritional

▪ Vocational

All evaluations and documents to support treatment services / assessments are reviewed and updated as appropriate.

ASSESSMENT OF ABILITY TO PROVIDE SERVICE

Prior to admission, an assessment will be made by the QP on the ability of The Ship Group Community Services Inc. to provide services to the referred consumer. This screening will include an assessment of the individual’s presenting problems and needs. If deemed appropriate for admission, notation will be made in the consumer record. If not deemed appropriate for admission, notation will be made in the consumer record of why such determination was made as well as disposition, referrals and recommendations, if any. A copy of the denial for admission will be submitted to the referring agency.