SECTION 75:15-5-3.1. Record content - service specific

(a)   Client records for specific services shall conform to the following:

(1)   Shelter Services:

(A)   On a client's entry to the shelter, staff or volunteer shall record the client's name, emergency contact person(s) and any referral for medical or emergency services. This information may be a part of the full intake interview if the full intake is done on entering the shelter. An evidence-based, dangerousness assessment and safety planning shall be offered to be done at this time;

(B)   Shelter clients shall be offered the full intake interview and screening within forty-eight (48) hours of entry into the shelter. If a client declines to participate with intake process, staff or volunteer shall document offer of services;

(C)   Service plans shall be offered and completed within five (5) business days of the shelter client's entry to the shelter. If a client declines to participate with the formation of a service plan, staff or volunteer shall document offer of services;

(D)   The service plan shall be offered to be reviewed and updated at least every two (2) weeks. If the client declines to review the service plan, staff or volunteer shall document offer of services;

(E)   The client's service plan shall be offered to include components which address the needs of each child accompanying the client. If the client declines to add components for their children, staff or volunteer shall document offer of services;

(F)   The service plan shall be offered to include safety issues for client and children. If the client declines to include safety issues, staff or volunteer shall document offer of services, and

(G)   A daily note.

(2)   Crisis Intervention Services:

(A)   All face-to-face contacts with clients are documented and contacts with persons not receiving additional services shall be offered and documented. Documentation shall minimally include the following:

(i)   Staff/Volunteer Name and signature;

(ii)   Date, time, length, and location of intervention;

(iii)   Safety planning based on risk;

(iv)   Client's name, age, race, county of residence, and contact number if given;

(v)   Protective order information if applicable;

(vi)   Personnel involved such as police, hospital, etc.;

(vii)   Summary of contact including injuries observed and services requested;

(viii)   Follow-up services shall be offered to all victims if victim safety is not compromised; and

(ix)   Outcome.

(B)   All telephone contacts shall be documented. Documentation shall minimally include the following:

(i)   Staff/Volunteer name;

(ii)   Date, time and length of call;

(iii)   Safety planning based on risk;

(iv)   Caller's name and contact number, if given however, no caller shall be required to give a name, phone number or any other identifying information as a condition to receive information or domestic violence, sexual assault or stalking services;

(v)   Summary of the call including services needed and offered;

(vi)   Outcome; and

(C)   Contact information is kept by the program.

(D)   Clients to be transported to shelter facilities shall be screened before the shelter referral is made. If the client is in immediate danger, or no safe housing is available, this screening may be initially waived. If the screening is waived, documentation shall reflect the reason(s) and the notification of such to the shelter.

(3)   Counseling, Support and Advocacy Services:

(A)   An assessment of the client's needs shall be completed by the third (3rd) counseling or advocacy session. If a client declines to participate staff or volunteer shall document offer of services;

(B)   A service plan shall be completed by the fifth (5th) advocacy or counseling session. If a client declines to participate staff or volunteer shall document offer of services; and

(C)   A service plan review and update shall be completed at a minimum of once every six (6) months. If a client declines to participate staff or volunteer shall document offer of services;

(4)   Sexual Assault Services:

(A)   For victims who continue in support or counseling sessions, a service plan shall be developed by the fifth (5th) visit. If a client declines to participate staff or volunteer shall document offer of services; and

(B)   Service plans shall be reviewed and updated at a minimum of once every ninety (90) days. If a client declines to participate staff or volunteer shall document offer of services.

(5)   Transitional Living Services:

(A)   A service plan including safety issues for the client and dependents shall be developed within five (5) business days of the client moving in; and

(B)   The service plan shall be reviewed and updated at least every ninety (90) days.

(6)   Safe Home Services

(A)   A service plan that includes goals agreed upon by the client and sponsoring family shall be developed within five (5) business days of the client moving in. On a client's entry to the Safe Home, the safe home provider shall record the client's name, emergency contact information, and pertinent medical information;

(B)   Safe Home clients shall receive a full intake interview and screening by program staff or volunteer within twenty-four (24) hours of admission or by the first business day following admission;

(C)   A service plan shall be developed within five (5) business days of the client's entry to the Safe Home; and

(D)   All records regarding the client shall be retained in the client's record at the sponsoring program.

(b)   Where required information is not obtained, efforts to comply with the requirements of this subsection shall be documented in the client record.

(c)   Compliance with 75:15-5-3.1 shall be determined by a review of client records, policy and procedures, call logs, and/or other supporting documentation.

[Source: Transferred from 450:19-5-3.1 by SB 236 (2005), eff 7-1-05 (Editor’s Notice published at 22 Ok Reg 2667); Amended at 23 Ok Reg 339, eff 11-8-05 (emergency); Amended at 23 Ok Reg 2200, eff 7-1-06; Amended at 24 Ok Reg 2508, eff 7-15-07; Amended at 26 Ok Reg 2426, eff 7-11-09; Amended at 27 Ok Reg 1709, eff 7-1-10; Amended at 28 Ok Reg 1906, eff 7-11-11; Amended at 29 Ok Reg 1759, eff 8-11-12; Amended at 30 Ok Reg 1915, eff 7-25-13; Amended at 31 Ok Reg 804, eff 9-12-14; Amended at 33 Ok Reg 1195, eff 9-11-16; Amended at 35 Ok Reg 863, eff 9-14-18]