Ohio Administrative Code 5122:2 — Department of Behavioral Health | Operations Management

Chapter 5122:2-1 Community Mental Health Board Operations

Ohio Adm.Code 5122:2-1-02 Board client rights and grievance procedure.

(A) The purpose of this rule is to describe the role and responsibilities of boards in the client rights and grievance procedures.

(B) The provisions of this rule are applicable to each board of alcohol, drug addiction, and mental health services constituted according to section 340.02 of the Revised Code, or a community mental health board or an alcohol and drug addiction services board as described in section 340.021 of the Revised Code. In addition, the provisions of rule 5122-26-18 of the Administrative Code are also applicable to each board which itself provides mental health or addiction services when permitted to do so in accordance with section 340.037 of the Revised Code.

(C) Definitions.

(1) "Board" means a board of alcohol, drug addiction, and mental health services constituted according to section 340.02 of the Revised Code, or a community mental health board or an alcohol and drug addiction services board as described in section 340.021 of the Revised Code.

(2) "Client advocate" means the individual designated by a community mental health or addiction services provider or board with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within each provider or board. For these purposes the the title has the same meaning as client rights officer or client rights specialist.

(3) "Contract provider" means a public or private service provider with which a board enters into a contract for the delivery of mental health or addiction services. A board which is itself providing mental health or addiction services is subject to the same requirements and standards which are applicable to contract providers, as specified in rule 5122:2-1-05 of the Administrative Code.

(4) "Grievance" means a written complaint initiated either verbally or in writing by a client or by any other person or provider on behalf of a client regarding denial or abuse of any client's rights.

(5) "Services" means the complete array of professional interventions designed to help a person achieve improvements in mental health such as counseling, individual or group therapy, education, community psychiatric supportive treatment, assessment, diagnosis, treatment planning and goal setting, clinical review, psychopharmacology, discharge planning, professionally-led support, etc.

(D) Board procedure.

(1) Each board shall assure that each contract provider has a grievance procedure in place which meets the requirements of rule 5122-26-18 of the Administrative Code. Each board shall recognize that, for a provider accredited and granted deemed status by the Ohio department of mental health and addiction services in accordance with rule 5122-25-02 of the Administrative Code, the requirements of rule 5122-26-18 of the Administrative Code are met by provider conformance to its accrediting body standards.

(2) Each board must establish a procedure for addressing client rights complaints, including, when applicable, complaints initiated in accordance with rule 5122-30-22 or 5122-30-22.1 of the Administrative Code on behalf of a resident of a residential facility. This procedure must include:

(a) Provision for accessing provider information relevant to the complaint;

(b) Provision of written copy of the board's grievance procedure to be available on request;

(c) Specification of time lines for a resolution of the grievance, not to exceed twenty-one working days from the date the grievance is filed;

(d) Provision for written notification and explanation of the resolution to be provided to the client, or to the griever if other than the client, with the client's permission;

(e) A statement regarding the option of the griever to further grieve with any or all of the following: Ohio department of mental health and addiction services, the Ohio protection and advocacy system (disability rights Ohio), or the U.S. department of health and human services. Appropriate professional licensing or regulatory boards' relevant names, addresses, and telephone numbers shall be included; and

(f) Provision for providing, upon request, relevant information about the grievance to one or more of the organizations specified in this paragraph to which the griever has initiated a complaint.

(E) Implementation and monitoring.

(1) Any board may accomplish its responsibilities in regard to the provisions of this rule and rule 5122-26-18 of the Administrative Code through utilization of its own staff or board members as appropriate, or through agreement with outside staff, agencies, providers, or organizations, except that:

(a) Each board must assure prompt accessibility of the client advocate.

(b) The utilization of outside persons must be clearly explained to clients, applicants, and grievers.

(2) The board shall also keep records of grievances it receives, the subject of the grievances, and the resolution of each, and shall assure the availability of these records for review by the department of mental health and addiction services upon request. The board shall summarize annually its records to include number of grievances received, types of grievances, and resolution status.

(3) The department of mental health and addiction services may periodically review the implementation of client rights policy and grievance procedures in each board area. Each board shall maintain a client rights policy and grievance procedure that is approved by the department of mental health and addiction services. Subsequent substantive changes to such written policy and procedure shall be submitted to and approved by the department before enactment.

History

• Effective: January 14, 2018
• Promulgated Under: 119.03

Ohio Adm.Code 5122-26-18

(A) As used in this rule:

(1) "Client advocate" means the individual designated by a provider with responsibility for ensuring compliance with the client rights and grievance procedure rule as implemented within each provider or board. "Client advocate" has the same meaning as client rights officer or client rights specialist.

(2) "Grievance" means a written complaint initiated either verbally or in writing by a client or by any other individual or provider on behalf of a client regarding denial or abuse of any client's rights.

(B) Each provider is to have all of the following:

(1) A written client rights policy that lists all of the client rights identified in this rule;

(2) A written client grievance procedure;

(3) A policy for maintaining, for at least two years from resolution, records of client grievances that include, at a minimum, the following:

(a) A copy of the grievance;

(b) Documentation reflecting process used and resolution/remedy of the grievance; and

(c) Documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty business days.

(C) Posting of client rights

(1) The client rights policy and grievance procedure is to be posted as follows:

(a) In each location in which services are provided, unless the provider location is not under the control of the provider (i.e., a shared location such as a school, jail, etc., and it is not feasible for the provider to do so); and

(b) On the provider's website in a conspicuous location, along with contact information for the client advocate. At a minimum, the contact information for the client advocate includes the client advocate's name, telephone number, and email address.

(2) The client rights policy and grievance procedure is to be posted in a conspicuous location that is accessible to individuals served, their family or significant others, and the public.

(3) When a location is not under the control of the provider and it is not feasible for the provider to post the client rights policy and grievance procedure, the provider is to assure that copies are available at the location for each individual that may request a written copy.

(D) Except for clients receiving forensic evaluation service as defined in rule 5122-29-07 of the Administrative Code from a certified forensic center, or attending a driver intervention program as defined in rule 5122-29-12 of the Administrative Code, each client has all of the following rights:

(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.

(2) The right to protection from physical, sexual or emotional abuse, neglect, and inhumane treatment and sexual exploitation.

(3) The right to receive services or supports in the least restrictive, feasible environment.

(4) The right to participate in any appropriate and available service or support that is consistent with an individualized treatment plan, regardless of the refusal of any other certified service or support, unless that certified service or support is a necessity for clear treatment reasons and involves the individual's participation.

(5) The right to give informed consent to or to refuse any certifiable service or support.

(6) The right to participate in the development, review, and revision of one's own individualized treatment plan and receive a copy of it.

(7) The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others.

(8) The right to be informed of and refuse any unusual or hazardous treatment procedures.

(9) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not exclude a provider from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas.

(10) The right to confidentiality of communications and personal identifying information within the limitations and constraints for disclosure of client information under state and federal laws and regulations.

With respect to an adult client receiving residential and withdrawal management substance use disorder services as described in rule 5122-29-09 of the Administrative Code, the right to confidentiality of communications includes the right to write or receive uncensored, unopened correspondence subject to the provider's rules regarding contraband when such rules do not conflict with federal postal regulations.

With respect to an unemancipated minor client receiving residential and withdrawal management substance use disorder services as described in rule 5122-29-09 of the Administrative Code, the right to confidentiality of communications includes the right to write or receive mail subject to the provider's policy regarding contraband and directives from the parent or legal guardian, when such rules and directives do not conflict with federal postal regulations.

(11) The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan is to include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.

(12) The right to be informed in advance of the reason for terminating participation in a certifiable service or support, and to be provided a referral, unless the certifiable service or support is unavailable or not necessary.

(13) The right to be informed of the reason for denial of a certifiable service or support.

(14) The right not to be discriminated against for receiving certifiable services or supports on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner forbidden by local, state or federal laws.

(15) The right to know the cost of certifiable services or supports.

(16) The right to be verbally informed of all client rights and receive a written copy upon request.

(17) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.

(18) The right to file a grievance.

(19) The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested.

(20) The right to be informed of one's own condition.

(21) The right to consult with an independent treatment specialist or legal counsel at one's own expense.

(E) Client rights - forensic evaluations

A client receiving a forensic evaluation service from a certified forensic center has all of these rights:

(1) The right to be treated with consideration and respect for personal dignity.

(2) The right to be evaluated in a physical environment affording as much privacy as feasible.

(3) The right to service in a humane setting which is the least restrictive feasible if such setting is under the control of the forensic center.

(4) The right to be informed of the purpose and procedures of the evaluation service.

(5) The right to consent to or refuse the forensic evaluation services and to be informed of the probable consequences of refusal.

(6) The right to freedom from unnecessary restraint or seclusion if such restraint or seclusion is within the control of the forensic center.

(7) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recordings, televisions, movies, or photographs, or other audio and visual technology, unless ordered by the court, in which case the client has to be informed of such technique. This right does not exclude a provider from using closed- circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms.

(8) The right not to be discriminated against in the provision of certifiable services or supports on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner forbidden by local, state or federal laws.

(9) The right to be fully informed of all rights.

(10) The right to exercise any and all rights without reprisal in any form.

(11) The right to file a grievance.

(12) The right to have oral and written instructions for filing a grievance including an explanation that the filing of a grievance is exclusively an administrative proceeding within the behavioral health system regulated by the department and will not affect or delay the outcome of the criminal charges.

(F) Client rights - driver intervention programs

Each client participating in a driver intervention program has all of these rights:

(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.

(2) The right to protection from physical, sexual or emotional abuse and inhumane treatment.

(3) The right to give informed consent to or to refuse any certifiable service or support.

(4) The right to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others.

(5) The right to be informed of and refuse any unusual or hazardous procedures.

(6) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not exclude a provider from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas.

(7) The right to confidentiality of communications and personal identifying information within the limitations and constraints for disclosure of client information under state and federal laws and regulations.

(8) The right to have access to one's own client record.

(9) The right to be informed of the reason for terminating participation in a certifiable service or support.

(10) The right to be informed of the reason for denial of a certifiable service or support.

(11) The right not to be discriminated against for receiving certifiable services or supports on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner forbidden by local, state or federal laws.

(12) The right to know the cost of certifiable services or supports.

(13) The right to be verbally informed of all client rights, and to receive a written copy upon request.

(14) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.

(15) The right to file a grievance.

(16) The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested.

(17) The right to be informed of one's own condition.

(18) The right to consult with an independent treatment specialist or legal counsel at one's own expense.

(G) Provision of client rights

(1) The provider is to explain and maintain documentation in the ICR of explanation of rights to each individual served prior to or when beginning assessment or certifiable treatment services or supports.

(2) In a crisis or emergency situation, or when the client does not present for certifiable services or supports in person such as through a hotline, the provider may verbally advise the client of at least the immediately pertinent rights only, such as the right to consent to or to refuse the offered treatment and the consequences of that agreement or refusal. Full verbal explanation of the client rights policy is to be provided at the first subsequent meeting.

(3) Clients or recipients of referral and information service or consultation service as described in Chapter 5122-29 of the Administrative Code may have a copy and explanation of the client rights policy upon request.

(4) Explanations of rights is to be in a manner appropriate for the individual's understanding.

(H) All staff are expected to follow the client rights policy and client grievance procedure. There is to be documentation in each employee's personnel file, including the file of contract staff, volunteers, and student interns, that each staff member has received a copy of the client rights policy and the client grievance procedure and has agreed to abide by them.

(I) The client grievance procedure is to have provisions for at least the following:

(1) Statement to whom the client is to give the grievance. At least one person to whom the client may give a grievance will be available on site during a core number of hours each day the provider is open. This person does not have to be a client advocate but is to be a person trained to receive a grievance and pass it along to the client advocate.

(2) Designation of one or more client advocates who will be available onsite or through videoconferencing or other virtual means for a core number of hours each week the provider is open to assist the client in filing a grievance. If the provider offers a videoconferencing or other virtual option for access to a client advocate, the provider is to offer each client who chooses to access the client advocate in this way a private space on the provider's premises, along with the necessary equipment, to meet with the client advocate through videoconferencing or other virtual means. The client advocate is to have their name, title, location, hours of availability, telephone number, and email address included with the posting of client rights as necessitated by paragraph (C) of this rule.

(3) Necessitate that the grievance be in writing. The grievance may be made verbally and the client advocate is to be responsible for preparing a written text of the grievance.

(4) Necessitate that the written grievance is to be dated and signed by the client, the individual filing the grievance on behalf of the client, or have an attestation by the client advocate that the written grievance is a true and accurate representation of the client's grievance.

(5) Necessitate that the grievance include, if available, the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved.

(6) Statement that the provider will make a decision on the grievance within twenty business days of receipt of the grievance. Any extenuating circumstances indicating that this time period will need to be extended has to be documented in the grievance file and written notification given to the client.

(7) Statement that a client has the option to file a grievance with outside organizations, that include, but are not limited to, the following, with the mailing address and telephone numbers for each stated:

(a) Applicable board of alcohol, drug addiction, and mental health services;

(b) Ohio department of behavioral health;

(c) Disability rights Ohio; and

(d) U.S. department of health and human services, civil rights regional office in Chicago.

(8) Necessitate that a written acknowledgment of receipt of the grievance be provided to each grievant. Such acknowledgment is to be provided within three business days from receipt of the grievance. The written acknowledgment is to include, but not be limited to, the following:

(a) Date grievance was received;

(b) Summary of grievance;

(c) Overview of grievance investigation process;

(d) Timetable for completion of investigation and notification of resolution; and

(e) Provider contact name, address, and telephone number.

Last updated August 3, 2026 at 8:36 AM

History

• Effective: August 1, 2026
• Promulgated Under: 119.03

Ohio Adm.Code 5122:2-1-05

(A) The purpose of this rule is to establish the requirements and procedures for department of mental health and addiction services authorization of a board of alcohol, drug addiction, and mental health services to operate a facility or provide an addiction service or mental health service.

(B) The provisions of this rule apply to any mental health or addiction service or activity specified section 340.036 of the Revised Code, or to any facility in which such services are provided, and which operate under contract with the board.

(C) Definitions

For the purposes of this rule and section 340.037 of the Revised Code the following definitions apply:

(1) "Board" means a board of alcohol, drug addiction, and mental health services constituted according to section 340.02 of the Revised Code, or a community mental health board or an alcohol and drug addiction services board as described in section 340.021 of the Revised Code.

(2) "Director" means the chief executive and administrative officer of the Ohio department of mental health and addiction services.

(3) "Emergency" means the imminent risk of a severe disruption or discontinuation of direct client services. For example, the sudden and unanticipated loss of funding or the loss of key staff may create a severe disruption or discontinuation of services.

(4) "Facility" means a building, structure or other improvement, equipment, and real property and interests in real property.

(5) "Operation of services, or facilities" means decision making or control and influence over decision making in the management or performance of a service, or facility.

(D) Section 340.036 of the Revised Code requires that addiction servess and mental health services be delivered by providers under contract with a board. Services may be directly provided by a board only in the exceptional circumstances described in section 340.037 of the Revised Code.

(E) Where prior approval of the director is required pursuant to either division (A)(1) or division (B)(3) of section 340.037 of the Revised Code for a board to operate a facility or provide an addiction service or mental health servicee, the request for approval shall include:

(1) Evidence that either:

(a) There is no other qualified private or public facility, community addiction services provider, or community mental health services provider that is immediately available and willing to operate such a facility or provide the service; or,

(b) There exists an emergency necessitating the board operating the facility or providing the service;

(2) The projected time period during which the board intends to operate the facility or provide the service;

(3) Assurance of the prompt development of a plan for ensuring that another provider will assume responsibility for operating the facility or provide the service; and,

(4) The operating plan for board provision of the service or facility.

(F) Any board which operates a facility or provides a service under the provisions of this rule and section 340.037 of the Revised Code shall comply with all requirements and standards as specified in rules of the department promulgated pursuant to Chapter 119. of the Revised Code which are applicable to contract providers.

(G) The director shall notify the requesting board of approval or disapproval in writing within sixty days of department receipt of all required evidence, assurances, and plans as specified in paragraph (E) of this rule. If a board submits a request to operate a facility or mental health or addiction service in an emergency, the director shall notify the requesting board of approval or disapproval within fourteen days of department receipt of all required evidence, assurances and plans, or the director shall notify the requesting board of the date by which the department expects to issue a response. The time frame for response shall take into consideration the nature of the emergency and the projected date identified by the board to begin operation of services or a facility, and shall not exceed sixty day of receipt of all required evidence, assurances and plans as specified in paragraph (E) of this rule.

History

• Effective: January 14, 2018
• Promulgated Under: 119.03

Ohio Adm.Code 5122-25-02

(A) This rule specifies the procedure a provider is to follow when applying for initial certification of at least one certifiable service or support.

If the provider is already certified for at least one certifiable service or support and seeks to add one or more certifiable services or supports to the menu of services or supports it provides, the provider has two options:

(1) If the provider is seeking to add services or supports during its certification term, submit an update application to the department using the procedure in rule 5122-25-03 of the Administrative Code.

(2) If the provider is seeking to add services or supports when renewing certification for other services or supports, submit a renewal application to the department using the procedure in rule 5122-25-04 of the Administrative Code and indicate the desire for the certification of the additional services or supports in that application.

(B) A provider is to submit an application for initial certification to the department through the department's licensure and certification tracking system. If a provider has a parent organization that operates multiple providers, each provider under that parent organization is to submit its own application.

The application for initial certification consists of all of the following:

(1) An initial application form mandating all of the following information:

(a) The provider's legal name as it is filed with the Ohio secretary of state and, if applicable, any other name under which the provider does business.

(b) The provider's federal tax identification number (FTID). If the provider has a parent organization, the FTID listed is to be the FTID of the provider and not the FTID of the parent organization.

(c) If applicable, the numbers of all certificates or licenses the provider already possesses from the department.

(d) The addresses and telephone numbers for each physical (i.e., brick and mortar) site at which the provider intends to provide certifiable services or supports and the address the provider uses to receive legal notices and correspondence. For purposes of this subparagraph, each provider is to own or lease at least one physical site in Ohio where certifiable services and supports are to be provided. All of the following do not qualify as a physical site:

(i) A co-working or shared workspace used on an "as-needed basis";

(ii) A library;

(iii) A restaurant, cafe, or similar environment;

(iv) A school, except where a school-based provider has an office on the premises of a school or a school operates a permanent site for the delivery of one or more certifiable services or supports; or

(v) A site which would be considered the client's natural environment (e.g., home or county department of job and family services location).

If the physical location is leased by the provider, any room where clients are seen is not to be shared with other lessees or individuals who are not affiliated with the provider.

(e) The provider's governing structure and the names and contact information for each member of the provider's governing body, board of directors, or similar body.

(f) The provider's table of organization.

(g) The name and email address of the provider's executive director, chief executive officer, or president.

(h) The name and email address of the individual who serves as the provider's primary contact.

(i) The provider's history of licensure or certification for certifiable services or supports or their equivalent in this state and all other jurisdictions where the applicant provides mental health services, addiction services, or recovery supports.

(j) A list of the certifiable services or supports specified in Chapter 5122-29 of the Administrative Code that are to be provided during the term of certification, along with identification of each service or support that is accredited by, or for which an application for accreditation is pending with, one or more of the following national accrediting organizations specified in division (B)(3) of section 5119.36 of the Revised Code, the status of that accreditation (e.g., full, provisional, conditional, etc.), and the name of each national accrediting organization accrediting each service or support:

(i) The joint commission;

(ii) The commission on accreditation of rehabilitation facilities;

(iii) The council on accreditation; or

(iv) Any other national accrediting organization the director considers appropriate.

For a provider that solely operates or seeks to operate opioid treatment programs exclusively serving clients who are enrolled as opioid treatment program participants (meaning the provider does not operate or seek to operate any site that serves clients who are not enrolled as opioid treatment program participants), the department will accept opioid treatment program national accreditation as sufficient evidence of national accreditation for purposes of compliance with division (B) of section 5119.36 of the Revised Code for the following certifiable services and supports needing to be certified under rule 5122-40-04 of the Administrative Code: general services as described in rule 5122-29-03 of the Administrative Code, substance use disorder (SUD) case management services as described in rule 5122-29-13 of the Administrative Code, and crisis intervention service as described in rule 5122-29-10 of the Administrative Code.

(k) The number of beds for each residential and withdrawal management substance use disorder services location.

(l) A description of the provider's purpose, mission, and goals.

(m) Notification if the provider plans to use seclusion and restraint as defined in rule 5122- 26-16 of the Administrative Code.

(n) Any other information the department requests for the purpose of determining that the provider's services and supports meet certification standards.

(2) If requested by the department, any of the following corporate information:

(a) A copy of the provider's articles of incorporation and all amendments thereto;

(b) Identification of the statutory corporate agent for service; and

(c) If an out-of-state corporation, a copy of the corporation's registration with the Ohio secretary of state to do business in Ohio.

(3) For each jurisdiction where the provider already provides certifiable services or supports or their equivalent, whether any adverse action, as defined in section 5119.367 of the Revised Code, was taken against the provider, any owner or principal of the provider, or any subsidiary of the provider or owner within the three-year period immediately preceding the date of application.

(4) The applicable non-refundable fee or fees specified in rule 5122-25-12 of the Administrative Code.

(5) A copy of each national accrediting organization survey report and any modifications to the survey reports, if applicable.

(6) A copy of each certificate, license, or plaque issued by a national accrediting organization.

(7) A copy of each accreditation award notification letter issued by a national accrediting organization.

(8) Copies of approved physical inspections, either initial or renewal, for each physical (i.e., brick and mortar) site at which the provider intends to provide certifiable services or supports, including:

(a) A building inspection by a local certified building inspector or a certificate of occupancy issued by the department of industrial relations, to be re-inspected whenever there are major alterations or modifications to the building or facility. An additional building inspection is mandated for any major change in the use of space that would make the building or facility subject to review under different building code standards;

(b) An approved fire inspection conducted within the previous twelve months, free of deficiencies, that was conducted by a certified fire authority or, where none is available, by the division of the state fire marshal of the department of commerce;

(c) A water supply and sewage disposal inspection, if these systems are not connected with public services, to certify compliance with rules of the department of health and any other state or local regulations, rules, codes, or ordinances;

(d) A current boiler certificate of operation, if applicable;

(e) A current elevator permit, if applicable; and

(f) A food service license or permit, if required by the department of health.

(C) Upon receipt of an application for initial certification, the department will review it to determine whether it is complete and compliant. If the application is incomplete or not compliant, the department will notify the provider of the corrections or additions that are needed and may return the application to the provider. Return of the application or failure to issue a certificate is not a denial of an application for certification.

A provider that fails to respond to a request to submit corrections or additions to an application for initial certification within forty-five days of the request is to automatically be considered to have withdrawn its application. If the provider desires to seek certification again, the provider is to file a new application for initial certification.

(D) Following the department's determination that an application for initial certification is complete and compliant and that the standards specified in section 5119.36 of the Revised Code and rules adopted under that section are satisfied, the director will, in accordance with division (A) of section 5119.36 of the Revised Code, inform the board of alcohol, drug addiction, and mental health services serving the alcohol, drug addiction, and mental health service district in which the provider's certifiable services or supports will be provided of the receipt of the application. On the board's request, the director is to provide the board with a copy of the application. In addition, the director will determine, in accordance with paragraph (D)(1) of this rule, whether an on-site review is needed or permitted and take the appropriate action. If necessary pursuant to paragraph (D)(2) of this rule, the department will complete a written statement of noncompliance.

(1) On-site reviews

(a) The director may conduct an on-site review of the provider if the director needs additional information to determine whether the standards in section 5119.36 of the Revised Code and any rules adopted under that section are satisfied.

Otherwise, if the director determines that the standards specified in section 5119.36 and any rules adopted under that section are satisfied without the need for additional information, the director will issue the certification without further evaluation of the services or supports.

If the director chooses to conduct an on-site review under these circumstances, the director may conduct the on-site review in cooperation with a board of alcohol, drug addiction, and mental health services that seeks to contract or has a contract with a provider under section 340.036 of the Revised Code. It is up to the department's discretion as to whether the department will notify a provider in advance of such an on-site review.

(b) If the director determines that national accreditation does not exist for at least one of the certifiable services or supports or equivalent services or supports for which the provider is seeking certification, however, an on-site review is mandatory. Under these circumstances, it is the director's obligation to conduct an on-site review of the provider for certifiable services or supports for which national accreditation does not exist.

(c) In addition to an on-site review conducted under paragraph (D)(1)(a) or (D)(1)(b) of this rule, the department may, as authorized by division (H) of section 5119.36 of the Revised Code, conduct an on-site review or otherwise evaluate a provider at any time based on cause, including complaints made by or on behalf of individuals receiving certifiable services or supports and confirmed or alleged deficiencies brought to the director's attention. The department has the discretion to determine whether it will notify a provider in advance of such an on-site review. In conducting an on-site review under these circumstances, the department may do so in cooperation with a board of alcohol, drug addiction, and mental health services that seeks to contract or has a contract with the provider under section 340.036 of the Revised Code.

(d) Regardless of whether the department is conducting an on-site review under paragraph (D)(1)(a), (D)(1)(b), or (D)(1)(c) of this rule, the department is to have access to all of the provider's records, regardless of format, to verify compliance with certification standards. In addition, the department may conduct interviews with members of the provider's governing body, staff, and others and, with client permission, the client.

(2) Written statement of noncompliance

If the department determines that a provider fails to comply with any certification standards applicable to the provider, the department is to send to the provider a written statement citing the items that are not in compliance. The statement is to describe the deficiencies and specify the actions needed for correction. The provider's plan of correction is to describe the actions the provider plans to take and a time frame in which the provider plans to correct all deficiencies.

A provider that fails to respond to a request to submit a corrective response (e.g., a plan of correction) within ninety days is to automatically be considered to have withdrawn its application. If the provider desires to seek initial certification again, the provider is to file a new application for initial certification.

Last updated August 3, 2026 at 8:26 AM

History

• Effective: August 1, 2026
• Promulgated Under: 119.03

Ohio Adm.Code 5122-30-22

(A) The operator shall be responsible for assuring the compliance by the facility with all resident rights. Facility violations of resident rights shall be regarded as sufficient cause to institute proceedings to deny or revoke the facility's license.

(B) In addition to the definitions appearing in rule 5122-30-03 of the Administrative Code, the following definitions apply to this rule:

(1) "Grievance" means a written complaint initiated either verbally or in writing by a resident or by any other person or agency on behalf of a resident regarding denial or abuse of any resident's rights.

(2) "Reasonable" means a standard for what is fair and appropriate under usual and ordinary circumstances.

(3) "Resident rights advocate" means the residential facility staff , or a representative of the state long-term care ombudsman program, with responsibility for implementing the grievance procedure.

(C) Each facility shall have the following:

(1) Written resident rights policy that lists all of the resident rights identified in this rule;

(2) Written resident grievance procedure, written in a manner that residents can understand and which allows for reasonable accommodation for residents with disabilities;

(3) Policy for maintaining for at least three years from resolution, records of resident grievances that include, at a minimum, the following:

(a) Copy of the grievance;

(b) Documentation reflecting process used and resolution/remedy of the grievance; and,

(c) Documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond twenty-one calendar days.

(D) Posting of resident rights.

The resident rights policy, the grievance procedure, and the name of the resident rights advocate shall be posted in a conspicuous location that is readily accessible to all residents.

(E) Each resident has all of the following rights.

(1) The right to be verbally informed of all resident rights in language and terms appropriate for the resident's understanding, prior to or at the time of residency, absent a crisis or emergency.

(2) The right to request a written copy of all resident rights and the grievance procedure.

(3) The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations.

(4) The right to file a grievance.

(5) The right to be treated all times with courtesy and respect, and with consideration for personal dignity, autonomy and privacy.

(6) The right to receive services in the least restrictive, feasible environment.

(7) The right to receive humane services in a clean, safe, comfortable, welcoming, stable and supportive environment.

(8) The right to reasonable protection from physical, sexual and emotional abuse, neglect, and exploitation.

(9) The right to freedom from unnecessary or excessive medication, and the right to decline medication, except a class one facility which employs staff authorized by the Ohio Revised Code to administer medication and when there is imminent risk of physical harm to self or others.

(10) The right to be free from restraint or seclusion unless there is imminent risk of physical harm to self or others.

(11) The right to be advised and the right to refuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs or other audio and visual technology. This right does not prohibit a facility from using closed-circuit monitoring to observe seclusion rooms or other areas in the facility, other than bathrooms or sleeping areas, or other areas where privacy is reasonably expected, e.g. a medical examination room.

(12) The right to confidentiality of communications and personal identifying information within the limitations and requirements for disclosure of resident information under state and federal laws and regulations.

(13) The right to have access to one's own record unless access to certain information is restricted for clear treatment reasons. If access is restricted, a treatment/service plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment/service being offered to remove the restriction.

(14) The right to be informed of one's own condition.

(15) The right not to be discriminated against on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental disability, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws.

(16) The right to practice a religion of his or her choice or to abstain from the practice of religion.

(17) The right to be informed in writing of the rates charged by the facility as well as any additional charges, and to receive thirty days' notice in writing of any change in the rates and charges.

(18) The right to reside in a class one residential facility, as available and appropriate to the type of care or services that the facility is licensed to provide, regardless of previous residency, unless there is a valid and specific necessity which precludes such residency. This necessity shall be documented and explained to the prospective resident.

(19) The right to continued residency unless the facility is no longer able to meet the resident's care needs; the resident presents a documented danger to other residents, staff or visitors; or the monthly charges have not been paid for more than thirty days.

(20) The right not to be locked out of the facility at any time.

(21) The right of adult residents not to be locked in the facility at any time for any reason.

(22) The right to consent to or refuse treatment or services, or if the resident has a legal custodian, the right to have the legal custodian make decisions about treatment and services for the resident.

(23) The right to consult with an independent treatment specialist or legal counsel at one's own expense.

(24) The right to communicate freely with and be visited without staff present at reasonable times by private counsel and, unless prior court restriction has been obtained, to communicate freely with and be visited at reasonable times by a personal physician, psychologist or other health care providers, except that employees of a board, a provider, personnel of the Ohio protection and advocacy system, or representatives of the state long-term-ombudsman program may visit at any time when permitted by the Revised Code.

The right to communicate includes receiving written communications, which may be opened and inspected by facility staff in the presence of the resident recipient so long as the communication is then not read by the staff and given immediately to the resident.

(25) The right to meet with staff from the Ohio department of mental health and addiction services in private.

(26) The right not to be deprived of any legal rights solely by reason of residence in the facility.

(27) The right to personal property and possessions:

(a) The right of an adult resident to retain personal property and possessions.

(b) The right of a child resident to personal property and possessions in accordance with one's health and safety considerations, and developmental age, and as permitted by his/her parent or guardian.

(28) The right of an adult resident to manage his/her own financial affairs, and to possess a reasonable sum of money.

(29) The right to use the common areas of the facility.

Adult residents shall have right of access to common areas at all times.

Children and adolescent residents shall have the right of access to common areas in accordance with the facility's program schedule.

(30) The right to engage in or refrain from engaging in activities:

(a) The right of an adult to engage in or refrain from engaging in cultural, social or community activities of the resident's own choosing in the facility and in the community.

(b) The right of a child or adolescent to access cultural and social activities.

(31) The right to meet or communicate with family or guardians, and visitors and guests:

(a) The right of an adult:

(i) To reasonable privacy and the freedom to meet with visitors and guests at reasonable hours.

(ii) To make and/or receive confidential phone calls, including free local calls.

(iii) To write or receive uncensored, unopened correspondence subject to the facility's rules regarding contraband.

(b) The right of a minor:

(i) To visitors and to communicate with family, guardian, custodian, friends and significant others outside the facility in accordance with instructions from the minor's parent or legal guardian.

(ii) To write or receive mail subject to the facility's rules regarding contraband and directives from the parent or legal guardian, when such rules and directives do not conflict with federal postal regulations.

(32) The right to be free from conflicts of interest; no residential facility employee may be a resident's guardian, custodian, or representative with the exception of an employee that has a previously established legal relationship to a resident, e.g. parent, spouse or child if permitted by facility policy.

(F) Provision of client rights.

(1) The provider shall explain and maintain documentation in the resident's record an explanation of rights to each person served prior to or when beginning residency.

(2) In a crisis or emergency situation, the provider may verbally advise the resident of at least the immediately pertinent rights only, such as the right to consent to or to refuse the offered treatment and the consequences of that agreement or refusal. Full verbal explanation of the resident rights policy shall be provided at the first appropriate occasion, based upon the resident's functioning.

(3) Explanations of rights shall be in a manner appropriate for the person's understanding.

(G) All staff shall be trained on and follow the resident rights policy and resident grievance procedure. There shall be documentation in each employee's personnel file, including contract staff, volunteers and student interns that each staff member has received a copy of the resident rights policy and the resident grievance procedure and has agreed to abide by them.

(H) The resident rights advocate, or designee, shall:

(1) Be promptly accessible; and,

(2) Have their name, title, location, hours of availability, and telephone number included with the posting of resident rights as required by paragraph (D) of this rule.

(I) The resident grievance procedure shall have provisions for at least the following:

(1) Statement to whom the resident is to give the grievance;

(2) Designation of staff who will be available to assist a resident in filing of a grievance;

(3) Requirement that the grievance must be put into writing; the grievance may be made verbally and the resident rights advocate shall be responsible for preparing a written text of the grievance;

(4) Requirement that the written grievance must be dated and signed by the resident, the individual filing the grievance on behalf of the resident, or have an attestation by the resident rights advocate that the written grievance is a true and accurate representation of the resident's grievance;

Grievances may not be made anonymously, but grievance procedure shall provide method for confidential submission of grievance. Resident rights advocate shall keep such submissions and subsequent investigations confidential.

(5) Requirement that the grievance include, if available, the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved;

(6) Statement that the program will make a resolution decision on the grievance within twenty-one business days of receipt of the grievance. Any extenuating circumstances indicating that this time period will need to be extended must be documented in the grievance file and written notification given to the resident;

(7) Statement that a resident has the option to file a grievance with outside organizations, that include, but are not limited to, the following, with the mailing address and telephone numbers for each stated:

(a) Applicable board for residents receiving mental health services;

(b) Ohio department of mental health and addiction services;

(c) Disability rights Ohio; or,

(d) U.S. department of health and human services, civil rights regional office in Chicago.

(8) Requirement that a written acknowledgment of receipt of the grievance be provided to each grievant. Such acknowledgment shall be provided within three business days from receipt of the grievance. The written acknowledgment shall include, but not be limited to, the following:

(a) Date grievance was received;

(b) Summary of grievance;

(c) Overview of grievance investigation process;

(d) Timetable for completion of investigation and notification of resolution; and,

(e) Treatment provider contact name, address and telephone number

History

• Effective: January 1, 2018
• Promulgated Under: 119.03

Ohio Adm.Code 5122:2-1-03 County withdrawal from a joint-county community mental health board.

(A) The purpose of this rule is to establish the criteria and procedures for department of mental health and addiction services authorization of the withdrawal by one or more board(s) of county commissioners from participation in a joint-county board.

(B) The provisions of this rule are applicable to all counties which participate in joint-county boards and particularly to each board of county commissioners which proposes to withdraw from a joint-county board.

(C) Procedures for requesting withdrawal.

(1) The board(s) of county commissioners of the county or counties requesting withdrawal shall submit to the director of the department of mental health and addiction services and to the commissioners and boards of alcohol, drug addiction, and mental health services of each county in the joint-county board a resolution of the county commissioners requesting withdrawal together with a comprehensive written plan which shall include:

(a) Reasons for requesting such withdrawal;

(b) Description of the proposed new board service district and a map showing all relevant civil subdivisions, major lines of transportation, and location of mental health, addiction, health, and social service agencies in the proposed new board district to be comprised of or to include the withdrawing county(ies);

(c) Analysis and projection of the demographic and organizational elements to be affected including

(i) Projection, for at least four years from the proposed first year, of the populations in the proposed new and remaining board service districts, respectively, and

(ii) Identification of any existing contractual networks of mental health and addiction service programs which cross county boundaries and which would be disrupted if the proposed withdrawal occurs; and if a disruption is contemplated, a plan to assure continued service to clients must be included in the general plan;

(d) Evidence of the adequacy of community interest and of potential resources in the proposed new board service district, including the endorsement of civic and professional leaders and the adequacy of funding resources within the proposed new board service district, to support the organization and delivery of mental health and addiction services and programs which meet at least the minimum program standards of the department, including services to client population groups in the district that are designated by the department for high priority;

(e) Evidence that relevant community organizations, including at least all mental health, addiction, health, and social service agencies and providers within the proposed new board service district, have been informed in writing of the proposed new board service district, its population and funding resources in relation to ability to provide needed services in accordance with the approved board comprehensive annual plan as required by section 340.03 of the Revised Code, and that these agencies and providers have been invited to submit written comments to the board(s) of county commissioners in the proposed new board service district; and

(f) Evidence that a public hearing has been announced to all relevant agencies and providers and to the general public within the proposed new board service district to be comprised of or to include the withdrawing county(ies), that such a public hearing has been conducted, and evidence of all written comments and other testimony received.

(g) Evidence that any county withdrawing from a joint-county board would continue to have levied against its tax list and duplicate any tax levied by the district during the period in which the county was a member of the joint-county board until such time as the levy expires or is renewed or replaced.

(h) Evidence of the provision for the equitable adjustment and division of all mental health and addiction services, assets, property, debts, and obligations, if any, of the joint-county district.

(D) Review by the department

(1) On receipt of the written proposed plan by the department, the director shall consider the request for withdrawal to assure:

(a) Compliance with all required standards and procedures in paragraph (C) of this rule;

(b) That relevant organizations and the general public have had the opportunity for comment and that all substantive, relevant questions, issues, and complaints have been appropriately resolved;

(c) That the remaining county or counties from which the withdrawal is proposed are able to assure continuation of services and programs which meet at least minimum program standards of the department.

(2) However, if substantive issues have not been resolved, or the proposed plan is not generally endorsed, or if the director has reason to believe the proposed plan is not in the best interest of the citizens of the county or the currently existing district, the director may, within thirty days of receipt of the proposed plan, request that a hearing be held to examine the relevant facts and opinions in order to make a decision. The hearing process shall be as follows:

(a) Reasonable public notice shall be given prior to the date set for the hearing and shall include:

(i) A statement that the department of mental health and addiction services will hold a hearing on the proposed plan for withdrawal of one or more county(ies) from a joint-county district, and

(ii) The date, time and place of the hearing. All efforts will be made to hold the hearing in the county(ies) requesting withdrawal.

(b) On the date, time and place designated in the notice, the department of mental health and addiction services will conduct a hearing at which any person or representative of any organization affected by the proposed action of the county may appear and be heard in person. Written or oral comment may be provided.

(c) The director shall designate a hearing officer to preside at said hearing. Such officer shall review the testimony and make a recommendation within thirty days to the director.

(3) The director shall notify the requesting board(s) of county commissioners of the department's approval or disapproval of the proposed plan in writing within sixty days after the department's receipt of the proposed plan for withdrawal, or within sixty days after the date of the hearing.

(4) No county participating in a joint-county service district may withdraw therefrom without the consent of the director nor earlier than one year after the submission of such resolution unless all of the participating counties agree to an earlier withdrawal.

History

• Effective: January 14, 2018
• Promulgated Under: 119.03

Ohio Adm.Code 5122:2-1-04 Department of mental health and addiction services appointments to boards.

(A) Purpose. The purpose of this rule is to establish a procedure for the Ohio department of mental health and addiction services (OhioMHAS) appointment of members of boards established pursuant to section 340.02 of the Revised Code, including reasonable notification of the interested public.

(B) "Board" for the purposes of this rule means any community mental health board; alcohol, drug addiction, and mental health services board; alcohol and drug addiction services board; or any other board established pursuant to section 340.02 of the Revised Code.

(C) Procedure

(1) When a vacancy becomes available for a department appointment or reappointment to a board, the board shall notify the OhioMHAS office of community support.

(2) The board may use public notification through posting, media, etc., to assure reasonable notification of the interested public. Any such notification shall include:

(a) Eligibility requirements for board membership under section 340.02 of the Revised Code;

(b) Duties and responsibilities of a board member as defined by statute;

(c) Length of the term of the vacancy being filled;

(d) Specific requirements for the board vacancy which is under consideration, if such requirements are present;

(e) Procedure and time limits for application;

(f) Process of obtaining state application form for appointment;

(g) Application and selection procedure as described in paragraph (B)(3) of this rule.

(3)

(a) Applications shall be prepared on the form provided by OhioMHAS, which shall include the board being applied for, appointment type, name of applicant, address, county of residence, education, experience, any applicable licensing information, a personal statement, demographic information, the applicant's signature, and the opportunity for the board to recommend the appointment and request waiver of appointment types.

(b) The receipt of applications, review and screening of applications, and interviewing of applicants may be delegated upon the discretion of the director of OhioMHAS. Notice of this delegation of authority shall be given to the board in written form with directions for forwarding to the department the results of these activities.

(c) The director, or the director's designee, will evaluate eligible candidates with the following priorities:

(i) Statutory requirements regarding the appointment;

(ii) Effort to balance the composition of the board.

(D) The names, occupations, and length of service of all current board members at the time of adoption of this rule shall be forwarded to the department as of the effective date of this rule. An updated list forwarded to the department will be required when any appointments are requested.

History

• Effective: December 19, 2013
• Promulgated Under: 119.03

Ohio Adm.Code 5122:2-1-06 Mediation procedures for boards of alcohol, drug addiction, and mental health services and service providers of those boards.

(A) The purpose of this rule shall be to establish mediation procedures for boards of alcohol, drug addiction, and mental health services (boards) and community addiction, gambling addiction, or community mental health services providers (service providers) contracted by those boards.

(B) The provisions of this rule shall be applicable to the department of mental health and addiction services, boards and service providers.

(C) The provisions of this rule shall be liberally construed to promote resolution of disputes between boards and service providers.

(D) Request for mediation

(1) If either a board or a service provider with which it contracts for services, programs, or facilities proposes not to renew the contract or proposes substantial changes in contract terms, the other party shall be given written notice at least one hundred twenty days before the expiration date of the contract.

(2) The party given such notice may request advisory mediation within sixty days before the expiration date of the contract.

(3) Request for mediation shall be in writing addressed to the "Office of Legal and Regulatory Services, Department of Mental Health and Addiction Services, 30 E. Broad Street, Columbus, Ohio 43215."

(4) Requests shall include a copy of the contract or agreement between the parties and a brief statement of issues in dispute.

(5) The office of legal regulatory services shall contact the other party to the dispute within seven calendar days of receipt of the request to determine whether that party agrees to mediate the dispute.

(6) Should one party not agree to mediation, the office of legal and regulatory services shall notify both parties accordingly. No further procedures are then required by this rule.

(E) Selection of a mediator

After the requirements of paragraph (D) of this rule have been satisfied, the parties will attempt to select an impartial mediator by mutual agreement. In the event the parties cannot reach such an agreement, by joint letter they will request the office of legal and regulatory services to submit a panel of not more than five names of persons considered qualified to mediate disputes by the office. Representatives of the parties shall strike names from the panel alternately until one name remains. That person shall serve as mediator.

(F) Function of mediator

(1) The sole function of the mediator shall be advisory in nature.

(2) The mediator shall have the authority to:

(a) Request documents or other material from either party in order to mediate the dispute;

(b) Submit written questions to either party;

(c) Conduct joint meeting between the parties;

(d) Make written recommendations to the parties for resolution of the dispute;

(e) Establish timelines for resolution of the dispute.

(G) Joint meeting

(1) The mediator shall arrange a meeting between the parties for the purpose of receiving arguments and written material concerning each party's position.

(2) Each party shall designate one representative, authorized to represent the party pending ratification by the appropriate board, to the meeting. The parties may send other personnel to the meeting in addition to the representative.

(3) Each party shall present arguments on the merits of their position and submit written material or exhibits relevant to a resolution of the dispute at the meeting, provided that the mediator may require presentation of written material to the other party and the mediator, prior to the meeting.

(4) The mediator shall preside at the meeting and at his discretion:

(a) Limit the length of each party's oral presentation;

(b) Limit the amount of written material or exhibits submitted by a party at a meeting;

(c) Decide whether material submitted is relevant to the issues in dispute and exclude material that is not relevant or cumulative;

(d) Provide for the meeting to be recorded, by tape recorder or other means;

(e) Adopt other procedures to govern the conduct of the meeting or necessary for equitable presentation of each party's position.

(5) The "Ohio Rules of Evidence" shall not apply to the proceeding between the parties at a joint meeting.

(6) At the conclusion of the joint meeting, the mediator shall set a date for issuance of his written recommendations for resolution of the dispute.

(H) Recommendations:

(1) The mediator shall make written recommendations for resolution of the dispute.

(2) A copy of the mediator's recommendations shall be sent to the office of legal and regulatory services and the parties.

(3) The mediator's recommendations shall not be binding on either party.

(I) Time for completion of mediation

(1) The mediation shall be completed and the written recommendations issued not later than twenty days before the expiration date of the cotnract, unless both parties agree to a time extension.

(2) An agreement to extend the time for mediation must be in writing, signed by a representative of both parties and contain a date for completion of the mediation.

(J) Mediation fees

(1) The fee, if any, of the mediator shall be divided equally between the parties.

(2) Each party shall otherwise be responsible for their own expenses arising from the utilization of the mediator.

History

• Effective: April 16, 2018
• Promulgated Under: 119.03