Virginia Law

A. The provider shall implement a written crisis assessment policy. The policy shall define how crisis assessments will be conducted and documented.

B. The provider shall actively involve the individual and the individual's authorized representative, if applicable, in the preparation of crisis assessment. In the crisis assessment, the provider shall consider the individual's needs, strengths, goals, preferences, and abilities within the individual's cultural context.

C. The crisis assessment policy shall designate appropriately qualified employees or contractors who are responsible for conducting, obtaining, or updating assessments and medical screenings. These employees or contractors shall have experience working with the needs of individuals who are being assessed, with the crisis assessment tools being utilized and with the provision of services that the individuals may require. The crisis assessment policy shall include methods the provider will utilize to identify other appropriate services to assist individuals who are not admitted to the provider's service.

D. Assessment is an ongoing activity. The provider shall make reasonable attempts to obtain previous assessments or history relevant to the crisis. The provider shall use the individual's previous assessments or other relevant history within the course of treatment, if applicable, as noted within subsection F of this section.

E. Providers shall utilize standardized state-sanctioned or federally sanctioned crisis assessment tools as approved by the department or utilize their own crisis assessment tools that shall meet the requirements in subsection F of this section.

F. A crisis assessment shall be initiated prior to or at admission to the service. With the participation of the individual and the individual's authorized representative, if applicable, the provider shall complete or obtain information from other qualified providers in order to complete a crisis assessment detailed enough to (i) determine whether the individual qualifies for admission and (ii) initiate a safety plan or crisis ISP as required by this chapter for those individuals who are admitted to the service. The crisis assessment shall assess the individual's service, health, and safety needs and, at a minimum, include:

1. For community-based crisis stabilization providers providing the mobile crisis component of the service and crisis receiving centers:

a. Diagnosis, including current and past substance use or dependence and risk for intoxication or substance withdrawal, and co-occurring mental illness or developmental disability;

b. Risk of harm, including elements that may make an individual a danger to self or others;

c. Cognitive functional status, including the individual's ability to protect from self-harm and provide for the individual’s basic human needs;

d. Precipitating issues, including recent stressors or events;

e. Presenting needs, including the individual's stated needs, psychiatric needs, support needs, and the onset and duration of needs. The assessor shall record:

(1) Any physical reaction to the presenting crisis if these issues are mentioned by the individual or observed during the assessment. Examples include issues with sleep, appetite, or daily activities;

(2) The individual's housing arrangements and living situation if mentioned by the individual; and

(3) Any trauma, such as sexual abuse, physical abuse, or natural disaster, if appropriate, including if a trauma is related to the current crisis or mentioned by the individual;

f. Additional current medical issues and symptoms, if applicable;

g. Current medications, including recent changes to medications. The assessor shall review current medications to the best of the individual's ability;

h. Barriers that will impact the individual's ability to seek treatment or continue to participate in services, including the individual's mood, ability, and willingness to engage in treatment, and access to transportation;

i. The individual's recovery environment and circle of support; and

j. Communication modality and language preference.

2. For crisis stabilization units and community-based crisis stabilization providing services other than mobile crisis, the assessment shall also include:

a. Relevant treatment history and health history, to include as applicable:

(1) Past prescribed medications;

(2) Hospitalizations for challenging behaviors, mental illness, or substance use;

(3) Other treatments for challenging behaviors, mental illness, or substance use;

(4) Allergies, including allergies to food and medications;

(5) Recent physical complaints and medical conditions;

(6) Nutritional needs;

(7) Chronic conditions;

(8) Communicable diseases;

(9) Restrictions on physical activities, if any;

(10) Restrictive protocols or special supervision requirements;

(11) Preferred interventions in the event behaviors or symptoms become a danger to self or others;

(12) All known contraindications to the use of seclusion, time out, or any form of physical or mechanical restraint, including medical contraindications and history of trauma;

(13) Past serious illnesses, serious injuries, and hospitalizations;

(14) Serious illnesses and chronic conditions of the individual's parents, siblings, and significant others in the same household; and

(15) Other interventions and outcomes, including interventions and outcomes that were unsuccessful. The provider should ensure previous assessments are utilized to note these interventions.

b. The individual's housing arrangements or living situation;

c. Trauma, such as sexual abuse, physical abuse, or natural disaster; and

d. Current or previous involvement in systems, such as legal, adult protective services, or child protective services.

3. If applicable to the individual's crisis, the assessment shall include:

a. The individual’s social, behavioral, developmental, and family history and supports;

b. Employment, vocational, and educational background;

c. Cultural and heritage considerations; and

d. Financial stressors, if applicable.

G. The timing for completion of the crisis assessment shall be as soon as possible after admission but no later than 24 hours after admission.

H. The provider shall retain documentation of the assessments in the individual's record for a minimum of six years following the last patient encounter, in accordance with § 54.1-2910.4 of the Code of Virginia.