Standards for public agencies

2020 Edition

Mental Health and/or Substance Use Services (PA-MHSU) 3: Intake and Assessment

The agency's intake and assessment practices ensure that persons served receive prompt and responsive access to appropriate services.

Interpretation

For detoxification treatment programs, due to the physical and mental state of the service recipient, family involvement in the intake and assessment process may not be appropriate. Therefore, the process will focus on the individual and his or her care needs.
2020 Edition

Currently viewing: MENTAL HEALTH AND/OR SUBSTANCE USE SERVICES (PA-MHSU)

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Purpose

Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning and attain recovery and wellness.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Screening and intake procedures
  • Assessment procedures
  • Copy of assessment tool(s)
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 

PA-MHSU 3.01

Persons served are screened and informed about: 
  1. how well their request matches the agency's services; 
  2. what services will be available and when; and
  3. rules and expectations of the program. 

Interpretation

For agencies providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program.
NA Another agency is responsible for screening, as defined in a contract.
Examples: Screenings will vary based on the program’s target population and services offered and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, suicide and self-harm history and current level of risk, and/or risk of harm to others.

 
Fundamental Practice

PA-MHSU 3.02

Prompt, responsive intake practices: 
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations including access to expedited service planning;
  3. facilitate the identification of individuals and families with co-occurring conditions and multiple needs;
  4. support timely initiation of services; and
  5. provide for placement on a waiting list or timely referral to appropriate resources when individuals cannot be served or cannot be served promptly.

Interpretation

Individuals discharged from emergency rooms or psychiatric inpatient facilities after a suicide attempt remain a high-risk group post discharge. To reduce the risk of suicide re-attempt, these individuals should be contacted within 24 hours, receive access to services within three to seven calendar days, and active outreach should be initiated in cases of a missed appointment until contact is made.
Examples: Referral providers for crisis situations may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotlines. Urgent situations can also include those in which an individual has a child in the child welfare system.

 

PA-MHSU 3.03

Persons served participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. appropriately tailored to meet the age and developmental level of persons served;
  3. updated as needed based on the needs of persons served; and
  4. focused on information pertinent for meeting service requests and objectives.

Interpretation

For an assessment to be trauma-informed, the agency understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the agency actively prevents instances that could potentially re-traumatize persons served.
Examples: When working with children, assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, a thorough health and developmental history, and/or involvement in other systems including education, child welfare, and juvenile justice.

 
Fundamental Practice

PA-MHSU 3.04

The comprehensive assessment includes: 
  1. the service recipient’s behavioral health, physical health, and community and social support service needs and goals;
  2. a brief screen for trauma history and recent incidents of trauma followed by a comprehensive, evidence-based trauma assessment conducted by an appropriately qualified individual when indicated;
  3. individual and family strengths, risks, and protective factors; 
  4. natural supports, resources and helping networks that can increase service participation and achievement of agreed-upon goals; 
  5. a risk evaluation to assess risk of suicide, self-injury, neglect, exploitation, and violence towards others; and  
  6. a summary of symptoms and diagnoses based on a standardized diagnostic tool.

Interpretation

The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

Interpretation

Due to the short-term nature and focus of detoxification treatment programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process. 

Interpretation

Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.
Examples: Assessment of behavioral health can include an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks.

 

PA-MHSU 3.05

The agency uses a comprehensive, evidence-based suicide risk assessment tool to assess the following when suicide risk is identified: 
  1. suicidal desire;
  2. capability;
  3. intent; and 
  4. buffers/protective factors.

 
Fundamental Practice

PA-MHSU 3.06

Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include: 
  1. medication monitoring and management;
  2. physical examinations or other physical health services;
  3. medical detoxification;
  4. laboratory testing and toxicology screens; or
  5. other diagnostic procedures.

Interpretation

The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The agency is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.

Interpretation

Agencies providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement. See PA-MHSU 7.01 for more information.

All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.

 

PA-MHSU 3.07

Reassessments are conducted as necessary, according to the needs of the service recipient.

Interpretation

Certain events may heighten or trigger suicide risk, as could a new physical or mental health diagnosis, and should prompt a new suicide risk assessment as part of the reassessment. Once any potential suicide risk is identified, it may be important to conduct reassessments regularly even if these trigger events are not observed.
NA The agency provides Diagnosis, Assessment, and Referral Services only.
Examples: Timeframes for reassessment depend on the service population and length of treatment, or may be delineated by regulatory requirements. The agency may conduct a reassessment during specific milestones in the treatment process, for example: 
  1. after significant treatment progress;
  2. after a lack of significant treatment progress;
  3. after new symptoms are identified;
  4. after changes in treatment strategy and/or medication;
  5. when significant behavioral changes are observed; 
  6. when there are changes to a family situation; or
  7. when significant environmental changes or external stressors occur.