Okla. Admin. Code § 450:24-7-5

Current through Vol. 42, No. 4, November 1, 2024

Section 450:24-7-5 - Clinical record content, screening and assessment

(a) All facilities shall complete a face-to face screening with each individual to determine appropriateness of admission.

(b) The CCARC shall document the face-to-face screening between the potential consumer and the CCARC including how the consumer was welcomed and engaged, how the consumer was assisted to identify goals and experience hope, how the consumer received integrated screening to identify both immediate and ongoing needs and how the consumer was assisted to determine appropriateness of admission, and/or to access other appropriate services.

(c) All facilities shall assess each consumer for appropriateness of admission to the treatment program. Facilities must ensure that a consumer's refusal of a particular service does not preclude the consumer from accessing other needed mental health or substance-related or addictive disorder treatment services. Should the service provider determine the consumer's needs cannot be met within the facility, clinical assessments and referrals for the consumer shall be documented.

(d) Any consumer seeking admission to inpatient or residential services, including medically-supervised withdrawal management and non-medical withdrawal management while under the influence or undergoing withdrawal of alcohol or drugs, shall be assessed prior to admission for medical needs. The written criteria to be used for medical needs assessment of persons under the influence or undergoing withdrawal of alcohol or drugs, and the protocols for determining when physician review of the assessment is needed, shall be approved by the facility's consulting physician.

(e) Compliance with 450:18-7-21 may be determined by a review of the following:

(1) Policies and procedures;

(2) Intake protocols;

(3) assessment instruments;

(4) Treatment records;

(5) Interviews with staff and consumers; and

(6) Other facility documentation.

Okla. Admin. Code § 450:24-7-5

Added at 28 Ok Reg 2025, eff 10-1-11

Amended by Oklahoma Register, Volume 34, Issue 24, September 1, 2017, eff. 10/1/2017

Amended by Oklahoma Register, Volume 35, Issue 24, September 4, 2018, eff. 10/1/2018

Amended by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/15/2021

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/15/2022