(A) Mental health assessment is a clinical evaluation provided by an eligible individual either at specified times or in response to treatment, or when significant changes occur. It is a process of gathering information to assess client needs and functioning in order to determine appropriate service/treatment based on identification of the presenting problem, evaluation of mental status, and formulation of a diagnostic impression. The outcome of mental health assessment is to determine the need for care, and recommend appropriate services/treatment and/or the need for further assessment. Results of the mental health assessment shall be shared with the client.
(B) An initial mental health assessment must be completed prior to the initiation of any mental health services. The only exceptions to this would be the delivery of crisis intervention mental health services or pharmacologic management services as the least restrictive alternative in an emergency situation.
(1) The initial mental health assessment must, and subsequent mental health assessments may, include at minimum:
(a) An age appropriate psychosocial history and assessment, to include consideration of multi-cultural/ethnic influences;
(b) The presenting problem;
(c) A diagnostic impression and treatment recommendations;
(d) For any service provided in a type 1 residential facility licensed by ODMH pursuant to rules 5122-30-01 to 5122-30-30 of the Administrative Code, a physical health screening to determine the need for a physical health assessment. Such screening shall be completed within one week of admission to the facility; and
(e) As determined by the provider, any other clinically indicated areas. Such areas may include, but are not limited to:
(i) Age appropriate areas of assessment such as for children, e.g., growth and development, family effect on child and child effect on family, and play and daily activities;
(ii) Use of alcohol/drugs;
(iii) Behavioral/cognitive/emotional functioning;
(iv) Mental status exam;
(v) Environment and home;
(vi) Leisure and recreation;
(vii) Childhood history;
(viii) Military service history;
(ix) Financial status;
(x) Usual social, peer-group and environmental setting, (to include involvement in consumer-operated or peer services);
(xi) Sexual orientation/history/issues;
(xii) Family circumstances/custody status;
(xiii) Vocational assessment;
(xiv) Educational assessment;
(xv) Legal assessment;
(xvi) Early detection of mental illness that is life-threatening to self or others;
(xvii) Nutritional status;
(xviii) Maladaptive or problem behaviors;
(xix) Psychiatric evaluation;
(xx) Psychological assessment including intellectual, projective, neuropsychological, and personality testing;
(xxi) Evaluations of language, self-care, visual-motor, and cognitive functioning;
(xxii) Current level of functioning/functional status;
(xxiv) Relationships with family/significant others;
(xxvi) Health/medical history, including current health and dental status as well as the presence of any physical disabilities; and
(xxvii) Indications of abuse and/or neglect.
(2) Mental health service providers may accept mental health assessments from prior evaluations. The clinical record shall reflect that such assessments have been reviewed and updated when appropriate prior to the initiation of any mental health services.
(C) The following shall apply with regard to the use of interactive videoconferencing. Interactive videoconferencing is defined in Chapter 5122-24 of the Administrative Code:
(1) "Client site" means the location of a client at the time at which the service is furnished via interactive videoconferencing technology.
(2) "Provider site" means the site where the eligible practitioner furnishing the service is located at the time the service is rendered via interactive videoconferencing technology.
(3) The agency shall obtain from the client/parent/legal guardian, signed, written consent for the use of videoconferencing technology.
(4) It is the responsibility of the agency to assure contractually that any entity or individuals involved in the transmission of the information guarantee that the confidentiality of the information is protected. When the client chooses to utilize videoconferencing equipment at a client site that is not arranged for by the agency, e.g., at his/her home or that of a family or friend, the agency is not responsible for any breach of confidentiality caused by individuals present at the client site.
(5) The agency shall provide the client written information on how to access assistance in a crisis, including one caused by equipment malfunction or failure.
(6) It is the responsibility of the agency to assure that equipment meets standards sufficient to:
(a) Assure confidentiality of communication;
(b) Provide for interactive videoconferencing communication between the practitioner and the client; and
(c) Assure videoconferencing picture and audio are sufficient to assure real-time interaction between the client and the provider and to assure the quality of the service provided.
(d) The client site must also have a person available who is familiar with the operation of the videoconferencing equipment in the event of a problem with the operation.
(e) If the client chooses to utilize videoconferencing equipment at a client site that is not arranged for by the agency, e.g., at his/her home or that of a family or friend, the agency is only responsible for assuring the equipment standards at the provider site.
(7) The decision of whether or not to provide initial or occasional in-person sessions shall be based upon client choice, appropriate clinical decision-making, and professional responsibility, including the requirements of professional licensing, registration or credentialing boards.
(D) Mental health assessment service shall be provided and supervised by staff who are qualified according to rule 5122-29-30 of the Administrative Code.
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5119.22, 5119.61(A), 5119.611(C)
Rule Amplifies: 5119.22, 5119.61(A), 5119.611(C)
Prior Effective Dates: 1-22-1979, 4-18-1991, 7-15-2001, 3-25-2004, 8-23-2007, 7-1-2008