SECTION 450:17-5-178. Initial screening, assessment and comprehensive evaluation

(a)   The facility will directly provide screening, assessment and diagnosis, including risk assessment, for behavioral health conditions. The facility must determine the extent to which each consumer's needs and preferences can be adequately addressed within the array of required services.

(b)   For new consumers requesting or being referred for behavioral health services, an integrated screening approach in accordance with OAC 450:17-3-21 will be used to determine the consumer's acuity of needs. The facility shall use standardized and validated screening and assessment tools, and where appropriate, brief motivational interviewing techniques.

(1)   If the screening identifies an emergency/crisis need, the facility will take appropriate action immediately, including any necessary subsequent outpatient follow-up.

(2)   If the screening identifies an urgent need, clinical services are provided and the initial evaluation completed within one business day of the time the request is made. An urgent need is one that if not addressed immediately could result in the person becoming a danger to self or others, or could cause a health risk.

(3)   If screening identifies unsafe substance use including problematic alcohol or other substance use, the facility will conduct a brief intervention and the consumer is provided or referred for and successfully linked with a full assessment and treatment, if applicable.

(4)   If the screening identifies routine needs, services will be provided and the initial evaluation completed within 10 business days.

(c)   A Licensed Behavioral Health Professional (LBHP) or Licensure Candidate, acting within his/her scope of practice requirements, must complete an initial assessment in accordance with the standard in OAC 450:17-3-21 for consumers who have not been assessed by the facility within the past 6 months.

(d)   For consumers presenting with emergency or urgent needs, the initial assessment may be conducted by telemedicine but an in-person assessment is preferred. If the initial assessment is conducted via telemedicine, once the emergency is resolved, the consumer must be seen in person at the next subsequent encounter and the initial assessment reviewed.

(e)   Prior to assigning a consumer to a CCBHC intensive level of care, a comprehensive evaluation must be completed by the interdisciplinary team performing within each team member's scope of practice consistent with each consumer's immediate needs and include a written narrative in each of the following areas:

(1)   Psychiatric and substance use history, mental status, and a current DSM diagnosis;

(2)   Medical, dental, and other health needs;

(3)   Education and/or employment;

(4)   Social development and functioning;

(5)   Activities of daily living; and

(6)   Family structure and relationships.

(g)   The facility must ensure access to the comprehensive evaluation within 60 calendar days of the initial request for services. This requirement does not preclude the provision of treatment during the 60 day period.

(h)   The comprehensive evaluation must be updated as needed but no less than every six (6) months.

(i)   Compliance with this Section will be determined by on-site observation, review of organizational documents, program descriptions, outcome monitoring and other performance improvement activity reports, and clinical records.

[Source: Added at 33 Ok Reg 964, eff 9-1-16; Amended at 34 Ok Reg 1777, eff 10-1-17]