Topic Number2.3.28Effective DateJanuary 1, 2017
ProcedureUrine Drug Screen (UDS) Administration and Management
PurposeTo document WWRC’s use of voluntary Substance Abuse Urine Drug Screening (UDS) tests, their administration, documentation standards and expectations, confidentiality and dissemination of results
Accountability Indicators
Policy Reference
Detailed Governance ReferenceWWRC BHS Department Manual, Substance Abuse
Executive Staff ContactBarb Ostrander, WWRC Division Director, Medical Rehabilitation Services


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Governance Procedure

In the substance abuse field, confidentiality is governed by federal law (42 U.S.C. § 290dd-2) and regulations (42 CFR Part 2) that outline under what limited circumstances information about the client's treatment may be disclosed with and without the client's consent.  This governance procedure documents WWRC's use of voluntary Substance Abuse Urine Drug Screening (UDS) tests, their administration, documentation standards and expectations, confidentiality protocols, and allowable procedures for dissemination of results.


WWRC Urine Drug Screening (UDS) Administration & Management Overview


Psych Service clinicians in WWRC's Behavioral Health Department are authorized to use UDS solely for clinical purposes; this includes use as a part of a comprehensive substance abuse assessment and use for monitoring clients in substance abuse treatment.  The WWRC Consulting Psychiatrist may order a drug screen for other clinical purposes (e.g., making certain that the client is taking a prescribed medication, ascertaining whether the client is taking a substance which might interact with prescribed medications.)

Because WWRC does not have access to a certified laboratory to perform a confirmatory gas chromatography or mass spectrometry (GC/MS) test, WWRC may not use UDS for any administrative or law enforcement purpose that might be challenged in a court of law or an administrative hearing.

The sole exception to this policy is that Psych Service Clinicians will provide pre-employment/ preplacement UDS when requested by a potential employer, a Student Internship Site, or External Training Option site.  Only negative screens will be reported. Positive screens will be managed as per procedure below.


Substance Abuse Assessment & Treatment Protocols

Individuals may be referred for substance abuse assessment by a WWRC or DARS Rehabilitation Counselor, a WWRC Conduct Review Board (CRB) or CRB Appeals Panel, the WWRC Admissions Committee, the WWRC Center Threat Assessment Team, and/or through the Orientation screening process, in consultation with the assigned Rehabilitation Counselor.


The Substance Abuse Assessment includes:

1.  Clinical Interview

2.  Complete Substance Abuse History

3.  Relevant Psychiatric, Family, Educational, and Legal Histories

4.  Mental Status Examination

5.  UDS (if clinically indicated.)

6.  Screening Test (e.g., Substance Abuse Subtle Screening Inventory)

7.  Conclusions, Diagnoses, and Recommendations


A UDS is not clinically indicated when the individual admits using the substance.  Though there are exceptions, in that case, the results are typically not useful.  With the consent of the client, the results of the substance abuse assessment including information on the UDS are returned to the referral source. 


A WWRC Psych Service Clinician may ask a client in ongoing individual or group treatment to take a UDS if there are concerns about relapse. UDS is voluntary and may be refused.  A refusal will be reported to the referral source.  For clients in substance abuse treatment, a refusal is considered a positive result.  Thus if an individual is in a later stage recovery group which requires that members be clean, refusal of the UDS would be considered a relapse and the individual might not be permitted to continue in the group.


A WWRC Psych Service Clinician will provide pre-employment/ preplacement UDS when required by a potential employer, Student Internship Site, or External Training Option (ETO) site and requested by the Rehabilitation Counselor.  The cost for these services in the community is prohibitive.  Results of the Pre-Employment / Pre-Placement UDS will be provided to the client and to the Rehabilitation Counselor.  If the result is positive, a substance abuse assessment might be recommended.


If a client disputes the results of a UDS, a second UDS may be administered, where possible from a different lot or batch of tests.  Because WWRC does not have access to a certified laboratory to perform a confirmatory GC/MS test, WWRC must use some discretion in interpreting results.  The tests WWRC uses are between 96 and 99 percent accurate.


WWRC UDS Administration Protocols

Any qualified Licensed Psych Service Clinician may order a drug screen.  Drug screens are voluntary.  If the individual has not already done so, the client is first asked to complete NUR-2553 DRUG SCREEN CONSENT FORM.  Note that only one form needs to be completed for each admission to WWRC but the consent covers any number of UDS.   


The Psych Service Clinician then completes the PSY-2930 UDS Report with the name and PID of the client, the panel requested, the clinician's name and credentials, signature, time and date.  The clinician then brings the client along with the UDS device to Student Health who will administer the test.  If possible, please contact Student Health to arrange the time in advance. The client should not be unsupervised between the time the UDS Report is prepared and the urine is gathered at Student Health. 


Licensed Nursing Staff will administer the UDS and indicate on the report whether the screen is valid, whether it was negative or positive and for what substance(s).  The licensed Nursing Staff will then sign and print name and credentials.   The UDS Device is then placed on the report form where indicated and two photocopies are made.  One photocopy is sent directly to Records Management, the other is returned to the Psych Service Clinician.


Circulation of Results

UDS results for WWRC clients are maintained in DocFinity, with authorized access limited to WWRC Psych Service Clinicians, the WWRC Medical Director, and the WWRC Medical Services Division Director.  Reports of substance abuse assessments are returned to the referral source and the Rehabilitation Counselor.