SECTION 340:110-3-154. Social services

(a)   Admission. The program involves the resident and parents in the admission process.

(1)   On admission, an assessment is completed for each resident indicating the placement is appropriate. The admission assessment is documented and available for Licensing review. An assessment includes the resident's:

(A)   circumstances leading to the referral;

(B)   family description and relationships with family members and other significant adults and children;

(C)   current and past behavior description, including both appropriate and maladaptive behavior;

(D)   immunization record, medical and dental histories, including current medical problems;

(E)   school history, including the current educational level, special achievements, and school problems;

(F)   placement history outside of the home, including placement reasons;

(G)   mental health history; and

(H)   record documentation indicating efforts to obtain identifying information in (A) through (G) of this paragraph, when not obtainable.

(2)   Resident admission for 4 years of age and younger.

(A)   A program may only accept residents 4 years of age and younger when maintaining a sibling group, maintaining a child with a parent, or when there is a need for special services, such as:

(i)   medical care or monitoring;

(ii)   awake supervision; or

(iii)   crisis intervention, assessment, or treatment.

(B)   When a resident 4 years of age and younger is in care at the program, the admission assessment and the service plan document why this placement is in the resident's best interest.

(3)   Individuals 19 years of age and older are not admitted to the program. A program may continue to serve an individual who entered the program prior to his or her 19th birthday through the service plan completion.

(4)   Upon admission, the program obtains the parents' signature, for:

(A)   authority to provide care;

(B)   authority to provide medical care;

(C)   financial agreement, when a charge is made for the resident's care;

(D)   authority to use the resident or the resident's picture in publicity, when applicable; and

(E)   a release noting understanding that volunteer drivers or specialized service professionals are not required to complete the criminal history review per Oklahoma Administrative Code (OAC) 340:110-3-153.1. Specific activities or events are identified in the release.

(5)   Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program.

(6)   On admission, the program advises the resident of all program rules and regulations.

(7)   Program policies provided to residents and parents include:

(A)   resident's rights;

(B)   grievance procedures;

(C)   behavior management policies;

(D)   trips away from the program;

(E)   use of volunteers; and

(F)   frequency of reports to the parents.

(8)   Acceptance of out-of-state residents is made per the Interstate Compact on the Placement of Children.

(b)   Service planning. The service plan is available for Licensing review.

(1)   Comprehensive service plan. A written service plan is developed and documented for each resident within 30-calendar days of admission.

(A)   The program involves the resident and parents in service plan development. When parents do not participate in service plan development, the non-participation reason is documented.

(B)   The service plan identifies and includes, the:

(i)   resident's needs, such as counseling, education, physical health needs, medical care, or recreation, in addition to basic needs for food, shelter, clothing, routine care, and supervision;

(ii)   strategies for meeting the resident's needs, including instructions to staff. Individual health needs must be addressed in the program's medical plan. Refer to OAC 340:110-3-154.3;

(iii)   estimated length of stay;

(iv)   goals and anticipated plans for discharge;

(v)   program's plan to involve the resident's parents, including visitation guidelines; and

(vi)   names and dated signatures of those participating in service plan development.

(2)   Service plan review. Service plan reviews are available for Licensing review.

(A)   The service plan is reviewed within 90-calendar days after development and at least every six months thereafter.

(B)   The program involves the resident and parents in the service plan review. When the parents do not participate in the service plan review, the non-participation reason is documented.

(C)   The service plan review includes:

(i)   evaluation of progress toward meeting identified needs;

(ii)   new needs identified since the plan was developed or last reviewed along with strategies to meet those needs, including instructions to staff;

(iii)   estimated length of stay update and discharge plans;

(iv)   continued appropriateness of placement assessment with the goal of determining when the resident may be returned home, placed in a foster home, transferred to some other care better suited for the resident's development, or maintained for a longer period in the residential program; and

(v)   names and dated signatures of review participants.

(c)   Services. The program provides or facilitates the provision of services for meeting service plan goals.

(d)   Discharge procedures. The program involves the resident, parents or legal custodian, and personnel in discharge planning.

(1)   Except in an emergency, a resident is not discharged to anyone other than the resident's parents or legal custodian without written authorization.

(2)   An emergency discharge occurs when a resident presents a danger to self or others. Upon emergency discharge of a resident, the program informs the parents or legal custodian, immediately.

(3)   The individual to whom the resident is discharged produces photographic identification and signs the discharge form before leaving with the resident.

(4)   The resident's discharge date, time, destination, and circumstances are documented in the resident's record. The documentation also includes the individual's name, address, and relationship to whom the resident is discharged.

(e)   Resident's records. The program maintains a written record for each resident that is retained for three years following the resident's discharge.

(1)   The record includes:

(A)   resident's name, address, phone number, Social Security number, sex, race, religion, birth date and place;

(B)   admission assessment;

(C)   required authorizations, per (a)(4) of this Section;

(D)   medical records;

(E)   comprehensive service plan and reviews;

(F)   educational information;

(G)   serious incident reports are not limited to, suicide attempts, injuries requiring medical treatment, runaway attempts, crimes committed and abuse allegations, neglect, or any allegation of behavior management violations per OAC 340:110-3-154.2(b) - (d). The report includes incident nature, date and time, individuals involved, and surrounding circumstances;

(H)   reports of separation, use of physical restraint, and other restrictions;

(I)   discharge summary; and

(J)   signed documentation the resident and parents were provided copies of program policies.

(2)   Resident's records are confidential as defined by federal and state laws.

[Source: Amended at 10 Ok Reg 3663, eff 7-12-93; Amended at 18 Ok Reg 3331, eff 10-1-01 (emergency); Amended at 19 Ok Reg 1171, eff 5-13-02; Amended at 22 Ok Reg 1304, eff 6-1-05; Amended at 26 Ok Reg 2239, eff 7-1-09; Amended at 31 Ok Reg 154, eff 11-1-13 (emergency); Amended at 31 Ok Reg 1854, eff 9-15-14; Amended at 35 Ok Reg 1732, eff 11-1-18]