SECTION 450:18-7-21. Clinical record content, screening and assessment

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

(b)   The facility shall maintain written screening policies and procedures that, at a minimum include: (1) how the screening is to be conducted; (2) that the screening conducted is an integrated screening to identify both immediate and ongoing needs, which includes screening for whether the consumer is a risk to self or others, including suicide risk factors; and (3) how the consumer is assisted with admission for services, and/or with accessing other appropriate services.

(c)   All facilities shall assess each consumer for appropriateness of admission to the treatment program. Each presenting consumer for substance use disorder treatment shall be assessed, according to ASAM criteria, which includes a list of symptoms for all six dimensions and each level of care to determine a clinically appropriate placement in the least restrictive level of care. The Oklahoma Determination of ASAM Service Level (ODASL) must be completed when determining clinically appropriate residential treatment placement. For facilities offering gambling disorder treatment services, each presenting consumer for gambling disorder treatment shall be assessed using the Southern Oaks Gambling Screen (SOGS). 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, shall be approved by the facility's consulting physician.

(e)   Upon determination of appropriate admission, consumer assessment demographic information shall contain, but not be limited to, the following:

(1)   Date of initial contact requesting services;

(2)   Date of the screening and/or assessment;

(3)   Consumer's name;

(4)   Gender;

(5)   Birthdate;

(6)   Home address;

(7)   Telephone number;

(8)   Referral source;

(9)   Reason for referral;

(10)   Significant other to be notified in case of emergency; and

(11)   PICISdata core content, if the facility reports on PICIS.

(f)   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.

[Source: Added at 13 Ok Reg 2769, eff 7-1-96; Amended at 14 Ok Reg 676, eff 12-24-96 (emergency); Amended at 14 Ok Reg 1934, eff 5-27-97; Amended at 19 Ok Reg 2375, eff 7-1-02; Amended at 22 Ok Reg 2109, eff 7-1-05; Amended at 23 Ok Reg 1953, eff 7-1-06; Amended at 24 Ok Reg 2580, eff 7-12-07; Amended at 27 Ok Reg 2237, eff 7-11-10; Amended at 31 Ok Reg 2004, eff 10-1-14; Amended at 33 Ok Reg 982, eff 9-1-16; Amended at 34 Ok Reg 1791, eff 10-1-17; Added at 35 Ok Reg 1821, eff 10-1-18]