Okla. Admin. Code § 450:1-9-5.6

Current through Vol. 41, No. 19, June 17, 2024

Section 450:1-9-5.6 - Quality clinical standards for facilities and programs

(a)Staff qualifications.

(1) All staff who provide clinical services within facilities and programs shall have documented qualifications or training specific to the clinical services they provide.

(2) Each facility or program shall have policies and procedures for documenting and verifying the training, experience, education, and other credentials of service providers prior to their providing treatment services for which they were hired. All staff shall be documented as privileged prior to performing treatment services.

(3) All direct care staff shall be at least eighteen (18) years old.

(4) Each facility or program shall minimally perform a review each calendar year of current licensure, certifications, and current qualifications for privileges to provide specific treatment services.

(b)Staff development and training.

(1) All facilities and programs shall have a written staff development and training plan for all administrative, professional and support staff. This plan shall include, at a minimum:

(A) Orientation procedures;

(B) In-service training and education programs;

(C) Availability of professional reference materials;

(D) Mechanisms for ensuring outside continuing educational opportunities for staff members; and

(E) Performance improvement activities and their results.

(2) In-service training shall be conducted each calendar year and shall be required within thirty (30) days of each employee's hire date and each calendar year thereafter for all employees on the following topics:

(A) Fire and safety, including the location and use of all fire extinguishers and first aid supplies and equipment;

(B) Universal precautions and infection control;

(C) Consumer's rights and the constraints of the Mental Health Patient's Bill of Rights;

(D) Confidentiality;

(E) Oklahoma Child Abuse Reporting and Prevention Act, 10 O.S. §§ 7101-7115;

(F) Facility policy and procedures;

(G) Cultural competence (including military culture if active duty or veterans are being served);

(H) Co-occurring disorder competency and treatment principles;

(I) Trauma informed service provision;

(J) Crisis intervention;

(K) Suicide risk assessment, prevention, and response; and

(L) Age and developmentally appropriate trainings, where applicable.

(3) All clinical staff, direct care staff, and/or volunteers providing direct care shall have non-physical intervention training in techniques and philosophies addressing appropriate non-violent interventions for potentially physical interpersonal conflicts, staff attitudes which promote dignity and enhanced self-esteem, keys to effective communication skills, verbal and non-verbal interaction and non-violent intervention within thirty (30) days of being hired with updates each calendar year thereafter. Staff and volunteers shall not participate in an intervention without first completing this training. This standard shall not apply to facilities or programs subject to Chapter 27 of this Titleor outpatient programs subject to Chapter 18 of this Title.

(4) The local facility Executive Director shall designate which positions and employees, including temporary employees, will be required to successfully complete physical intervention training. A designated employee or volunteer shall not provide direct care services to consumers until completing this training. This standard shall not apply to facilities or programs subject to Chapter 16 or Chapter 27 of this Title, or outpatient programs subject to Chapter 18 of this Title.

(5) The training curriculum for (3) and (4) of this subsection must be approved by the ODMHSAS commissioner or designee.

(6) Each site providing residential level of care services and/or subject to Chapter 23 of this Title shall have staff during all hours of operation who maintain current certification in basic first aid and Cardiopulmonary Resuscitation (CPR).

(c)Clinical supervision.

(1) With the exception of facilities certified under Chapter 16 of this Title, all facilities and programs shall have written policies and procedures, operational methods, and documentation of the provision of clinical supervision for all direct treatment and service staff. For facilities that employ only one service provider, supervision will be in the form of clinical consultation from a qualified service provider in the same field. These policies shall include, but are not limited to:

(A) Credentials required for the clinical supervisor;

(B) Specific frequency for case reviews with treatment and service providers;

(C) Methods and time frames for supervision of individual, group, and educational treatment services; and

(D) Written policies and procedures defining the program's plan for appropriate counselor-to-consumer ratio, and a plan for how exceptions may be handled.

(2) Ongoing clinical supervision shall be provided and shall address:

(A) The appropriateness of treatment selected for the consumer;

(B) Treatment effectiveness as reflected by the consumers meeting their individual goals; and

(C) The provision of feedback that enhances the clinical skills of service providers.

(d)Clinical record keeping, basic requirements.

(1) All facilities and programs shall establish and maintain an organized clinical record system for the collection and documentation of information appropriate to the treatment processes; and which insures organized, easily retrievable, usable clinical records stored under confidential conditions and with planned retention and disposition.

(2) Each facility or program shall maintain an individual record for each consumer.

(3) The facility's or program's policies and procedures shall:

(A) Define the content of the consumer record in accordance with all applicable state and federal rules, requirements, and statutes;

(B) Define storage, retention and destruction requirements for consumer records in a manner that prevents unauthorized information disclosures;

(C) Require consumer records not in electronic format be maintained in locked equipment which is kept within a locked room, vehicle, or premise;

(D) Require legible entries in consumer records, signed with first name or initial, last name, and dated by the person making the entry;

(E) Require the consumer's name or unique identifier be typed or written on each page in consumer records not in electronic format;

(F) Require a signed consent for treatment before a consumer is admitted on a voluntary basis; and

(G) Require consent for release of information in accordance with federal and state laws, guidelines, and standards, including OAC 450:15-3-20.1 and OAC 450:15-3-20.2. For disclosure of information related to substance use disorder referral, payment, and follow up, a signed consent is required.

(4) If electronic clinical (medical) records are maintained, there shall be proof of compliance with all applicable state and federal rules and statutes related to electronic medical records, encryption, and other required features.

(5) ODMHSAS operated facilities shall comply with Records Disposition Schedule 82-17 as approved by the Oklahoma Archives and Records Commission.

(6) The facility or program shall assure consumer records are readily accessible to all staff providing services to consumers. Such access shall be limited to the minimum necessary to carry out the staff member's job functions or the purpose for the use of the records.

(e)Discharge summary.

(1) A completed discharge summary shall be entered in each consumer's record within fifteen (15) days of the consumer completing, transferring, or discontinuing services. The summary shall be signed and dated by the staff member completing the summary. Consumers who have received no services for one hundred eighty (180) days shall be discharged if it is determined that services are no longer needed or desired.

(2) A discharge summary shall include, but not be limited to, the consumer's progress made in treatment, initial condition and condition of the consumer at discharge, diagnoses, summary of current medications, when applicable, and recommendations for referrals, if deemed necessary. It shall include a discharge plan which lists written recommendations and specific referrals for implementing aftercare services, including medications. Discharge plans shall be developed with the knowledge and cooperation of the consumer, when possible. This standard shall not apply to facilities certified under Chapter 16 of this Title.

(3) The signature of the staff member completing the summary and the date of completion shall be included in the discharge summary.

(4) In the event of death of a consumer, in lieu of a discharge summary, a summary statement including applicable information shall be documented in the record.

(f)Critical incidents.

(1) All facilities and programs shall have written policies and procedures requiring documentation and reporting of critical incidents and analysis of the contributors to the incident to ODMHSAS.

(2) The documentation of critical incidents shall contain, at a minimum:

(A) Facility name and signature of the person(s) reporting the incident;

(B) Names of the consumer(s), and/or staff member(s) involved;

(C) Time, date, and physical location of the incident;

(D) Time and date incident was reported and name of person within the facility to whom it was reported;

(E) Description of incident;

(F) Severity of each injury, if applicable. Severity shall be indicated as follows:

(i) No off-site medical care required or first aid care administered on-site;

(ii) Medical care by a physician or nurse or follow-up attention required; or

(iii) Hospitalization or immediate off-site medical attention was required;

(G) Resolution or action taken and date resolution or action was taken; and

(H) Signature of the facility administrator, or designee of the facility administrator. Designees shall be identified in the facility's policy and procedures.

(3) Critical incidents shall be reported to ODMHSAS with specific timeframes, as follows:

(A) Critical incidents requiring medical care by a physician or nurse or follow-up attention and incidents requiring hospitalization or immediate off-site medical attention shall be delivered via fax, or ODMHSAS designated electronic system, to ODMHSAS within seventy-two (72) hours of the incident.

(B) Critical incidents involving allegations constituting a sentinel event or consumer abuse shall be reported to ODMHSAS immediately via telephone or fax, but within not more than twenty-four (24) hours of the incident. If reported by telephone, the report shall be followed with a written report within twenty-four (24) hours of the incident.

Okla. Admin. Code § 450:1-9-5.6

Adopted 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

Amended by Oklahoma Register, Volume 40, Issue 22, August 1, 2023, eff. 9/15/2023