A chemical dependency professional (CDP), or a CDP trainee under supervision of a CDP, must conduct and document an assessment of each patient's involvement with alcohol and other drugs. The CDP's assessment must include:
(1) A face-to-face diagnostic interview with each patient to obtain, review, evaluate, and document the following:
(a) A history of the patient's involvement with alcohol and other drugs, including:
(i) The type of substances used;
(ii) The route of administration; and
(iii) Amount, frequency, and duration of use.
(b) History of alcohol or other drug treatment or education;
(c) The patient's self-assessment of use of alcohol and other drugs;
(d) A relapse history;
(e) A legal history; and
(f) In addition, for persons who have been charged with a violation under RCW 46.61.502
RCW, ensure the assessment includes an evaluation in the written summary of the patient's:
(i) Blood or breath alcohol level and other drug levels or documentation of the patient's refusal at the time of the arrest, if available;
(ii) Self reported driving record and the abstract of the patient's legal driving record; and
(iii) If the initial finding is other than substance dependence, the assessment must also include:
(A) The police report or documentation of efforts to include this information;
(B) A court originated criminal case history or documentation of efforts to include this information; and
(C) The results of a urinalysis or drug testing obtained at the time of the assessment or documentation of efforts to include this information.
(2) If the patient is in need of treatment, a CDP or CDP trainee under supervision of a CDP must evaluate the assessment using PPC dimensions for the patient placement decision.
(3) If an assessment is conducted on a youth, and the patient is in need of treatment, the CDP, or CDP trainee under supervision of a CDP, must also obtain the following information:
(a) Parental and sibling use of alcohol and other drugs;
(b) History of school assessments for learning disabilities or other problems, which may affect ability to understand written materials;
(c) Past and present parent/guardian custodial status, including running away and out-of-home placements;
(d) History of emotional or psychological problems;
(e) History of child or adolescent developmental problems; and
(f) Ability of parents/guardians to participate in treatment.
(4) Documentation of the information collected, including:
(a) A diagnostic assessment statement including sufficient data to determine a patient diagnosis supported by criteria of substance abuse or substance dependence;
(b) A written summary of the data gathered in subsections (1), (2), and (3) of this section that supports the treatment recommendation;
(c) A statement regarding provision of an HIV/AIDS brief risk intervention, and referrals made; and
(d) Evidence the patient:
(i) Was notified of the assessment results; and
(ii) Documentation of treatment options provided, and the patient's choice; or
(iii) If the patient was not notified of the results and advised of referral options, the reason must be documented.
(5) Completion and submission of all reports required by the courts, department of corrections, department of licensing, and department of social and health services in a timely manner.
(6) Referral of an adult or minor who requires assessment for involuntary chemical dependency treatment to the county-designated chemical dependency specialist.
[Statutory Authority: RCW 70.96A.040, chapter 70.96A RCW, and 42 C.F.R. Part 8. 08-24-083, § 388-805-310, filed 12/1/08, effective 1/1/09. Statutory Authority: RCW 70.96A.090, 70.96A.142, 70.96A.157, chapter 70.96A RCW, 2004 c 166, 2005 c 70 and 504, 42 C.F.R. Parts 2 and 8. 06-11-096, § 388-805-310, filed 5/17/06, effective 6/17/06. Statutory Authority: RCW 70.96A.090, chapter 70.96A RCW, 2001 c 242, 42 C.F.R. Part 8. 03-20-020, § 388-805-310, filed 9/23/03, effective 10/25/03. Statutory Authority: RCW 70.96A.090 and chapter 70.96A RCW. 00-23-107, § 388-805-310, filed 11/21/00, effective 1/1/01.]