Ohio Adm.Code 5122 | Ohio Administrative Code 5122 — Department of Behavioral Health

Chapter 5122-1 General Provisions

Ohio Adm.Code 5122-1-01 Definitions.

As used throughout these internal management rules, unless the context requires otherwise, the following definitions shall apply:

(A) "Central office" means the executive office of the department in Columbus, Ohio, where the director and his/her staff, including deputy directors, and medical director are located.

(B) "Chief" means an individual who is the principal administrator of an office located within the central office of the department.

(C) "Chief clinical officer" (CCO) means the medical director of a regional psychiatric hospital as defined in division (K) of section 5122.01 of the Revised Code.

(D) "Chief executive officer" (CEO) means an individual who directs and oversees the operation of a regional psychiatric hospital.

(E) "Chief legal counsel" means the person appointed by the director to advise the department in all legal matters.

(F) "Client" means any person who is receiving care and treatment in a regional psychiatric hospital. Client shall have the same meaning as "consumer" and "patient".

(G) "Client rights specialist" means an individual responsible for planning, implementing and coordinating regional psychiatric hospital (RPH) or campus of multi-site RPHs client advocacy programs; representing and assisting persons served who have or are receiving RPH inpatient services, by promoting recovery, mental and emotional well-being, social and economic well-being, protecting and promoting the human and civil rights of persons served; investigating and responding to grievances; and providing client advocacy services as stated in rule 5122-7-02 of the Administrative Code. The client rights specialist reports directly to the chief executive officer (CEO) of the RPH.

(H) "Community support network" (CSN) means community mental health services provided by a regional psychiatric hospital to persons with severe mental illnesses who are living in the community.

(I) "Department" means the Ohio department of mental health (ODMH).

(J) "Deputy director" means an individual responsible for the management of one of the divisions of the department.

(K) "Director" means the chief administrative official and appointing authority, appointed by the governor, who regulates, guides or directs the overall operation and official business of the department.

(L) "Division" means one of the operations units of the department.

(M) "Guardian" means any person charged by law with power to act for, or responsible for the care and management of the person, estate or both of an individual deemed incompetent or minor.

(N) "Hospital" means any facility/entity delivering hospital/inpatient services.

(O) "Hospital services" (HS) means the ODMH system of regional psychiatric hospitals which provide inpatient and community mental health services.

(P) "The joint commission" (TJC) means the independent, not-for-profit accreditation organization which develops standards for general hospitals, psychiatric hospitals, other healthcare facilities and health-related programs, community mental health agencies, and residential facilities for persons with mental illness.

(Q) "Leadership support team" (LST) means the group of central office employees, comprised of the director, deputy directors, and other individuals identified by the director, responsible for policy, fiscal, and operations review and discussion.

(R) "Medical director to the department" means the physician appointed by the director to advise the department in all matters relating to medical and psychiatric policies and priorities.

(S) "Office" means an organizational branch which is charged with specific duties and is located within the central office of the department.

(T) "Regional psychiatric hospital" (RPH) means a facility operated by the department that provides inpatient care, and may provide community mental health services, and is supported primarily through state appropriations.

(U) "Rule or rules" means any rule adopted, amended, repealed, or rescinded pursuant to the procedures and requirements of Chapter 119. or section 111.15 of the Revised Code.

History

Effective: June 6, 2011
Promulgated Under: 111.15

Ohio Adm.Code 5122-1-02 Notification and consultation with constituencies affected by rules, standards, and guidelines.

(A) Definitions.

(1) "Board" means any board authorized pursuant to Chapter 340. of the Revised Code, such as a board of alcohol, drug addiction, and mental health services; an alcohol and drug addiction services board; or a community mental health board.

(2) "Consultation" means the process described in this rule by which the department seeks information from relevant constituencies prior to the establishment of rules, standards, and guidelines. Such communications may be written or oral, in group or individual meetings, by review of proposals or responses, or other appropriate methods.

(3) "Department " means the Ohio department of mental health and addiction services.

(4) "Guideline" means a written set of principles by which to make a judgment or determine a course of action and which is required to be issued by the department under Chapter 340. or 5119. of the Revised Code.

(5) "Rule" as defined by division (C) of section 119.01 of the Revised Code, means a written statement having a general and uniform operation, adopted under Chapter 119. of the Revised Code, and enforced by the department under the authority of the laws governing the department.

(6) "Standard" means those standards required to be adopted as rules under Chapter 5119. of the Revised Code.

(B) Procedure for adopting rules, standards, and guidelines:

This paragraph sets forth the procedure that shall be used be the department when taking actions with respect to rules, guidelines, or standards.

(1) The department identifies rules, standards, or guidelines in need of either a change (amendment, rescission, or a new rule) or a rule due for the statutorily required five-year review, stakeholders may also propose changes or requests reviews of rules.

(2) The department develops proposals internally. During this development phase the department may consult with clinical roundtables and individual stakeholders, convene public meetings, or create ad-hoc committees.

(3) Upon internal approval of a proposal, the department shall then conduct a notification and consultation period by posting the proposal to the department's draft rules website and notifying stakeholders through the department's "adminrules" email list. The notification and consultation period shall be fourteen calendar days, unless circumstances require a different duration, and stakeholders may provide input for the department's consideration during this period.

(4) If the proposed rules have an adverse impact on business, as defined by section 107.52 of the Revised Code, the notification and consultation period may run concurrently with the review of the rule proposal by the common sense initiative office (CSIO) as warranted by the subject matter of the rule. If the notification and consultation period and the CSIO review run concurrently, the proposal shall be posted to the draft rules website with the business impact analysis (BIA) and the review period shall be a minimum of fifteen business days.

(5) During the notification and consultation period the department may use additional means beyond the email list to gather stakeholder input. The department may meet with individual stakeholders, convene public meetings, hold public hearings, or create ad-hoc committees.

(6) The department shall review all input received during the notification and consultation period, and may change the proposal as warranted.

(7) At the completion of the notification and consultation period, rules that were not submitted to CSIO concurrently with the notification and consultation period and which have an adverse impact shall be submitted for review by the CSIO for a minimum of fifteen business days and the BIA shall be posted to the draft rules website.

(8) Once the proposed rules have passed through the notification and consultation period and the CSIO review, if applicable, the proposed rules may be filed in accordance with either section 111.15 of the Revised Code or section 119.03 of the Revised Code. Public hearings shall be noticed and conducted in accordance with the statutory provisions under which the rules are promulgated.

Proposed guidelines and standards may be adopted as effective at the conclusion of the notification and consultation period. Changes made to rules, guidelines, or standards after the notification and consultation period or the CSIO review do not require another notification and consultation period.

Last updated December 1, 2021 at 10:11 AM

History

Effective: May 7, 2015
Promulgated Under: 119.03

Ohio Adm.Code 5122-1-03 HIPAA requirements, policies and procedures.

(A) Purpose. The purpose of this rule shall be to establish required policies and procedures for department-wide compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the American Recovery and Reinvestment Act of 2009 (ARRA), and implementing regulations.

(B) Procedure. All offices, hospitals, including CSN programs, and workforce members of the Ohio department of mental health (ODMH) are directed to follow all applicable mandates found in the "ODMH HIPAA Requirements, Policies, and Procedures Manual" maintained at each regional psychiatric hospital (RPH), at OSS, and in central office.

Failure to comply with this internal management rule and its referenced document, the "ODMH HIPAA Requirements, Policies, and Procedures Manual", may result in disciplinary sanctions as defined in ODMH policy AH-22, "Code of Conduct and General Work Rules", effective January 1, 2010, and as it may be amended.

History

Effective: January 24, 2011
Promulgated Under: 111.15

Ohio Adm.Code 5122-1-04 Access to confidential personal information.

(A) The purpose of this rule is to establish the requirements for regulating access to the confidential personal information that is maintained by the Ohio department of mental health and addiction services.

(B) For the purposes of administrative rules promulgated in accordance with section 1347.15 of the Revised Code, the following definitions apply:

(1) "Access" when used in this rule as a noun means an instance of copying, viewing, or otherwise perceiving.

"Access" when used in this rule as a verb means to copy, view, or otherwise perceive.

(2) "Acquisition of a new computer system" means the purchase of a "computer system," as defined in this rule, that is not a computer system currently in place nor one for which the acquisition process has been initiated as of the effective date of the department rule addressing requirements in section 1347.15 of the Revised Code.

(3) "Computer system" means a "system," as defined by section 1347.01 of the Revised Code, that stores, maintains, or retrieves personal information using electronic data processing equipment.

(4) "Confidential personal information" (CPI) has the meaning as defined by division (A)(1) of section 1347.15 of the Revised Code and identified by rules promulgated by the department in accordance with division (B)(3) of section 1347.15 of the Revised Code that reference the federal or state statutes or administrative rules that make personal information maintained by the department confidential.

(5) "Department" means the Ohio department of mental health and addiction services.

(6) "Employee" means each Ohio department of mental health and addiction services employee regardless of whether the employee holds an elected or appointed office or position within the department.

(7) "Incidental contact" means contact with the information that is secondary or tangential to the primary purpose of the activity that resulted in the contact.

(8) "Individual" means a natural person or the natural person's authorized representative, legal counsel, legal custodian, or legal guardian.

(9) "Information owner" means the individual appointed in accordance with division (A) of section 1347.05 of the Revised Code to be directly responsible for a system.

(10) "Person" means a natural person.

(11) "Personal information" has the same meaning as defined in division (E) of section 1347.01 of the Revised Code.

(12) "Personal information system" means a "system" that "maintains" "personal information" as those terms are defined in section 1347.01 of the Revised Code. "System" includes manual and computer systems.

(13) "Research" means a methodical investigation into a subject.

(14) "Routine" means commonplace, regular, habitual, or ordinary.

(15) "Routine information that is maintained for the purpose of internal office administration, the use of which would not adversely affect a person" as that phrase is used in division (F) of section 1347.01 of the Revised Code means personal information relating to employees and maintained by the agency for internal administrative and human resource purposes.

(16) "System" has the same meaning as defined by division (F) of section 1347.01 of the Revised Code.

(17) "Upgrade" means a substantial redesign of an existing computer system for the purpose of providing a substantial amount of new application functionality, or application modifications that would involve substantial administrative or fiscal resources to implement, but would not include maintenance, minor updates and patches, or modifications that entail a limited addition of functionality due to changes in business or legal requirements.

(C) Procedures for accessing confidential personal information for personal information systems, whether manual or computer systems.

(1) Personal information systems of the department are managed on a "need-to-know" basis whereby the information owner determines the level of access required for a department employee to fulfill the employee's job duties. The determination of access to confidential personal information shall be approved by the employee's supervisor and the information owner prior to providing the employee with access to confidential personal information within a personal information system. The department shall establish procedures for determining a revision to an employee's access to confidential personal information upon a change to that employee's job duties including, but not limited to, transfer or termination. Whenever an employee's job duties no longer require access to confidential personal information in a personal information system, the employee's access to confidential personal information shall be removed.

(2) Individual's request for a list of confidential personal information.

Upon the signed written request of any individual for a list of confidential personal information about the individual maintained by the department, the department shall do all of the following:

(a) Verify the identity of the individual by a method that provides safeguards commensurate with the risk associated with the confidential personal information;

(b) Provide to the individual the list of confidential personal information that does not relate to an investigation about the individual or is otherwise not excluded from the scope of Chapter 1347. of the Revised Code; and

(c) If all information relates to an investigation about that individual, inform the individual that the department has no confidential personal information about the individual that is responsive to the individual's request.

(3) Notice of invalid access.

(a) Upon discovery or notification that confidential personal information of a person has been accessed by an employee for an invalid reason, the department shall notify the person whose information was invalidly accessed as soon as practical and to the extent known at the time. However, the department shall delay notification for a period of time necessary to ensure that the notification would not delay or impede an investigation or jeopardize homeland or national security. Additionally, the department may delay the notification consistent with any measures necessary to determine the scope of the invalid access, including which individuals' confidential personal information invalidly was accessed, and to restore the reasonable integrity of the system.

"Investigation" as used in this paragraph means the investigation of the circumstances and involvement of an employee surrounding the invalid access of the confidential personal information. Once the department determines that notification would not delay or impede an investigation, the department shall disclose the access to confidential personal information made for an invalid reason to the person.

(b) Notification provided by the department shall inform the person of the type of confidential personal information accessed and the date(s) of the invalid access.

(c) Notification may be made by any method reasonably designed to accurately inform the person of the invalid access, including written, electronic, or telephone notice.

(4) Appointment and duties of a data privacy point of contact.

(a) The director of the department shall designate an employee of the department to serve as the data privacy point of contact.

(b) The data privacy point of contact shall work with the chief privacy officer within the Ohio department of administrative services office of information technology to assist the department with both the implementation of privacy protections for the confidential personal information that the department maintains and compliance with section 1347.15 of the Revised Code and the rules adopted thereunder.

(c) The data privacy point of contact shall ensure the timely completion of the "privacy impact assessment form" developed by the Ohio department of administrative services office of information technology.

(D) Valid reasons for accessing confidential person information.

Pursuant to the requirements of division (B)(2) of section 1347.15 of the Revised Code, this rule contains a list of valid reasons directly related to the department's exercise of its powers or duties, for which only employees of the department may access confidential personal information regardless of whether the personal information system is a manual system or computer system.

Performing the following functions, as part of the employee's assigned duties on behalf of the department, constitute valid reasons for authorized employees of the department to access confidential personal information:

(1) Responding to a public records request;

(2) Responding to a request from an individual for the list of confidential personal information the department maintains on that individual;

(3) Administering a constitutional provision or duty;

(4) Administering a statutory provision or duty;

(5) Administering an administrative rule provision or duty;

(6) Complying with any state or federal program requirements;

(7) Processing or payment of claims or otherwise administering a program with individual participants or beneficiaries;

(8) Auditing purposes;

(9) Licensure or certification processes;

(10) Investigation or law enforcement purposes;

(11) Administrative hearings;

(12) Litigation, complying with an order of the court, or subpoena;

(13) Human resource matters (e.g., hiring, promotion, demotion, discharge, salary/compensation issues, leave requests/issues, time card approvals/issues);

(14) Complying with an executive order or policy;

(15) Complying with a department policy or a state administrative policy issued by the Ohio department of administrative services, the office of budget and management or other similar state agency;

(16) Complying with a collective bargaining agreement provision; or

(17) Research in the furtherance of department specific programs in so far as allowed by statute.

(E) The following federal statutes or regulations or state statutes and administrative rules make personal information maintained by the department confidential and identify the confidential personal information within the scope of rules promulgated by this department in accordance with section 1347.15 of the Revised Code:

(1) 5 U.S.C. 552a. (social security numbers).

(2) 42 U.S.C. 1320d and 45 C.F.R. parts 160 and 164 (protected health information under the Health Insurance Portability and Accountability Act).

(3) 42 U.S.C. 9501 and 42 U.S.C. 10841 (patient records).

(4) 42 C.F.R. 482.13 (patient records).

(5) 42 C.F.R. Part 2 (confidentiality of alcohol and drug abuse patient records).

(6) 42 U.S.C. 1396a(a) (medicaid records).

(7) Sections 5119.27 and 5119.28 of the Revised Code (confidentiality of records).

(8) Sections 2305.24, 2305.25, 2305.251, 2305.252, 2305.253 and 5122.32 of the Revised Code (quality assurance and peer review records).

(9) Section 5122.31 of the Revised Code (patient certificates, applications, records, and reports).

(10) Section 5122.311 of the Revised Code (notification of bureau of criminal identification and investigation of adjudication of mental illness).

(11) Paragraph (I) of rule 5122-1-31 of the Administrative Code (voter registration of consumers and absentee voting assistance in behavioral healthcare organizations of the integrated behavioral healthcare system).

(12) Paragraph (D)(3) of rule 5122-2-25 of the Administrative Code (morbidity and mortality events).

(13) Paragraph (D)(4)(e) of rule 5122-3-13 of the Administrative Code (incident reports).

(F) Restricting and logging access to confidential personal information in computerized personal information systems.

For personal information systems that are computer systems and contain confidential personal information, the department shall do the following:

(1) Access restrictions.

Access to confidential personal information that is kept electronically shall require a password or other authentication measure.

(2) Acquisition of a new computer system.

When the department acquires a new computer system that stores, manages or contains confidential personal information, the department shall include a mechanism for recording specific access by employees of the department to confidential personal information in the system.

(3) Upgrading existing computer systems.

When the department modifies an existing computer system that stores, manages or contains confidential personal information, the department shall make a determination whether the modification constitutes an upgrade. Any upgrades to a computer system shall include a mechanism for recording specific access by department employees to confidential personal information in the system.

(4) Logging requirements regarding confidential personal information in existing department computer systems.

(a) The department shall require department employees who access confidential personal information within computer systems to maintain a log that records their access.

(b) Access to confidential information is not required to be entered into the log under the following circumstances:

(i) The department employee is accessing confidential personal information for official department purposes, including research, and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(ii) The department employee is accessing confidential personal information for routine office procedures and the access is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iii) The department employee comes into incidental contact with confidential personal information and the access of the information is not specifically directed toward a specifically named individual or a group of specifically named individuals.

(iv) The department employee accesses confidential personal information about an individual based upon a request made under either of the following circumstances:

(a) The individual requests confidential personal information about himself/herself

(b) The individual makes a request that the department takes some action on that individual's behalf and accessing the confidential personal information is required in order to consider or process that request

(v) For purposes of this paragraph, the department may choose the form or forms of logging, whether in electronic or paper formats.

(5) Log management.

The department shall issue a policy that specifies the following:

(a) Who shall maintain the log;

(b) What information shall be captured in the log;

(d) How long information kept in the log is to be retained.

(6) Nothing in this rule limits the department from requiring logging in any circumstance that it deems necessary

Last updated May 10, 2021 at 10:43 AM

History

Effective: May 10, 2021
Promulgated Under: 119.03

Ohio Adm.Code 5122-1-06 Research.

(A) The purpose of this rule shall be to establish policies and procedures for the planning, review, administration and coordination of all research projects which are funded by the department, or which utilize patients, staff or records of regional psychiatric hospitals (RPHs) or persons under the managing authority of the department.

(B) The provisions of this rule shall be applicable to all employees of the department and to individuals and organizations carrying out research approved (funded or non-funded) by the department.

(C) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

"Applied research" means an original, systematic study designed to answer a specific question, determine why something failed or succeeded, solve a specific pragmatic problem, or to acquire new knowledge and understanding. Applied research has immediate and direct impact on a specific problem.

(D) The department shall institute, encourage and support applied research projects in both communities and RPHs. The projects may include studies of causes, prevention, or treatment of mental illness, and means for enhancing the positive mental health of the citizens of Ohio.

(E) Policy

(1) All research funded by the department shall be reviewed and approved by the office of research and evaluation. Research approved for funding shall be consistent with priorities identified in the department's strategic plan. Depending upon the subject matter of this research, the review process shall also include other individuals such as the department medical director, staff in program offices, and external experts.

(2) All research (funded or non-funded) to be conducted in RPHs under the managing authority of the department, or which involves employees, patients or records of the department, shall be reviewed and approved by the RPH and the office of research and evaluation.

(3) The office of research and evaluation shall be responsible for issuing guidelines for submission of research proposals, and shall periodically distribute the department's research priorities to potential researchers as well as to RPHs and local mental health systems.

(4) The office of program evaluation and research shall specify appropriate procedures for protection of human subjects in research projects, including situations in which written informed consent is required.

(5) The office of research and evaluation shall disseminate reports of findings or outcomes of all funded research projects at the end of each biennium.

(F) Procedure

(1) Applicants for research funding will request approval by submission to the office of research and evaluation of four copies of the research abstract form DMH-RES-617 and four copies of a detailed project proposal. Applicants for no-funds approval will submit two copies of the research abstract form DMH-RES-617 and two copies of a detailed project proposal.

(2) Research proposals which originate from, and are to be carried out at, specific RPHs operated by the department must be approved by the chief executive officer and chief clinical officer of that RPH prior to submission to the office of research and evaluation for review and approval.

(a) These proposals may include:

(i) Those submitted by employees of the department and which utilize clients, staff, or records of the RPH; and

(ii) Those submitted by researchers who are not employees of the department (e.g. university professors, graduate students, etc.), and which utilize clients, staff, or records of the RPH.

(3) Implementation of approved research which does not originate at the RPH, and which utilizes clients, staff, or records of an RPH, will be coordinated by the office of research and evaluation with the chief clinical officer and chief executive officer of the RPH.

(4) All approved researchers shall be bound by applicable laws, rules, policies, guidelines, etc. (including but not necessarily limited to state and federal) concerning confidentiality with regard to information obtained from RPH records, staff interviews, or other data collection methods.

(5) Researchers are required to report the status of the research project to the office of research and evaluation on a quarterly basis. The quarterly report will be submitted within ten days of the end of each quarter.

(6) At the conclusion of a project or the end of a key phase of project, a report of findings must be submitted to the office of research and evaluation and the RPH.

History

Effective: September 18, 2010
Promulgated Under: 111.15

Ohio Adm.Code 5122-1-28 Industrial and entertainment funds.

(A) This rule is applicable to all employees of the Ohio department of mental health and addiction services regional psychiatric hospitals (RPHs).

(B) Process

(1) The chief executive officer of each RPH will take the necessary action to ensure that an industrial and entertainment fund is established.

(2) All monies received by an RPH that are designated for entertainment and benefit of the patients, including profits from the commissary fund operations, will be deposited in the industrial and entertainment fund and be used only for the entertainment and benefit of patients.

(3) All monies donated to a hospital that are ear-marked for a specific patient purpose will be deposited in a subsidiary account of the industrial and entertainment fund and be included in the total balance of the fund.

Income for the industrial and entertainment fund will be derived from, but not be limited to, the following sources:

(1) Donations;

(2) Vending machine commissions;

(3) Monies from occupational or activity therapy projects financed by industrial and entertainment funds;

(4) Confiscated monies;

(5) Telephone commissions from telephone calls by patients;

(6) Interest income;

(7) Funds transferred under the provisions of section 5119.56 of the Revised Code; and

(8) Profits generated by hospital commissaries in accordance with division (B) of section 5119.52 of the Revised Code.

(D) Disbursements

Disbursements may be made from the industrial and entertainment fund only for items that exclusively benefit patients and for which no appropriated or patient funds are available. Disbursements will be controlled and documented by a voucher system and supported by a verified roster of the patients served. Industrial and entertainment fund disbursements may be utilized for, but not limited to, the following items or activities:

(1) Recreation and entertainment;

(2) Recreation and entertainment supplies, equipment, and maintenance and repair of same;

(3) Holiday decorations;

(4) Books, magazines, newspapers, and other library supplies;

(5) Movie or game purchases and rentals;

(6) Chapel expenses;

(7) Bus rentals and bus fares;

(8) Occupational or activity therapy supplies; and

(9) Benefit clients of the community support network.

(E) Other disbursements

Disbursements in the amount of one thousand dollars or less may be made with the approval of the chief executive officer or the chief executive officer's designee. Expenditures in excess of one thousand dollars will have prior approval from central office. Approval will be secured in advance by submitting a request for approval to purchase form DMHAS-0205 as follows:

(1) The form will be prepared by the requesting RPH, numbered consecutively within each fiscal year, and signed by the chief executive officer.

(2) The form, accompanied by at least three letterhead bids, will be forwarded to the deputy director of hospital services for approval. A vendor's refusal to bid is acceptable as a bid.

(3) Items to be purchased from state term contracts or Ohio penal industries do not require bids.

(4) Upon central office approval, the copy of the certificate of approval will be returned to the initiating RPH. The original copy of the certificate will be retained by the RPH according to the department retention schedule.

Last updated April 4, 2022 at 8:49 AM

History

Effective: April 4, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5122-1-29 Operation of regional psychiatric hospital commissaries.

(A) The purpose of this rule is to establish procedures for the funding and operation of regional psychiatric hospital (RPH) commissaries under the managing responsibility of the Ohio department of mental health and addiction services, division of hospital services.

(B) The provisions of this rule apply to all RPHs.

(1) An RPH may create and maintain commissaries for the benefit of the patients. Upon receipt of central office approval, an RPH may transfer funds from the industrial and entertainment fund to establish a commissary operation.

(2) Hours of operation of commissaries will be established by the chief executive officer of the RPH as justified by sales records and dictated by the availability of employees designated and instructed in the workings of the commissary operation.

(3) The salaries or wages of all commissary employees, including assigned patient workers, will be paid from appropriated funds. A state employee must be accountable for the day-to-day operation of the commissary. All volunteers are to be covered by a fidelity bond.

(4) The recording of transactions of the commissaries will be directly supervised by the business office of each RPH and will be subject to audit by central office, and the auditor of state.

(D) Operation

(1) A cash register will be used to record all cash sales at the time of transaction. In addition to use of a cash register, accounting software may be used to track transactions.

(2) The commissary cash journal will be used to substantiate all charge sales. Fund transfers for all non-cash sales will be made within one day of the actual transactions.

(3) All deliveries will be checked and verified in the presence of the delivery person. A receiving document will be written to substantiate the delivery.

(4) Commissary invoices will be extended by commissary personnel and verified by business office personnel before figures are entered into the commissary ledger. The retail value and cash over/short columns will be completed. A-2 forms will be completed daily and turned into the business office monthly for approval and storage. All other generally accepted accounting practices will be implemented in maintaining proper financial records.

(5) Commissary revenue over and above operating costs will be considered profits. Commissary prices will be established locally at the lowest possible level which will generate a controlled net profit range of five per cent to fifteen per cent. All profits from commissary operations except those funds needed for equipment will be paid into the industrial and entertainment fund of the hospital to be used to benefit the patients. Profits will be transferred at regular intervals in like amounts to establish transfer patterns. Profits needed for replacement of equipment which would exceed normal maintenance costs may be held in reserve to a maximum time limit of six months, at which time the reserved amount shall either be utilized for the intended purpose or transferred to the industrial and entertainment fund. Once profits are transferred, there will be no rescission.

(6) Apparent merchandise shrinkage will be maintained at a level of not more than two per cent based on total charges for a one year audit period.

(7) No employee will gain personally from the operation of the commissary. There will be no wholesale transactions or personal items purchased through commissary vendors.

(8) Items for sale in or for operation of commissaries may be purchased from requisite purchase programs specified in Ohio administrative policy PM-01 (including the department's Ohio pharmacy services office) or from local suppliers. Before seeking bids from local suppliers, the business office of the RPH will determine whether the needed items are available from requisite purchase programs.

(9) Items purchased from local suppliers will be obtained at the lowest prices available and bidding for such items will occur at least annually using formal procedures. It is the responsibility of the business office to provide periodic checks for competitive prices from vendors.

(10) Disbursements in the amount of one thousand dollars or less may be made with the approval of the chief executive officer or designee. Equipment purchases or any expenditure in excess of one thousand dollars (other than items for resale) will have prior approval from central office. Approval will be secured in advance by submitting a request for approval to purchase form DMHAS-0205 as follows:

(a) The form will be prepared by the requesting RPH, numbered consecutively within each fiscal year, and signed by the chief executive officer.

(b) The form will be forwarded to the deputy director of hospital services for approval. With the form, the requesting RPH will verify that requisite purchase programs were reviewed to determine whether the needed items are available from those programs. If the items are unavailable from those programs, the form will also be accompanied by at least three letterhead bids.

(c) Upon central office approval, the copy of the approved request will be returned to the initiating RPH. The approved request will be retained by the RPH according to the department retention schedule.

(11) Appropriate expenditures to be paid from the commissary fund will include but not be limited to:

(a) All merchandise for resale;

(b) Overhead supplies, overhead foods, and raw foods;

(d) Repair and maintenance of equipment;

(e) Commissary sales taxes (state and local);

(f) Licenses (food service, etc.); and

(g) Check printing charges.

(12) The commissary area will be maintained in clean, neat, and orderly conditions at all times. The cost of building repair and maintenance will be the responsibility of the RPH.

Last updated April 4, 2022 at 8:49 AM

History

Effective: April 4, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5122-1-31 Voter registration of consumers and absentee voting assistance in regional psychiatric hospitals.

(A) The purpose of this rule shall be to establish a policy and to set forth procedures for the implementation of voter registration and absentee voting in all regional psychiatric hospitals (RPH) operated by the Ohio department of mental health (ODMH).

(B) The provisions of this rule shall be applicable to all RPHs providing mental health services operated by ODMH.

(C) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code.

(1) "Consumer" means any person receiving services or applying for admission to an RPH.

(2) "Persons qualified to register to vote" means any person over eighteen years of age and any person seventeen years of age who is within six months of his/her eighteenth birthday who has not been specifically adjudicated incompetent for voting purposes.

(D) The following services shall be made available to all consumers with every application for RPH services:

(1) Provide a consumer with a state voter registration application, absentee ballot application, and notice of rights form if requested by the individual;

(2) Assist a consumer in completing the voter registration or absentee ballot application form, if requested. Each consumer who requests assistance shall be provided the same degree of assistance with completion of the forms as is provided with the completion of any other form for which help is given;

(3) Provide all consumers with notification of all elections along with an absentee ballot form if requested by the individual;

(4) Accept completed voter registration and absentee ballot application forms regardless of whether the application was distributed by the RPH or other entities for transmittal to the appropriate local county board of election; and

(5) Advise consumers that they may mail or otherwise transmit completed voter registrations to the appropriate local county board of elections.

(6) Work with the local board of elections to assist consumers in completing absentee ballots, upon request.

(E) Voter registration and absentee ballot applications and assistance shall be made available to RPH consumers in alternative locations wherever applications, re-applications, and address changes are taken. An example of an alternative location would be an independent residence.

(F) The RPH shall not:

(1) Seek to influence a consumer's political preference or party registration;

(2) Display any political preference or party allegiance;

(3) Make any statement to a consumer or take any action, the purpose or effect of which is to discourage the consumer from registering to vote; or

(4) Make any statement to a consumer or take any action, the purpose or effect of which is to lead the person to believe that a decision to register or not to register has any bearing on the availability of services or benefits.

Information relating to a declination to register to vote may not be used for any purpose other than voter registration.

(G) The RPH shall establish an internal procedure for collection of all voter registration and absentee ballot application forms. The internal procedure shall include the selection of a designated individual at each RPH to serve as coordinator(s) for all activities related to absentee voting and voter registration.

The coordinator shall have the following responsibilities:

(1) Collect all voter registration forms and absentee ballot applications;

(2) Transmit voter registration forms and absentee ballot applications to the local county boards of election;

(3) Advise consumers that they may mail or otherwise transmit completed voter registration forms and absentee ballot applications to the appropriate local county board of elections;

(4) Train new RPH employees who will be assisting consumers in completing voter registration and absentee ballot applications;

(5) Maintain an adequate supply of voter registration and absentee ballot applications, and notice of rights forms at the RPH;

(6) Monitor voter registration and absentee voting activities; and

(7) Resolve questions and problems that arise, in coordination with state or county election officials.

(H) The RPH, with the assistance of the local county board of election shall establish procedures by which voter registration applications shall be transmitted. Transmission of completed voter registration forms shall occur no later than five working days after the date of receipt by the RPH. The voter registration transmission form shall be used for this purpose.

(I) The identity of the RPH from which voter registration and absentee ballot application forms are received shall remain confidential except as required by the secretary of state and county board of elections for record-keeping purposes.

(J) Completed voter registration forms and absentee ballot applications may be returned to any RPH in person or through another person. When voter registration applications or absentee ballots are accepted, these shall be collected and transmitted through procedures established with the local county boards of election.

History

Effective: April 9, 2013
Promulgated Under: 111.15

Chapter 5122-2 Regional Psychiatric Hospital Grievances

Ohio Adm.Code 5122-2-04 Client complaint and grievance procedure for regional psychiatric hospital inpatient services.

(A) The purpose of this rule is to promote individual recovery and provide a means for persons who have received or are receiving regional psychiatric hospital (RPH) inpatient services, or their representatives, to lodge complaints and file grievances and appeals regarding care, treatment, environmental conditions, and the exercise of patient rights or other aspects of inpatient care or services and to have those complaints, grievances, and appeals heard and acted upon in a timely manner. This rule also reinforces the obligation of all staff to listen to and respond to the complaints and grievances of persons served.

(B) The provisions of this rule apply to all RPHs providing inpatient services under the managing responsibility of the department.

(C) The deputy director of hospital services and medical director of the Ohio department of mental health and addiction services are to adopt a patient complaint and grievance procedure for each RPH.

(D) Each RPH may make changes to its patient complaint and grievance procedure with the approval of the RPH's governing body and the department's deputy director of hospital services, advocacy services administrator, and medical director.

(E) Each RPH patient complaint and grievance procedure is to be based on 42 CFR 482.13 and the centers for medicare and medicaid services state operations manual, appendix A, revised February 21, 2020.

(F) Each RPH patient complaint and grievance procedure is to be reviewed by the deputy director of hospital services, advocacy services administrator, and medical director not more than three years after the date of the last review of the procedure.

Last updated March 22, 2024 at 8:55 AM

History

Effective: August 15, 2023
Promulgated Under: 119.03

Chapter 5122-3 Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc

Ohio Adm.Code 5122-3-03 Evaluation and referral for electroconvulsive therapy (ECT).

(A) The purpose of this rule shall be to establish standards and criteria, indications, contraindications and limits for referral of adult ODMH regional psychiatric hospital (RPH) inpatients to an outside facility for ECT.

(B) The provisions of this rule shall be applicable to all RPHs under the managing responsibility of the department.

(1) "Chief clinical officer" and "CCO" mean the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(2) "Psychiatrist" means a licensed physician who has satisfactorily completed a residency training program in psychiatry, as approved by the residency review committee of the American medical association, the committee on post-graduate education of the American osteopathic association, or the American osteopathic board of neurology and psychiatry, or who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state medical association or the Ohio osteopathic association on the basis of formal training and five or more years of medical practice limited to psychiatry.

(3) "ECT" is a somatic psychiatric treatment mediated by a modified grand mal seizure, which is induced by the application of electrical current of the brain.

(4) "Informed consent" means the voluntary and knowing permission given by a person who has received all appropriate information.

(D) Requirements for referral

(1) ECT shall not be administered in ODMH RPHs.

(2) Only adult ODMH RPH inpatients shall be referred for ECT.

(3) The RPH psychiatrist must present clinical data to the RPH CCO to obtain approval for ECT referrals.

(4) It is required that any patient, voluntary or involuntary, competent or incompetent, shall be given a full explanation of ECT consistent with the specific items cited below:

(a) An explanation of the procedures to be followed and their purposes including identification of any procedures which are experimental. This explanation is to be given in such a way as to enable the individual to make a decision to grant/deny consent;

(b) A description of any attendant discomforts and risks reasonably to be expected;

(d) A disclosure of any appropriate alternative procedures/treatments that might be advantageous for that patient including an explanation of the consequences of those procedures/treatments;

(e) An offer to answer any inquiries concerning the procedures and answers to any such inquiries;

(f) An instruction that the individual may refuse to consent and that the individual is free to withdraw his consent and to discontinue the treatment at any time without prejudice unless informed consent for the ECT is given by guardian or court-ordered; and

(g) A notification that the individual may consult with an independent specialist and counsel.

(5) The competence of a patient to give informed consent shall be determined by the attending psychiatrist. The written opinion shall be incorporated into the patient's permanent medical record.

(6) The criteria for determining the competence of the patient, include but are not limited to:

(a) Whether or not the patient is physically and mentally able to receive the information required to be furnished;

(b) Whether or not the patient is able to explain his/her understanding of the information provided; and

(7) Competent adult patients

No competent adult patient shall be given ECT unless his/her informed consent has been obtained.

(8) Adult incompetent involuntary patients

(a) If an adult patient has been adjudicated incompetent to give informed consent for medical treatment by a probate court, the patient's guardian may give informed consent.

(b) If an adult patient has been determined to be incompetent to give consent according to the procedure outlined above, and has no guardian, ECT may be administered only under the following conditions:

(i) The attending psychiatrist must certify in writing that an indication for ECT use as outlined in paragraph (E) of this rule is evident;

(ii) The chief clinical officer recommends in writing the administration of ECT; and

(iii) If a durable power of attorney for healthcare issues exist, it should be followed. Otherwise, approval for ECT shall be obtained from the probate court.

(E) Indications for use

(1) General statement

Referrals for ECT are based upon a combination of factors, including the patient's diagnosis, nature and severity of symptomatology, treatment history, consideration of anticipated risks and benefits of viable treatment options, and patient preference. At present there are no diagnoses which should automatically lead to treatment with ECT. In most cases, ECT is used following treatment failure on psychotropic agents, although specific criteria do exist for use of ECT as a first-line treatment.

(2) Primary use of ECT

Situations where ECT may be used prior to a trial of psychotropic agents include, but are not limited to, the following:

(a) Where a need for rapid, definitive response exists on either medical or psychiatric grounds; or

(b) When the risks of other treatment outweigh the risks of ECT; or

(d) Patient preference.

(3) Secondary use of ECT

In other situations, a trial of an alternative therapy should be considered prior to referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

(a) Treatment failure, taking into account issues such as choice of agent, dosage, and duration of trial;

(b) Adverse effects which are unavoidable and which are deemed less likely and/or less severe with ECT; and

(4) Major diagnostic indications

Diagnoses for which either compelling data are present for efficacy of ECT or a strong consensus exists in the field supporting such use.

(a) Major depressive disorder. ECT is an effective treatment for all subtypes of major depressive disorder;

(b) Bipolar disorder. ECT is an effective treatment for all sub-types and phases of bipolar disorder including manic, depressed and mixed phases.

ECT may be an effective treatment for psychotic schizophrenic exacerbations including catatonia, when prominent affective symptoms are present and when there is a history of favorable response. ECT may be effective in other psychotic disorders.

(d) Mental disorders due to a general medical condition. ECT may be effective in the management of severe affective and psychotic symptoms concomitant with general medical conditions, or in treating delirium of various etiologies, including toxic and metabolic.

(e) Other diagnostic indications.

(i) For people with diagnoses for which efficacy data for ECT are only suggestive, or where only a partial consensus exists in the field, support its use. In such cases, ECT should be recommended only after standard alternatives have been considered as a primary intervention. The existence of such indications, however, should not deter the use of ECT for treatment of a concurrent major diagnostic medication.

(ii) Although ECT has sometimes been of assistance in the management of mental disorders other than those described above, such usage i snot adequately substantiated and should be carefully justified in the clinical record on a case-by-case basis.

(f) Medical disorders

(i) The neurobiologic effects associated with induced generalized seizure activity may be of benefit in treating a small number of medical disorders.

(ii) Such conditions include, but are not limited to:

(a) Catatonia secondary to medical conditions (ECT is indicated for catatonia of all causes);

(b) Hypopituitarism;

(d) Neuroleptic malignant syndrome; and

(e) Parkinson's disease.

(F) Contraindications and situations of high risk

(1) There are no absolute contraindications to ECT.

(2) Situations associated with substantial risk

(a) Situations exist in which ECT is associated with an appreciable likelihood of serious morbidity or mortality. In such cases, the decision for ECT should be based upon the premise that the patient's condition is too grave, (i.e., life threatening) to leave untreated, and that ECT is the safest treatment available.

(b) In these instances, careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to treatment modifications which may diminish the level of risk.

(i) Space-occupying cerebral lesion, or other conditions with increased intracranial pressure;

(ii) Seizure disorder;

(iii) Recent myocardial infarction with unstable cardiac function;

(iv) Recent intracerebral hemorrhage;

(v) Bleeding, or otherwise unstable, vascular aneurysm or malformation;

(vi) Retinal detachment;

(vii) Pheochromocytoma; and

(viii) Significant anesthetic risk.

(d) Concomitant medications. The following medications should be discontinued or dosage reduced:

(i) Benzodiazapines, as they are anti-convulsants - should be held for at least eight hours;

(ii) Lithium, as it can increase postictal delirium and prolong seizure activity - should be reduced in dose;

(iii) Bupropion, as it can induce late appearing seizures - should be discontinued;

(iv) Lidocaine markedly increases seizure threshold - should be held for at least eight hours;

(v) Theophylline increases the duration of seizures - should be discontinued;

(vi) Reserpine can cause respiratory and cardiovascular problems and should be discontinued; and

(vii) Other medications as determined by the IBHS pharmacy and therapeutics committee.

(G) Medical evaluation

When a patient remains an ODMH RPH patient when receiving ECT, the following medical evaluation will need to be completed by the ODMH RPH staff:

(1) Medical examination;

(2) Neurological examination;

(3) Laboratory evaluations including CBC and differential; blood and urine chemistries;

(4) Electrocardiogram;

(5) X-ray of lumbosacral region if spinal problems are suspected;

(6) Chest x-ray, if clinically indicated;

(7) In the presence of central nervous system symptoms (seizure disorder or a space occupying lesion), EEG and brain computed tomographic scan or magnetic resonance imaging;

(8) Dental examination for elderly patients and those with dental problems; and

(9) Anesthesiologist consults to evaluate risk of anesthesia. This may be completed at the facility where ECT is administered prior to ECT occurring.

(H) Referred facility requirement

(1) Properly accredited hospital or outpatient facility.

(2) The psychiatrist who is responsible for the administration of ECT has been credentialed and privileged in ECT by the facility where the ECT is being administered.

(I) Training

When ODMH RPH patients are receiving ECT as outpatients, the RPH nursing staff shall be provided with appropriate training on nursing care for these patients to assure competent care of pre- and post-ECT treatment.

(J) Reference

"Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, 2nd ed., 2001".

History

Effective: September 20, 2010
Promulgated Under: 111.15

Ohio Adm.Code 5122-3-05 Competency to stand trial assessment and restoration services for serious youthful offenders (SYOs).

(A) Purpose and background

(1) The purpose of this rule shall be to establish guidelines for competency assessment and restoration treatment of serious youthful offenders (SYOs). Pursuant to section 2152.13 of the Revised Code, effective January 1, 2002, SYOs are afforded all the rights a person who is criminally prosecuted would have if the crime were committed by an adult. This includes the right to be competent to stand trial and utilization of the procedure outlined in Chapter 2945. of the Revised Code, related to competency to stand trial.

(2) Placement/treatment of young children on adult units raises fundamental concerns about the safety and effectiveness of treatment, since ODMH only operates adult inpatient facilities. Treatment of children/adolescents must consider the child's developmental needs and mental status in order to be safe and effective. This rule establishes separate and distinct procedures and guidelines for competency assessment and restoration of children/adolescents. This rule will provide procedures for handling potential referrals from the juvenile courts in Ohio to ODMH facilities. Substantial precedent and common sense support the separation of children from adults in inpatient settings. Prior to the closure of ODMH children's hospitals, in accordance with section 5119.03 of the Revised Code, the department operated separate institutions for children and adults. ODMH private psychiatric hospital licensure rules require that children and adult beds be separate, except for certain emergency admissions of brief periods (forty-eight to seventy-two hours) for older adolescents, aged fifteen through seventeen.

Under this rule, seventeen year olds may be admitted and treated in an adult bed if the person is functioning as an adult in such areas as employment, family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult bed.

National professional guidelines clearly recognize that children and adolescents younger than fourteen should be admitted only to programs that are designed for youth and physically distinct from adult psychiatric inpatient programs. Adolescents sixteen and older may be admitted to adult units for valid clinical reasons, but should be treated in a program designed to meet their specific needs. Children and adolescent programs should address the youth's developmental needs including those for education and age-appropriate social interaction.

(B) Definitions

The following definition shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

"Serious youthful offender" and "SYO" have the same meaning as in division (X) of section 2152.02 of the Revised Code, i.e., a person who is eligible for a mandatory SYO or discretionary SYO, but who is not transferred to adult court under a mandatory or discretionary transfer.

(1) Young children (under age fourteen years) and younger adolescents (ages fourteen to fifteen) should not be placed in an ODMH regional psychiatric hospital (RPH) because adult facilities are not designed or staffed to provide age-appropriate services for youth. Additionally, because interaction with adult patients on these units may be problematic, these children should be placed in an age-appropriate inpatient psychiatric unit for children or a community residential treatment facility that would specifically meet their individual needs. Older immature adolescents and those not medically cleared for admission to an adult facility should also be treated in these types of settings

(2) Older adolescents (ages sixteen to seventeen) and some younger adolescents (ages fourteen to fifteen) in limited exceptional cases, may be admitted to adult units for valid clinical reasons but should be treated in an individualized program designed to meet their specific needs.

(D) Procedures for admission of adolescents to ODMH RPH inpatient units. Prior to such admissions for competency restoration services, the RPH chief clinical officer shall assure the following:

(1) The child must be medically assessed as appropriate for admission to an adult inpatient unit by a board-eligible or board-certified child psychiatrist with documented specialized training and experience in working with adolescents and their families in an inpatient treatment program;

(2) Other available less restrictive treatment resources (e.g., residential treatment, intensive outpatient), must have been considered and determined to not be available or not appropriate to meet the youth's mental health and safety needs; and

(3) An individual plan of care must be developed by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist to meet the adolescent's restoration to competency needs including the developmental, educational, safety, and environmental needs.

(E) Guidelines for adolescent competency to stand trial restoration treatment services provided in the RPH.

(1) Treatment for the adolescent should be supervised by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist;

(2) All relevant components of the competency to stand trial restoration service are to be adjusted to meet the adolescent's developmental, educational, safety, and environmental needs;

(3) Upon admission, an objective competency assessment should be performed. Standardized competency assessment tools may be utilized;

(4) Multi-modal, experiential competency restoration educational experiences, (e.g., discussions, reading, video, role playing or mock trial), may be utilized;

(5) An educational component should be included regarding the criminal charges, severity of charges, sentencing, pleas, plea bargaining, roles of the courtroom personnel, adversarial nature of the trial process and evaluating evidence;

(6) Periodic reassessment of competency should be made regarding the adolescent's progress toward restoration to competence; and

(7) Medication treatment may be needed in order for restoration to competence to occur.

History

Effective: January 24, 2011
Promulgated Under: 111.15

Ohio Adm.Code 5122-3-12 Duty to protect.

(A) The purpose of this policy is to implement the duty to protect requirements per section 2305.51 of the Revised Code.

(B) This policy shall apply to all mental health professionals employed or contracted by Ohio department of mental health hospitals.

(1) "Independently-licensed mental health professional" means psychiatrists, psychologists, social workers, counselors and clinical nurse specialists licensed to independently provide mental health services.

(2) "Knowledgeable person" means any person who has reason to believe that a patient has the intent and ability to carry out an explicit threat of inflicting imminent and serious physical harm to a clearly identifiable potential victim(s), who is either an immediate family member of the patient, an employee of the hospital, or an individual who, otherwise, personally knows the patient.

(3) "Mental health professional" means any individual who is licensed, certified or registered under the Revised Code, or otherwise authorized in this state, to provide mental health services.

(D) Procedures:

(1) Any mental health professional to whom an explicit threat of serious physical harm to another person or persons or identifiable structure is made, or who is made aware by a knowledgeable person of an explicit threat made by a patient, will initiate the duty to protect process.

(2) Any explicit threat by a patient shall be promptly communicated by the mental health professional who heard the threat or was made aware of the threat, to a registered nurse or psychiatrist on the patient's treatment team. The treatment team shall determine, based on the patient's history and current condition, whether the threat represents a credible danger to others.

(a) If the treatment team does not consider the threat to be a credible danger to others, this decision and the reason for this determination shall be documented in the medical record.

(b) If the treatment team considers the threat to be a credible danger, the threat shall be reported promptly by the treatment team to the chief clinical officer or designee of the hospital.

(3) The chief clinical officer or designee of the hospital shall assign an independently-licensed mental health professional to conduct a face-to-face evaluation with the patient as soon as possible after receiving notification of the threat, but no longer than two working days, in order to give a second opinion risk assessment of the threat.

(4) If the independently-licensed mental health professional determines that the threat does not meet the threshold requiring discharge of the duty to protect (e.g., threat is not imminent), this assessment should be documented on a form authorized by the regional psychiatric hospital (RPH) or in a progress note in the medical record.

(a) Each RPH shall establish policies and procedures that assure patient re-evaluation occurs prior to the patient being discharged or receiving unsupervised movement, including placing a "Duty to Protect" sticker on the patient's chart and adding a "Duty to Protect" problem on the treatment plan. (See Appendix 1 [DMH-0040a] for "Duty to Protect Tracking Form" which may be used by the RPH to monitor procedure compliance).

(b) The independently-licensed mental health professional shall record, in a progress note or indicate on a RPH form, that the patient does not have either the intent or ability to carry out the threat and record the reason(s) for this conclusion.

(c) Other clinical recommendations may be considered for this patient and should be documented as appropriate in the medical record.

(5) If the independently-licensed mental health professional determines that there is an explicit threat of imminent and serious physical harm and there is reason to believe the patient has the intent and ability to carry out the threat, the independently-licensed mental health professional completing the RPH form or documenting this assessment in a progress note in the medical record, must address each of the relevant options to discharge the duty to protect in section 2305.51 of the Revised Code and indicate the reason(s) each was, or was not, chosen.

(a) Since the patient in these instances is already hospitalized, the relevant options for further action under section 2305.51 of the Revised Code for discharging the duty to protect are as follows:

(i) Establishing and undertaking a treatment plan that is reasonably calculated to eliminate the possibility that the patient will carry out the threat (having performed this second opinion risk assessment consultation); and

(ii) Communicating to a law enforcement agency either where the victim or patient resides and, if feasible, communicating with the potential victim(s) and/or guardian(s) about the threat;

(b) If the option chosen by the independently-licensed mental health professional is to warn the potential victim(s) and appropriate law enforcement agency, the independently-licensed mental health professional shall notify the chief clinical officer (or designee) who will designate the person to give the warning;

(i) The information about who was warned, what information was shared, and the time of the warning shall be documented on the RPH form (Appendix 2 [DMH-0040]) or in the progress note in the medical record; and

(ii) Information shared should be restricted to the name and the description of the patient, the nature of the threat, and the name of potential victim(s) and/or potential structure threatened.

(6) Progress notes in the medical record should reflect any contacts with consultants, chief clinical officer (or designee), or the patient's treatment team as appropriate.

(7) The RPH authorized form, or a copy of the progress notes about the threat should be filed in the legal section of the medical record. A copy should be forwarded to the legal assurance administrator of the hospital.

(8) If the threat is considered to be serious but not imminent, and the independently-licensed mental health professional believes the threat should be re-evaluated closer to unsupervised movement, conditional release or discharge of the patient, the independently-licensed mental health professional will contact the treatment team social worker who will affix or cause to be affixed, a prominent sticker on the front of the patient's medical record noting a "Duty to Protect" and add a "Duty to Protect" problem to the treatment plan.

(9) When a "Duty to Protect" sticker is affixed to the medical record and a problem is added to the treatment plan, prior to unsupervised movement, conditional release or discharge, the treatment team social worker will notify the chief clinical officer (or designee) who will assign an independently-licensed mental health professional to conduct a face-to-face re-evaluation of the presence or absence of the threat, and if present, the credibility of the threat.

(10) If a patient with a "Duty to Protect" problem goes AWOL from a RPH, the treatment team (or on evenings, weekends, and holidays, the nurse manager) shall promptly give a recommendation to the chief clinical officer regarding warning law enforcement and, if feasible, potential victims in the community.

(11) In all re-evaluations, the independently-licensed mental health professional should locate the original RPH form or progress notes about the threat in the medical record or in the file of the legal assurance administrator.

(a) After the face-to-face re-evaluation, a new RPH authorized form or medical record progress note shall be completed and filed in the legal section of the medical record with a copy to the legal assurance administrator.

(i) If no active serious threat is present, this should be noted on the RPH form or in a progress note and no further formal action is necessary;

(ii) If an active, serious, and imminent threat remains, this should be documented on the RPH form or in a progress note and the actions identified in paragraphs (D)(5) to (D)(7) of this rule should be followed. In addition, the independently-licensed mental health professional shall promptly notify the treatment team for appropriate action regarding the pending unsupervised movement, conditional release, or discharge.

View AppendixView Appendix

History

Effective: August 5, 2011
Promulgated Under: 111.15

Chapter 5122-7 Client Services; Personnel

Ohio Adm.Code 5122-7-02 Client rights within regional psychiatric hospitals.

(A) The purpose of this rule is to promote and protect the rights of patients receiving services in Ohio's regional psychiatric hospitals (RPHs).

(B) The provisions of this rule apply to all RPHs providing inpatient services under the managing responsibility of the Ohio department of mental health and addiction services (OhioMHAS).

(1) "Interested party" means a parent, spouse, other relative, significant other, or guardian of a patient or an advocacy group or interested citizen.

(2) "Patient" means a person who is currently or has received inpatient or outpatient services at or through an RPH.

(D) The policy of OhioMHAS is to promote and protect the rights of patients receiving services consistent with a concern for human dignity, respect, recovery, and quality clinical care; to respond promptly and effectively to patient and interested party concerns, inquiries, complaints, and grievances; and to promote and evaluate patient satisfaction with services provided.

(E) Organization and responsibilities of OhioMHAS's advocacy program:

(1) An OhioMHAS advocacy services administrator lead for inpatient services is to be appointed for the department.

General responsibilities of the OhioMHAS advocacy services administrator lead include, but are not limited to, the following:

(a) Providing support for the rights and recovery administrator within each RPH;

(b) Serving as the resource person for patient advocacy issues;

(d) Ensuring that alleged patient abuse and neglect cases receive prompt and appropriate action;

(e) Promoting liaison with federal, state, local, community, legal, and civil rights advocacy groups;

(f) Consulting with appropriate OhioMHAS staff, including the executive committee team, regarding complaints, grievances, and grievance appeals, including those having a potential impact on policy development;

(g) Referring matters requiring legal expertise in the area of patient rights to the department's office of legal services;

(h) Investigating and responding to patient grievance appeals;

(i) Meeting with RPH rights and recovery administrators on at least a quarterly basis;

(2) Each RPH is to have at least one full-time rights and recovery administrator for inpatient services, who reports directly to the RPH chief executive officer (CEO) or the CEO's designee.

Each RPH is to have a rights and recovery administrator alternate, appointed by the RPH CEO and who reports to the CEO or the CEO's designee.

(3) Duties for the each RPH rights and recovery administrator include, but are not limited to, the following:

(a) Planning, implementing, and coordinating RPH advocacy programs, including all of the following:

(i) Developing policies and procedures for the promotion and protection of human rights in accordance with state and federal statutes, joint commission guidance, and centers for medicare and medicaid services policy;

(ii) Monitoring and evaluating RPH compliance;

(iii) Establishing mechanisms for resolution of patient advocacy problems;

(iv) Providing consultation, negotiation, training, and technical advice; and

(v) Representing RPH on matters concerning patient rights.

(b) Providing patient advocacy services, including all of the following:

(i) Assuring adequate privacy for patient interviews;

(ii) Being accessible to patients in person and at work locations;

(iii) Representing and assisting patients especially in the areas of rights, abuse and neglect, and fulfillment of recovery and human dignity;

(iv) Investigating and responding to grievances on behalf of patients;

(v) Attending RPH investigatory interviews with patients, as requested by patients;

(vi) Protecting human and civil rights;

(vii) Reviewing unusual incident reports as part of the quality assurance process;

(viii) Ensuring that patients have legal representation at court hearings related to hospital services; and

(ix) Ensuring that patient rights are prominently displayed in writing on every unit.

(c) Attending meetings related to patient advocacy; serving as a member of the executive governing body and other committees to ensure representation of the hospital's advocacy program; preparing reports for RPH or campus administration and central office; maintaining records; and responding in writing to correspondence pertaining to patient advocacy;

(d) Providing input into program and environmental changes to meet the needs identified by patients and assuring protection of patient rights, as well as being involved in administrative decisions affecting patient rights, choice, dignity, and recovery;

(e) Advising all levels of RPH staff and volunteers of patient rights, as well as consulting with appropriate department staff, including legal staff, regarding policy issues and responses to complaints or grievances;

(f) Advocating for patient access to community mental health systems and facilitating access to outside entities, including legal counsel, as needed;

(g) Assuring that equal opportunity is implemented with particular emphasis on advocating that people with disabilities are free from discrimination in the provision of services on the basis of religion, race, ethnicity, color, creed, sex, national origin, age, lifestyle, sexual orientation, gender identity, physical or mental handicap, disability, developmental disability, or inability to pay as prescribed in department policies and rules and state and federal statutes;

(h) Ensuring that each patient understands the functions of and resources available through the Ohio protection and advocacy system and receives a copy of the patient rights in oral and written format in accordance with all of the following:

(i) The written rights are to be furnished to a patient within twenty-four hours after admission;

(ii) If a patient is unable to read or speaks a language other than standard English as a primary means of communication, or has a limitation on their ability to communicate effectively (such as deafness or hearing impairment), the list of rights is to be explained to them by providing interpreters, readers, or appropriate communication devices, or by providing other assistance; and

(iii) The notification and explanation of patient rights is to be documented in the patient's health record.

(4) Compliance with paragraph (D)(3)(h) of this rule will be monitored by the RPH quality assurance programs.

Last updated August 15, 2023 at 8:20 AM

History

Effective: August 15, 2023
Promulgated Under: 119.03

Ohio Adm.Code 5122-7-04 Responsibilities of ODMH regional psychiatric hospital police and firearms restrictions.

(A) The purpose of this rule shall be to establish the minimum duties and responsibilities of Ohio department of mental health (ODMH) hospital police, and to establish that no firearms shall be dispensed, carried or discharged in any building or on the grounds of any facility that is operating under the control of ODMH, except as provided below.

(B) The provisions of this rule shall be applicable to all facilities under the managing responsibility of ODMH. The firearms restrictions stated in this rule shall include, but not be restricted to, employees of ODMH hospital police departments.

(C) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Chief of police" means an individual appointed to supervise ODMH hospital police department personnel, operations, and security functions. This individual is appointed by the hospital chief executive officer, subject to joint selection or approval by the ODMH security consultant (or in his/her absence, the ODMH chief legal counsel) and final approval by the director.

(2) "Police officer" means any special police officer, as defined in section 5119.14 of the Revised Code, who is under the supervision of the hospital chief of police. A police officer has special training and authority, including the power to arrest under section 5119.14 of the Revised Code. Hereinafter, ODMH police officers are referred to collectively as "hospital police."

(3) "Firearm" means any pistol, revolver, rifle, shotgun, or any part of any such weapon (or any ammunition for any such weapon, or any other weapon capable of discharging a projectile or projectiles that can wound, fatally or otherwise, the person of another). This definition includes unloaded firearms and any firearm which is inoperable but which can readily be rendered operable.

(4) "Securing the scene" means taking actions necessary to stabilize all existing factors and conditions which could destroy or disturb evidence at the scene of a death, an alleged patient abuse, or where any other suspected criminal offense has been committed.

(5) "Safety officer" means a hospital employee designated by the chief executive officer to develop, implement, and supervise the hospital's safety program.

(6) "Safety committee" and/or "environment of care committee" means a group of hospital employees responsible for reviewing, advising, and/or promoting the hospital's safety program.

(7) "Stun gun" means a weapon designed to stun or temporarily immobilize a victim, especially by delivering a high-voltage electric shock. This includes the trademark taser device.

(D) Requirements of hospital police

(1) Hospital police shall provide protection and security for the patients , visitors, staff, grounds and buildings under the operating authority of the hospital.

(2) Hospital police shall be aware of and sensitive to the therapeutic needs of patients, and shall participate whenever possible in assisting patients in their recovery.

(3) Hospital police may be required to serve as patient escorts as deemed necessary on a facility-by-facility basis.

(4) All reports, including reports of investigations, shall be properly filed, maintained, and secured to protect the confidentiality of persons involved as required by section 5122.31 of the Revised Code. All reports shall be made using standardized departmental forms or forms approved by the chief of police. Requests for access to, or copies of police reports shall follow ODMH policy L-13, "ODMH Public Records Policy."

(5) All inpatient and CSN incidents of workplace violence shall be reviewed annually by the hospital police department, as required by ODMH policy L-01, "Workplace Violence Policy and Procedure" and shared with the hospital chief executive officer in order to identify trends and learning opportunities.

(E) Responsibilities of hospital police

(1) The chief of police shall be responsible for all police department functions, supervision of all police department personnel, and regular performance of the following duties:

(a) Submission of routine reports to the chief executive officer, security consultant, and/or director as directed. An annual report shall be completed which includes measures to improve the operation of the hospital's police department.

(b) Preparation of a policy and procedure manual, which shall be reviewed and approved by the chief executive officer and used to instruct hospital police with respect to the police department's role in assisting patients in their recovery, police functions, and relationships with other departments and programs of the hospital.

(c) Immediate securing of the scene and notifying the chief executive officer or designee, the ODMH security consultant, and the Ohio state highway patrol of any criminal offense or of any allegation of patient/client abuse occurring on any property under the control of ODMH.

(2) Hospital police shall provide the following services:

(a) Enforce the laws of the state of Ohio and investigate any alleged violation of a state statute or organizational policy (as needed). In general, hospital police shall not manage the activities or behavior of patients unless a violation of state law is evident.

(b) Provide assistance to patients, family members and clinical staff in the ongoing process of recovery from the effects of a severe and persistent mental illness.

(c) Investigate all alleged crimes and report suspected illegal activities by employees to the hospital chief of police, who shall then make certain that the ODMH security consultant and the Ohio state highway patrol are both notified. If the Ohio state highway patrol elects not to handle a case, prosecution of suspected illegal activities will be pursued by the hospital police when the chief executive officer and ODMH security consultant concur.

(d) Investigate incidents, fires, and accidents pursuant to the applicable administrative rules promulgated by the department. A safety officer may be assigned to handle certain of these designated duties.

(e) Patrol the hospital's property and buildings in order to identify and report security, fire and safety hazards found and to request corrective maintenance action. Damaged property or conditions which are potentially dangerous to life or property and which are to be reported include defective fire or first aid equipment or unavailability of equipment.

(f) Remove or cause to be removed nuisances or obstructions from the hospital's property.

(g) Assist in the evacuation of patients, staff members and visitors in the event of an emergency and also to assist in providing security and shelter for those persons evacuated.

(h) Provide security, as needed, for public meetings on the property.

(i) Assist consumers, employees, or visitors by rendering emergency first aid, requesting medical assistance, or assisting in their transportation in emergencies.

(j) As an emergency intervention at the request of a clinical supervisor, assist in the control of a patient's behavior when such behavior presents a danger of physical harm to himself/herself and/or others.

(k) Investigate and file reports of vehicle accidents occurring on hospital property.

(l) Investigate employee accidents and complete police reports of these accidents; complete necessary documentation for possible workers' compensation claims in accordance with the hospital's written policies and procedures.

(m) Unless handled by the hospital's safety officer or safety/environment of care committee, develop and implement procedures for emergency evacuations and fire drills pursuant to the applicable rules promulgated by the department.

(n) Actively participate on the hospital's safety/environment of care committee, as appointed.

(o) Control the flow of vehicle traffic and parking on hospital property in accordance with hospital directives and the applicable administrative rules and state statutes.

(p) Maintain a daily radio/telephone log and make written reports of all activities.

(q) In addition to the aforementioned duties, hospital police shall observe the powers and duties as provided in section 5119.14 of the Revised Code.

(3) Training and expectations

(a) Training in job functions shall be available to all hospital BHO police and shall follow guidelines established by the training component of the appropriate division, including at least the minimum number of hours of training as mandated by the Ohio peace officers training council and provided by an academy which is recognized and accredited by the Ohio peace officers training council.

(b) First aid classes shall be mandatory for all hospital police.

(c) Hospital police shall not be expected to place their lives or the lives of other persons in jeopardy in order to discharge their duties.

(d) Hospital police shall not be expected to violate administrative rules or policies in the discharge of their duties.

(e) If the chief executive officer or any member of his or her administrative staff directs or orders the chief of police or a police officer to cease or not initiate an investigation of a reported or suspected violation of any state statute or administrative rule, such order shall not be carried out without first consulting the department security consultant. The order shall then be placed in writing with a copy to the director.

(F) Firearms restrictions

(1) Firearms shall not be stored, dispensed, carried or discharged in any building or on the grounds of any facility under the operating control of ODMH, except when a visiting police agency needs to lock its gun(s) in a safe area.

(2) No patient, visitor, hospital employee, including police officers, shall possess, store, dispense, carry or discharge a personally-owned firearm on the grounds of a facility under the operating control of ODMH.

(3) Ohio state highway patrol officers, local law enforcement authorities, or other persons duly authorized to carry firearms may not carry such weapons into patient contact areas of the facility unless a special request has been made by the chief executive officer in the event of a life-threatening emergency situation which could require the use of deadly force.

(4) Special requests granted by the chief executive officer, which are exceptions to the rule stated in paragraph (F)(1) of this rule, shall be reported immediately to the director of ODMH, or designee, and a written report of such incident shall be made to the director within twenty-four hours explaining the need for such actions.

(5) Any person who violates this policy shall have committed an action which may be cause for removal, as well as, arrest and prosecution under section 2921.36 of the Revised Code.

(G) Stun gun restrictions

(1) Except as authorized in ODMH policy L-14, "ODMH Hospital Police Use of Electronic Control Device" and when a visiting policy agency needs to lock its stun gun(s) in a safe area, stun guns shall not be stored, dispensed, carried or discharged in any building or on the grounds of any facility under the operating control of ODMH.

(2) No person, including police officers and other hospital employees, shall possess, store, dispense, carry or discharge a personally-owned stun gun on the grounds of a facility under the operating control of ODMH.

(3) Ohio state highway patrol officers, local law enforcement authorities, or other persons duly authorized to carry stun guns may not carry such weapons into patient contact areas of the facility unless a special request has been made by the chief executive officer in the event of a life-threatening emergency situation which could require the use of deadly force.

(4) Special requests granted by the chief executive officer, which are exceptions to the rule stated in paragraph (G)(1) of this rule shall be reported immediately to the director of ODMH, or designee, and a written report of such incident shall be made to the director within twenty-four hours explaining the need for such actions.

(5) Any person who violates this policy shall have committed an action which may be cause for removal.

(H) Equipment

(1) A night stick or riot baton may be carried by hospital police only when patrolling outside of buildings, and then only with prior approval of the chief executive officer. The use of a blackjack, slapjack, or similar type of weapon is prohibited.

(2) Equipment which discharges chemical gases, such as chemical mace, may be carried with prior approval of the chief executive officer, but only for patrolling outside of buildings. Such equipment shall not be used to control or subdue a patient.

(I) Implementation. The chief executive officer of each hospital shall be responsible for prescribing guidelines for implementation of this rule.

History

Effective: May 10, 2010
Promulgated Under: 111.15

Ohio Adm.Code 5122-7-21 Background check on applicants.

(A) The purpose of this rule is to establish policy and procedures for the conducting of background checks on prospective employees of the Ohio department of mental health and addiction services as mandated in section 5119.181 of the Revised Code. The purpose of the background checks will be to determine the fitness of applicants to serve in the positions sought whether in the classified or unclassified service. This rule also outlines the criteria to be applied in evaluating applicants based on information obtained from background checks.

(B)

(1) Except as provided in paragraph (B)(2) of this rule, this rule applies to all regional psychiatric hospitals (RPHs) or community support networks (CSNs) of the department and the central office.

(2) This rule does not apply to an applicant who seeks employment with a community support network and the applicant's intended work site is a residential facility as defined in section 5119.34 of the Revised Code. Instead, such an applicant is subject to a background investigation under rule 5122-30-31 of the Administrative Code.

(C) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code.

(1) "Applicant" means any person who is under final consideration for appointment to a position in the classified or unclassified service of the Ohio department of mental health and addiction services.

(D) The following paragraph pertains to crimes bearing a direct and substantial relationship to the position being filled.

(1) In accordance with section 5119.181 of the Revised Code, no appointing authority shall appoint a person to fill a position in the classified or unclassified service if the person has been convicted or has pleaded guilty to a violation of the following:

(a) Any felony contained in the Revised Code, if the felony bears a direct and substantial relationship to the position being filled; or

(b) Any crime contained in the Revised Code constituting a misdemeanor of the first degree and a felony on subsequent offenses if the crime bears a direct and substantial relationship to the position being filled; or

(c) An existing or former law of this state or of any other state or the United States if the law violated is substantially equivalent of any of the offenses described in paragraph (D)(1)(a) or (D)(1)(b) of this rule.

(2) The appointing authority shall determine what constitutes a direct and substantial relationship to the position being filled based on the following factors:

(a) Nature and gravity of the offense. For example, any conviction for a crime during which force was used or implied against another person, such as assault or armed robbery, would have a direct and substantial relationship to any position involving direct client contact;

(b) The length of time since the conviction. For example, convictions occurring more than ten years prior to the application carry less weight than more recent convictions; and

(3) Each applicant must be assessed on an individual basis based on the factors listed above.

(E) Procedure prior to hiring

(1) At the time of a conditional offer, the applicant shall be informed that a background check will be conducted.

(2) The following background checks are to be conducted on applicants prior to employment:

(a) For any position involving direct client contact, all previous employers who employed applicant in a similar position shall be contacted;

(b) The applicant's current and immediate prior employers shall be contacted as to work habits and reasons for leaving the employment;

(c) A request for information regarding prior criminal convictions shall be submitted to the law enforcement agency which has jurisdiction in the applicant's current or last area of residence;

(d) Personal references submitted by the applicant should be contacted as to their knowledge of the applicant; and

(e) An applicant shall be fingerprinted via electronic fingerprinting or other approved method, and shall be transmitted to the bureau of criminal identification and investigation (BCI&I) and the federal bureau of investigation (FBI).

The BCI&I's or FBI's response as to any felony convictions or pending criminal charges shall be compared to the information on the application signed by the applicant.

(3) Any falsification on the application which is disclosed by the background checks shall cause the applicant to be removed from further consideration for employment or, if already employed, shall cause the employee to be removed from employment.

(F) If, upon review by the appointing authority or their designee, the background check discloses information that the applicant has displayed character traits which would be detrimental to successful performance in the position sought, or that the applicant has been dismissed for good cause from any public or private service for a reason bearing a direct relationship to the position being filled, or that the applicant has been convicted of a crime bearing a direct and substantial relationship to the position, such applicant shall be precluded from further employment consideration.

(G) The applicable EEO officer shall be kept aware of specific reasons for hiring, or not hiring, an applicant under the provisions of this rule.

(H) All information obtained in the background checks shall be considered confidential. It is not a public record for purposes of section 149.43 of the Revised Code and shall not be made available to any person, except the applicant, the appointing authority or their designee, or any hearing officer or court involved in a case denying employment.

(I) Notwithstanding the provisions of this rule, the Ohio department of mental health and addiction services shall conduct a separate criminal background investigation on all applicants for unclassified positions as described by section 124.11 of the Revised Code. All offers of employment to prospective (new) employees shall be made contingent on the successful completion of the background check, including a review of state tax issues.

Last updated January 3, 2022 at 10:49 AM

History

Effective: January 3, 2022
Promulgated Under: 119.03

Chapter 5122-8 Waiting List for Alcohol and Drug Addiction Services

Ohio Adm.Code 5122-8-01 Waiting list for alcohol and drug addiction services.

(A) The following definitions shall apply to this chapter:

(1) "Provider" means a community addiction services provider as defined in division 5119.01 of the Revised Code.

(2) "First contact" means the date on which an individual contacts a provider requesting actual opioid and co-occurring drug addiction services and recovery supports, a first contact is indicated by making an appointment for an assessment or beginning services, an intake session, or other example of the individual beginning a therapeutic relationship with the provider.

(3) "Seeking" means those individuals who have made at least a first contact with a provider and are attempting to actually receive services and supports from the provider.

(B) For the purposes of this rule the services and recovery supports required to be tracked on the waitlist described by this rule shall be listed in appendix A to this rule.

(C) Providers shall maintain a waitlist of those individuals seeking opioid and co-occurring drug addiction services and recovery supports from the provider.

(D) Using the waitlist specified in paragraph (B) of this rule, providers shall determine for each individual, either:

(1) If the individual is not required to be clinically assessed for the need for services and support, the number of days starting with the day the individual first contacts the provider about accessing the services and supports and ending on the first day of the individual's access to the services and supports; or,

(2) If the individual is required to be clinically assessed for the individual's need for the services and supports:

(a) The number of days starting with the day the individual first contacts the provider about accessing the services and supports and ending on the day of initial assessment; and,

(b) The number of days starting with the day of the clinical initial assessment and ending on the first day of the individual's access to the services and supports.

(E) Providers shall maintain a count of all individuals who were referred to another provider because the originating provider does not provide the opioid and co-occurring drug addiction services and recovery supports requested or been assessed as having a clinical need for; and each type of service and support for which those individuals were referred.

(F) Providers shall use the information acquired by maintaining the waitlist pursuant to paragraph (C) of this rule to determine whether included opioid and co-occurring drug addiction services and recovery supports are insufficient to meet the needs of individuals on the waiting list.

(G) The provider shall attempt to notify individuals when slots for services become available according to the provider's own policies and procedures.

(1) For non-residential services, providers shall allow an individual up to twenty-four hours to contact the provider about the offered services before proceeding to paragraph (H) of this rule.

(2) For residential services, providers shall offer individuals slots for services in accordance with the provider's own policies and procedures before proceeding to paragraph (H) of this rule.

(H) If an individual does not respond to a provider regarding a service opening, the provider shall attempt to contact the individual and assess the individual's need for the service. If the individual still needs the service and wishes to remain on the waiting list, the provider shall retain the individual on the waiting list in accordance with the provider's policies and procedures.

(I) A provider may remove an individual from the waiting list if:

(1) The individual withdraws their request for opioid and co-occurring drug addiction services and recovery supports;

(2) The individual does not respond to contact attempts for the time period specified in paragraph (H) of this rule.

(J) Providers shall report the following to the department no later than the last day of each month using the secure electronic methods specified by the department.

(1) For each individual on the provider's waiting list in the immediately preceding month:

(a) Last four digits of social security number;

(b) First two letters of last name;

(d) Gender;

(e) Year of birth;

(f) The dates for each required tracked event in paragraph (D) of the rule;

(g) The date when the first assessment is offered, if applicable, and first offered date of services or supports if different from the start date of services or supports;

(h) The opioid and co-occurring drug addiction services and recovery supports for which the individual was waiting; and,

(i) The last known type of residential setting.

(2) Providers shall also report the following data:

(a) The count of individuals referred to another provider as required by paragraph (E) of this rule;

(b) The total number of individuals who did not contact the provider after receiving notices that the provider has a slot open and if known the reasons the why contact was not made; and,

(c) The total number of individuals who withdrew their requests for services and supports, the type of service and support the individual had requested or been assessed as having a clinical need for, and if known the reasons for withdrawing the request.

(K) The department shall report data received from from providers pursuant to paragraph (J) of this rule by the fifth day of each month as follows:

(1) Reports containing information about individuals residing in or requesting services and supports in the county served by a board of alcohol, drug addiction, and mental health services shall be made available in a secure, electronic manner to the board.

(2) Reports shall be published on the department's website in both a statewide aggregate and county aggregate basis.

(L) Each board of alcohol, drug addiction, and mental health services shall:

(1) Download the reports made available by the department in paragraph (K)(1) of this rule by the tenth day of each month, which shall be acknowledgment that the board has received and reviewed the reports.

(2) Determine using the reports received in this paragraph whether any included opioid and co-occurring drug addiction services and recovery supports are not meeting the needs of individuals in the area the board serves; and,

(3) Inform the department of any determination of insufficiency and related commentary determined necessary by the last day of the month in which the reports are received.

View Appendix

History

Effective: July 2, 2017
Promulgated Under: 119.03

Chapter 5122-9 Management of Funds

Ohio Adm.Code 5122-9-10 Management and control of internal funds.

(A) The purpose of this rule is to establish policy for management and control of the internal funds at each Ohio department of mental health and addiction services regional psychiatric hospital (RPH) business office, to establish books and accounts for each fund in a standardized and uniform manner, and to install a system of internal controls to ensure the safe guarding of assets.

(B) The provisions of this rule are applicable to all RPHs. Further, the provisions of this rule apply to all internal funds now on hand or which may be established in the future at the RPH. Should any conflict arise between the provisions of this rule and the provisions of rules 5122-2-03, 5122-1-28, and 5122-1-29 of the Administrative Code, the provisions of the latter rules will apply.

(C) The following definitions apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) "Cash journal" means a printed form (DMH-FIS-053), usually bound in a post binder, suitable for maintaining a daily record of money received and spent, and a stated balance of assets. The use of any other form, paper or electronic, is to be approved by the office of fiscal administration and support.

(2) "Patients' funds account" means the internal fund established under the authority of section 5119.56 of the Revised Code for the purpose of receiving and holding in trust those monies in the possession of patients on admission to a regional psychiatric hospital or received for them during the course of their residence at a RPH that may be disbursed for their benefit. There are specific earmarked portions within this fund called patients' funds account, patients' representative payee account, commissary fund, and savings fund.

(3) "Commissary cash journal" means a printed form, usually bound in a post-binder, used for maintaining a daily record of money received and spent, the balance of assets, and special columns in which to detail the exact nature of receipts and disbursements, as well as the retail value of merchandise bought for resale.

(4) "Internal funds" means those funds that are maintained and controlled by the managing officers at the hospital. Such funds may include, but are not limited to, the following:

(a) Patients' funds account pursuant to section 5119.56 of the Revised Code;

(b) Commissary fund pursuant to rule 5122-1-29 of the Administrative Code;

(d) Industrial and entertainment fund pursuant to rule 5122-1-28 of the Administrative Code;

(e) Petty cash fund pursuant to division (A)(6) of section 126.21 of the Revised Code; and

(f) Any other fund that may be established.

(5) "Pre-numbered receipts" means a multiple part form used for recording a sum of money from an organization or individual for credit to a specific account to which the money will be deposited. The forms are to be sequentially pre-numbered, and will have captions to describe from where the money came, the amount received in both alphabetic and numerical form, and the signature of an employee of the hospital who has been authorized by the managing officer to receive and deposit funds.

(6) "Rotary change fund" means a fixed sum of cash for the purpose of making small disbursements from any of the internal funds where cash is appropriate or required, and for tendering change to patrons in the conduct of the commissary sales activity. A change fund drawer or cash box is to contain the total of the fixed amount at all times, such total to be comprised of cash, paid invoices, or any combination of the two. The cash journal will be posted only when checks are drawn to replenish the change fund. All change funds or modifications are to have the prior approval of the chief of fiscal administration.

(7) "Subsidiary ledger" means a special section of a cash journal by which to account for a portion of an internal fund that has been designated for a specific purpose, the balance of which is to be included in the total assets of the fund.

(8) "Voucher" means a printed form used for each internal fund to identify the purpose and amount of a disbursement and provide an authorization for payment by the managing officer or the managing officer's designee. It is to be supported by an invoice or invoices and other related documents, such as patient roster, receiving reports, freight bill, etc., to assure accuracy, completeness, and validity.

(D) Procedure

(1) Pre-numbered receipts will be used as the source document to record all income in each internal fund.

(2) Cash withdrawal form DMH-CA-001 will be the source document to authorize all disbursements from the patients' fund account.

(3) Cash receipts will be deposited intact on a timely basis in a bank checking account, but in no instance later than every Friday, allowing a minimum to remain on hospital grounds over a weekend. The deposit amount will be posted in the checkbook from the certified amount listed on the bank deposit ticket.

(a) All monies accruing to a fund in excess of current needs should be invested in interest-bearing accounts. This does not apply to patients' fund account where savings may be established only in the name of individual patients. Savings accounts may be established in commissary funds only to the extent of anticipated or projected needs for repairs, remodeling, or replacement of equipment.

(b) A cash journal will be established for each fund in which to record daily all receipts and disbursements. A special cash journal will be established for commissaries. Subsidiary ledgers may be established within the cash journals of certain funds as necessary.

(c) All disbursements from internal funds will be by check. Cash requirements will be met through the use of a rotary change fund which is reimbursed by check. The bank signature cards are to be updated as needed and maintained in a current status.

(d) Disbursements from internal funds will be controlled and documented by a voucher system. Disbursements made for supplies, clothing, or equipment are to be supported by a receiving report prior to payment. Disbursements made for the entertainment of patients will be documented by a verified roster of the patients served.

(E) To the extent possible, there is to be a division of responsibility between the cash receiving and cash disbursing functions. These duties should be divided into two positions. The first will receive all income and deposit it intact into the appropriate account. The second will tender all cash pay outs and prepare checks. This separation should reduce the possibility of records being manipulated for personal gain.

(F) Daily procedures for maintaining funds

(1) Post the total sum of cash receipts to the cash journal of each fund.

(2) Post all disbursements to the cash journal as checks are drawn.

(3) The patients' fund receipts and disbursements will be posted on-line to the patient accounting system. At the conclusion of the business day, the daily posting journal and daily balance reports will be printed and maintained in accordance with the department's retention schedule. The patients' fund daily reconciliation form is to be completed verifying liabilities (amount due patients) agree with the assets of the fund.

(G) Procedures to be completed monthly

(1) Foot the receipts and disbursements columns of all cash journals, reconcile the amounts shown in the balance columns, and balance these sums to the total cash on hand and in the bank for each fund.

(2) When all funds have been balanced to the bank statement, a monthly report of cash book balances and bank reconciliations will be forwarded to the internal audit group.

Last updated April 4, 2022 at 1:06 PM

History

Effective: April 4, 2022
Promulgated Under: 119.03

Ohio Adm.Code 5122-9-16 Shared service agreements.

(A) The purpose of this rule shall be to establish procedures for writing, processing, amending, and canceling shared service agreements.

(B) The provisions of this rule shall be applicable to all employees of the Ohio department of mental health.

(C) The following definition shall apply to this rule in addition to those appearing in section 5122.01 of the Revised Code:

"Shared service agreement" means a written agreement used by the department in order to thoroughly identify costs which hospital services incurs by providing direct and indirect services to divisions and sections within the department and to outside agencies.

(D) Policy

(1) The department of mental health shall use the current procedure manual for shared service agreement as a guideline in the preparation of shared service agreements.

(2) Shared service agreements shall be used to provide a basis for recovering the costs which hospital services incurs by providing direct and indirect services to divisions and sections within the department and to outside agencies.

(3) Shared service agreements shall be used to verify any adjustments claimed in medicare/medicaid cost reports for audit purposes.

(4) Shared service agreements shall be used as a tool in budgeting and allocating spending authority to department accounts.

(E) Implementation

All chief executive officers, deputy directors and office chiefs of the department shall be responsible for implementation of this rule.

History

Effective: June 6, 2011
Promulgated Under: 111.15

Chapter 5122-14 Licensing of Psychiatric Hospitals and Units

Ohio Adm.Code 5122-14-01 Definitions and applicability.

(A) The provisions of Chapter 5122-14 of the Administrative Code apply to each inpatient psychiatric service provider licensed pursuant to section 5119.33 of the Revised Code by the department of mental health and addiction services.

(B) The following definitions apply to Chapter 5122-14 of the Administrative Code:

(1) "Abuse" means any act or absence of action caused by an employee inconsistent with rights that results in or could result in physical injury to a patient; any act that constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, when such activity would constitute an offense against a patient under that chapter; insulting or coarse language or gestures directed toward a patient that subjects the patient to humiliation or degradation; or depriving a patient of real or personal property by fraudulent or illegal means.

(2) "Abused child" has the same meaning as in section 2151.031 of the Revised Code.

(3) "ACHC" means the accreditation commission for health care.

(4) "Admission" means acceptance by the inpatient psychiatric service provider of a person with the intent of providing at least twenty-four hours continuous care and treatment to that person.

(5) "Advance directives" means a legal document an adult can use to direct in advance the decisions about their mental or physical health treatment if in the future they lack the capacity to make their own health care decisions.

(6) "Certified nurse practitioner" has the same meaning as in section 4723.01 of the Revised Code.

(7) "Chemical restraint" means any medication that alters the functioning of the central nervous system in a manner that limits physical and cognitive functioning to the degree that the patient cannot attain the patient's highest practicable physical, mental, and psychosocial well-being.

(8) "Child and adolescent psychiatrist" means a psychiatrist who is certified in child and adolescent psychiatry by the American board of psychiatry and neurology or has successfully completed training in a child and adolescent psychiatry program approved by the residency review committee of the accreditation council for graduate medical education of the American medical association. A child and adolescent psychiatrist is also a psychiatrist as defined in this rule.

(9) "Clear treatment reasons" means that a patient would present a substantial risk of physical harm to themselves or others, or that effective treatment of the patient would be substantially precluded.

(10) "Clinical nurse specialist" has the same meaning as in section 4723.01 of the Revised Code.

(11) "Clinical privileges" means authorization granted to a practitioner to provide specific health care services in the organization within well-defined limits, based on the following factors, as applicable: license, certification, registration, education, training, experience, competence, health status, and judgment.

(12) "CMS" means the centers for medicare and medicaid services, a federal agency within the U.S. department of health and human services.

(13) "Community addiction services provider" has the same meaning as in section 5119.01 of the Revised Code.

(14) "Community mental health services provider" has the same meaning as in section 5119.01 of the Revised Code.

(15) "Counselor" means an individual who is licensed as a professional counselor or a professional clinical counselor in accordance with Chapter 4757. of the Revised Code.

(16) "Cultural sensitivity" means an awareness, understanding, and responsiveness to the beliefs, values, customs, and institutions (family, religious, etc.) of a group of people, particularly those of a race or ethnic group different from one's own, or those identified cultures of persons with specific disabilities such as deafness.

(17) "Culturally relevant" means incorporating awareness, understanding, and responsiveness to the beliefs, values, customs, and institutions (family, religious, etc.) and ethnic heritage of individuals or those identified cultures of persons with specific disabilities such as deafness, into training, treatment, and services designed to impact upon, or meet the needs of individuals or groups.

(18) "Department" means the Ohio department of mental health and addiction services.

(19) "Det norske veritas (DNV) healthcare, inc." means the organization, a division of det norske veritas, which operates the national integrated accreditation for healthcare organizations program.

(20) "Developmental disability" has the same meaning as in section 5123.01 of the Revised Code.

(21) "Director" means the director of the Ohio department of mental health and addiction services.

(22) "Dietitian" means an individual who is licensed as a dietitian in accordance with Chapter 4759. of the Revised Code.

(23) "Emergency" means an impending or crisis situation that creates circumstances demanding immediate action.

(24) "Expressive therapist" means an individual who provides treatment intervention through the use of such activities as art, music, or dance and who (a) is certified or registered by the national expressive therapist association, certification board for music therapists, American arts therapy association, American dance therapy association or (b) is licensed, certified or registered by another recognized state or national body to practice expressive therapy.

(25) "Family members" means persons related by family to a patient.

(26) "Grievance" means a written record of dissatisfaction with mental health services expressed by a patient, family member, significant other, patient rights advocate, or other interested person or agency.

(27) "Guardian" means any person, association, or corporation appointed by the probate court to have responsibility for the care and management of a minor or a person declared incompetent in accordance with Chapter 2111. of the Revised Code.

(28) "Incident" means any event that poses a danger to the health and safety of patients, staff, or visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the hospital.

(29) "Informed consent" means the voluntary, knowing, reasoned choice of a person, or, as appropriate, the person's legal guardian to a proposed treatment or procedure.

(30) "Inpatient psychiatric service provider" or "hospital" means a psychiatric hospital or psychiatric inpatient unit administered by a general hospital, community mental health service provider, or other facility that provides inpatient psychiatric services.

(31) "Involuntary" means against an individual's will or without having been provided informed consent.

(32) "Joint commission" (TJC) means the joint commission, formerly known as the joint commission on accreditation of healthcare organizations (JCAHO).

(33) "License" means the department's written approval and authorization for an inpatient psychiatric service provider to receive persons with a mental disorder for care and treatment.

(34) "Licensed practical nurse" has the same meaning as in section 4723.01 of the Revised Code.

(35) "Mechanical restraint," "physical restraint," and "prone restraint" have the same meanings as in rule 5122-26-16 of the Administrative Code.

(36) "Medical record" means the account of a patient's hospitalization, compiled by health care professionals, including but not limited to a patient's history, present illness, findings on examination, details of care, services and treatment, and progress notes.

(37) "Medication" means therapeutic drugs (or agents or compounds) dispensed, personally furnished, or administered pursuant to a prescription or order by an appropriately licensed independent practitioner.

(38) "Neglect" means a purposeful or negligent disregard of duty imposed on an employee or staff member by statute, rule, or professional standard and owed to a patient by that employee or staff member.

(39) "Nursing staff" means clinical nurse specialists, certified nurse practitioners, registered nurses, licensed practical nurses, nursing assistants, and other nursing personnel who perform patient care.

(40) "Occupational therapist" has the same meaning as in section 4755.04 of the Revised Code.

(41) "Occupational therapy assistant" has the same meaning as in section 4755.04 of the Revised Code.

(42) "Patient" means a person admitted to a hospital or inpatient unit either voluntarily or involuntarily who is under observation or receiving treatment or is receiving any other mental health services by the inpatient psychiatric service provider.

(43) "Patient rights specialist" means a person designated by each inpatient psychiatric service provider to safeguard patient rights and to assist patients in exercising their rights, including the rights in this chapter and in Chapter 5122. of the Revised Code.

(44) "Physician" means a person authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery or a medical officer of the government of the United States while in this state in the performance of his or her official duties.

(45) "Psychiatric intensive care" means a program within a defined secure physical space (normally including patient lounge and sleeping room space) utilized to provide a more intense form of care for those patients requiring closer observation, decreased environmental stimulation, or a more intensive staff to patient ratio.

(46) "Psychiatrist" has the same meaning as in section 5122.01 of the Revised Code.

(47) "Psychiatrist with clinical privileges in adolescent psychiatry" means a psychiatrist who is qualified through training and experience specific to the needs of adolescent patients and has specific hospital clinical privileges to provide treatment to adolescent patients.

(48) "Psychiatrist with clinical privileges in geriatric psychiatry" means a psychiatrist who is qualified through the American board of psychiatry and neurology or through other documented training or experience specific to the needs of geriatric patients and has specific hospital clinical privileges to provide treatment to geriatric patients.

(49) "Psychologist" means an individual who holds a current, valid license to practice psychology issued under section 4732.12 of the Revised Code.

(50) "Psychotropic medication" means that group of medications having a specific and intended effect on central nervous system functions that are ordinarily used to alter disorders of thought, perception, mood, or behavior.

(51) "Recovery" means a personal process of overcoming the negative impact of a psychiatric disability despite its continued presence.

(52) "Recreational therapist" means an individual who is registered by the Ohio recreational therapy registration board or certified by the national council for therapeutic recreation certification or who is licensed, certified, or registered by another recognized state or national body to practice recreational therapy.

(53) "Registered nurse (R.N.)" has the same meaning as in section 4723.01 of the Revised Code.

(54) "Rehabilitation therapist" means an occupational therapist, occupational therapy assistant, recreational therapist, or expressive therapist as defined in this rule. Such individuals are to comply with current, applicable scope of practice and supervisory requirements as identified by their appropriate licensing, certifying, or registering bodies.

(55) "Rehabilitation therapy services" means structured activities designed to help a patient develop or maintain functional living skills including physical, social, and creative skills through participation in activities of daily living, vocational, recreational, social, expressive, or other activities designed to promote patient recovery, resiliency, and independence in both the hospital and community setting.

(56) "Reportable incident" means an incident that has to be submitted to the department through the web enabled incident reporting system (WEIRS), maintained by the department, in accordance with the rules in this chapter. As referenced in division (G) of section 5119.36 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident".

(57) "Resiliency" means the personal and community qualities that enable individuals to rebound from adversity, trauma, tragedy, threats, or other stresses and to go on with life with a sense of mastery, competence, and hope.

(58) "Restraint" means any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

(59) "Seclusion" means the involuntary confinement of a patient alone in a room where the patient is physically prevented from leaving.

(60) "Significant other" means an individual who is significant and important to the well-being of the patient, as identified by the patient.

(61) "Social worker" means a person licensed under Chapter 4757. of the Revised Code to practice as a social worker or independent social worker.

(62) "Transitional hold" means a brief hold, without undue force, of a person in order to calm or comfort them; or holding a person's hand to safely escort them from one area to another. At no time may a transitional hold be a prone restraint, mechanical restraint, or physical restraint as defined in this rule. Transitional holds are not seclusion or restraint.

(63) "Treatment plan" means a written statement of goals and objectives for a patient with corresponding treatment interventions and services.

(64) "Variance" means permission granted by the director or designee in writing to an inpatient psychiatric service provider to change the conditions or specific mandates of a rule.

(65) "Waiver" means permission granted by the director or designee in writing to an inpatient psychiatric service provider to be exempted from the conditions of specific mandates of a rule.

Last updated April 24, 2024 at 8:35 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-02 Accreditation.

(A) Each inpatient psychiatric service provider licensed by the department is to be accredited under a hospital accreditation program by either the joint commission (TJC), the accreditation commission for health care inc. (ACHC), or DNV healthcare USA inc. (DNV).

(B) Proof of such accreditation is to be submitted by the inpatient psychiatric service provider as indicated in paragraphs (A)(1)(h) and (B)(7) of rule 5122-14-03 of the Administrative Code.

Last updated April 24, 2024 at 8:35 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-03 Licensure procedure.

(A) An inpatient psychiatric service provider wishing to establish inpatient services for the first time for persons with mental disorders will, prior to occupancy and provision of services, make application for full licensure to the department.

(1) At a minimum, an application is to consist of all of the following:

(a) A completed application form;

(b) An approved building inspection or certificate of occupancy report;

(d) A non-refundable annual licensure fee;

(e) A reduced line drawing showing the location and function of all patient and staff areas including the floor and social space square footage;

(f) A comprehensive plan of service;

(g) Before September 30, 2024, and only if applicable, proof of psychiatric bed registration as reported annually to the Ohio department of health;

(h) Verification of current TJC, ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation;

(i) A completed self-survey checklist;

(j) A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age, and the number of licensed beds designated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older is to equal the total number of licensed beds for the inpatient psychiatric service provider; and

(k) If applicable, the notification required by section 5119.334 of the Revised Code.

(2) The proposed inpatient psychiatric service provider will be subject to an on-site inspection by a designee of the department prior to occupancy to determine if the inpatient psychiatric service provider is in compliance with section 5119.33 of the Revised Code and the rules in this chapter.

(3) An interim license not to exceed ninety days may be issued to the inpatient psychiatric service provider upon completion and departmental approval of the mandates specified in paragraphs (A)(1) and (A)(2) of this rule.

(4) Prior to expiration of the interim license, the department may issue a full license based on review and approval by the department of both of the following:

(a) Implementation of policies and procedures; and

(b) Documentation of being in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter.

(B) For an inpatient psychiatric service provider holding a current license, annual renewal of full licensure will be based on receipt and approval by the department of all of the following:

(1) A completed application form that assures that the private inpatient psychiatric service provider remains in compliance with section 5119.33 of the Revised Code and the licensure rules in this chapter;

(2) Documentation of the substantial changes in written policies and procedures the provider has made during the current licensure period specific to the inpatient psychiatric service provider treatment and licensure rules in this chapter;

(3) An approved fire inspection report, dated within one year of licensure renewal date;

(4) An approved building inspection report, if renovations or major changes in the building have been made or a major change has been made in the use of space;

(5) The non-refundable annual licensure fee;

(6) A statement of the number of licensed beds designated for treatment of persons less than eighteen years of age and the number of licensed beds dedicated for treatment of persons eighteen years of age and older. The sum of beds designated for treatment of persons less than eighteen years of age and beds designated for treatment of persons eighteen years and older is to equal the total number of licensed beds for the inpatient psychiatric service provider;

(7) Verification of current TJC, ACHC, or DNV accreditation as demonstrated by the submission of a copy of the most recent letter of accreditation; and

(8) If applicable, the notification required by section 5119.334 of the Revised Code.

The department will issue automated notices from the licensure and certification tracking system (LACTS) to the inpatient psychiatric service provider prior to the expiration of the annual license

(C) A designee of the department will conduct an on-site survey of the inpatient psychiatric service provider every three years to ensure compliance with section 5119.33 of the Revised Code and the rules in this chapter. Whenever possible, the department will give the inpatient psychiatric service provider notice at least thirty days before the survey is to occur.

(D) The department will provide to an inpatient psychiatric service provider a written communication identifying any deficiencies or non-compliance with licensure rules in this chapter subsequent to an on-site survey or whenever the inpatient psychiatric service provider is found to be in non-compliance with such rules.

(1) If deficiencies or non-compliance with such rules are present, the inpatient psychiatric service provider is to submit documentation of its corrective actions as specified by the department in its written report.

(2) When the deficiencies have been corrected, or a plan to do so has been received and granted approval by the department, the department may then issue a full or probationary license. The existing license is to remain in effect until the department grants a full, probationary, or interim license, or rescinds the license in accordance with provisions of Chapter 119. of the Revised Code.

(3) The inpatient psychiatric service provider is to fully implement its plan of correction within the timeframes specified by the department.

(E) A license will be issued to a specific inpatient psychiatric service provider for a specified total maximum daily census expressed as licensed beds and is not to be transferred, modified, or changed without prior approval from the department.

(1) Before September 30, 2024, licensed beds are to be registered annually with the Ohio department of health pursuant to section 3701.07 of the Revised Code.

(2) Before making any change in the location or the total number of licensed beds, the licensee is to seek approval from the department.

(3) The number of licensed beds refers to the actual number of set up and staffed beds available for immediate patient occupancy or that can be made available for patient occupancy within twenty-four hours.

(a) If an inpatient psychiatric service provider has temporarily designated patient bed space for other purposes to best meet space allocation needs, or if beds have been unavailable for occupancy due to renovation of psychiatric hospital or inpatient unit physical facilities, these beds may be licensed (once available for patient occupancy) upon application by the inpatient psychiatric service provider to the department.

(b) Before September 30, 2024, the total number of licensed beds is not to exceed the number of beds registered with the department of health pursuant to section 3701.07 of the Revised Code.

(4) If an inpatient psychiatric service provider wishes to cease provision of inpatient services, it is to notify the department in writing so that its license can be terminated. The inpatient psychiatric service provider is to also notify the department of health, as applicable.

(F) An inpatient psychiatric service provider may be visited at any time by a designee of the department to determine compliance with rules in this chapter. The department is to have access to, and may have copies of, any of the provider's records, regardless of format, to verify compliance with section 5119.33 of the Revised Code and the rules in this chapter. In addition, the department may conduct interviews with members of the provider's governing body, staff, and others and, with patient permission, a patient.

Last updated April 24, 2024 at 8:35 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-04 Classification of licenses.

(A) Licenses are classified as follows:

(1) A probationary license, which expires within one hundred twenty days of the date of issuance, to be used in either of the following circumstances:

(a) Serious deficiencies are found during the department's on-site survey of an inpatient psychiatric service provider; or

(b) An inpatient psychiatric service provider's documented corrective action is not approved by the department.

(2) An interim license, which expires within ninety days after the date of issuance, to be used for emergency licensure purposes or administrative reasons as determined by the department.

An inpatient psychiatric service provider applying for its first license, and who has preliminary, interim, or similar accreditation, is to be issued an interim license until it obtains full accreditation from either TJC, ACHC, or DNV.

(3) A full license expires one year after the date of issuance.

(B) All licenses are renewable, except that an interim license may be renewed only twice.

(C) A license will specify authorization to admit either one or both age categories of patients based upon the provision of age appropriate diagnostic and treatment services. The child/adolescent category applies to all persons less than eighteen years of age upon admission. The adult category applies to all persons eighteen years of age and older upon admission.

(1) Persons less than eighteen years of age are to be admitted only to authorized child/adolescent designated beds;

(2) Persons eighteen years of age and older are to be admitted only to authorized adult designated beds.

(3) The following will be the only exceptions permitted for not admitting a patient to an age appropriate bed. All exceptions are based on clinical needs specific to each patient or the unavailability of age appropriate designated beds. For all exceptions there is to be documentation in the patient's medical record of the reasons for the exception and ongoing concurrent utilization review. The inpatient service provider is to maintain a log which is to contain the reason for admission, length of stay, referral arrangements, and reason for the exception. The department is to review the log annually.

(a) For child/adolescent admissions to adult beds due to the unavailability of child/adolescent beds, the concurrent utilization review is to include documentation indicating all efforts made to seek appropriate resources and linkages with child/adolescent providers for consultation including treatment planning and after hospitalization care.

(b) The inpatient psychiatric service provider is to inform the parent or legal guardian of the reasons for the decision to admit a child/adolescent to an adult designated bed and also provide information about all available child/adolescent designated beds.

(c) When the admission is an emergency and all child/adolescent designated beds are unavailable, a person less than eighteen years of age upon admission may be admitted to an adult designated bed.

(i) A sixteen or seventeen-year-old patient may remain in an adult designated bed for up to seventy-two hours, and if all child/adolescent beds remain unavailable, the admission may be extended for an additional seventy-two hours. If the admission is extended beyond the first seventy-two hours, an assessment mandated by paragraph (E)(2)(g) of rule 5122-14-13 of the Administrative Code is to be conducted, and rehabilitation therapy services and family therapy/interventions are to be available in accordance with paragraphs (K)(3) to (K)(4) of rule 5122-14-12 of the Administrative Code.

(ii) A fifteen-year-old or younger patient may remain in an adult designated bed for a maximum of forty-eight hours if all child/adolescent beds remain unavailable.

(d) A seventeen-year-old person may be electively admitted and treated in an adult designated bed if the person is functioning as an adult in such areas as employment (with limited or no school involvement), family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult designated bed, provided that such treatment best meets the patient's needs.

(e) A patient eighteen to twenty-one years old may be admitted to a child/adolescent designated bed based on developmental or other clinical needs specific to the patient.

(4) To receive authorization to admit persons less than eighteen years of age, the licensee is to have diagnostic and treatment services that meet the needs of these patients in accordance with rules 5122-14-12 and 5122-14-14 of the Administrative Code.

Last updated April 24, 2024 at 8:35 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-05 Termination of license.

(A) The inpatient psychiatric service provider's existing license is to remain in effect until the department grants a full, probationary, or interim license or rescinds the license in accordance with provisions of Chapter 119. of the Revised Code.

(B) The department may revoke or refuse to grant or renew a full, probationary, or interim license in accordance with Chapter 119. of the Revised Code if any of the following is the case:

(1) An inpatient psychiatric service provider is found to not be in compliance with section 5119.33 of the Revised Code or any or all rules in this chapter and a plan of correction is requested of the inpatient psychiatric service provider by the department and is either not received within the time period specified by the department, is not granted approval by the department, or is not implemented by the inpatient psychiatric service provider;

(2) An inpatient psychiatric service provider's submitted application materials are not approved by the department;

(3) An inpatient psychiatric service provider ceases provision of inpatient services;

(4) An inpatient psychiatric service provider presents or submits false or misleading information as part of a license application, renewal, or investigation;

(5) An inpatient psychiatric service provider has been cited for a pattern of serious noncompliance or repeated violations of statutes or rules during the period of current or previous licenses;

(6) An inpatient psychiatric service provider does not apply for licensure renewal at least thirty days prior to the expiration date of the license; or

(7) The applicant, or any owner, sponsor, medical director, administrator, or principal of the applicant, is or has been the subject of an adverse action as defined in section 5119.334 of the Revised Code unless:

(a) A minimum period of three years has passed from the date of the adverse action; and

(b) The adverse action was not due to any act or omission that violated the patient's right to be free from abuse, neglect, or exploitation.

(C) Notice of the department's intent to deny or revoke a license is to be provided to the inpatient psychiatric service provider in accordance with section 119.07 of the Revised Code. An opportunity for a hearing is to be afforded the inpatient psychiatric service provider in accordance with Chapter 119. of the Revised Code.

(D) The submission of incomplete materials for the application is to be considered a failure to submit an application for licensure, and the non-issuance of an initial license or a renewal license due to an incomplete application is not to be considered the denial or revocation of a license.

(E) In proceedings initiated to deny, refuse to renew, or revoke licenses, the department may deny, refuse to renew, or revoke a license regardless of whether some or all of the deficiencies that prompted the proceedings have been corrected at the time of the hearing.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-06 Waivers and variances.

(A) An inpatient psychiatric service provider may submit a dated, written request to the department for a waiver or variance. The written request is to clearly state the licensure rule of the waiver/variance request, the rationale and need for the requested waiver or variance, and the consequence of not receiving approval of the request.

(B) Upon receipt of a written request for a waiver or variance that provides a clear and valid statement of need, the department in its discretion may grant a waiver or variance for a period of time determined by the department but that is not to exceed the expiration date of the current license.

(C) The department will acknowledge and respond to the waiver/variance request within thirty days of receipt by the department.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-07 Display of license.

(A) The current license is to be displayed by the inpatient psychiatric service provider in a conspicuous place that is readily accessible to the patients and the public.

(B) The license is to remain the property of the department; revoked or terminated licenses are to be returned to the department.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-08 Fee schedule.

(A) The purpose of this rule is to state the fees for various classifications of license.

(B) The provisions of this rule applies to each inpatient psychiatric service provider licensed by the department.

(D) An inpatient psychiatric service provider is to pay an annual fee with each application for full licensure or full licensure renewal according to the following schedule:

Fee Schedule

Fee schedule

| Psychiatric bed capacity | Fee | | --- | --- | | 25 or less persons | $750 | | 26-50 persons | $1350 | | 51-75 persons | $1650 | | 76-100 persons | $1950 | | Over 100 persons | $2250 |

(E) Fees for probationary and interim licenses or re-issuance of a license due to a change in the number of licensed beds may be assessed and will be prorated based on the annual fee.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-10 Patient safety and physical plant requirements.

(A) Each inpatient psychiatric service provider is to comply with all applicable TJC, ACHC, or DNV mandates and federal, state, and local laws and regulations regarding patient care, safety, sanitation, and fire protection.

(1) A building inspection is to be made upon application for an initial license and repeated whenever renovations or changes in the building are made that would affect either the maximum number of licensed patient beds or substantially change the services provided by the inpatient psychiatric service provider, as well as when the department deems a building inspection is necessary.

(2) If an inpatient psychiatric service provider occupies part of a building, the entire building is to be inspected except where there is a fire wall or other fire resistant separation between the part of the building to be licensed and the rest of the building. If this fire separation does not exist the total building is to be used to determine safety for inspection purposes only.

(3) A building inspection is to be performed by a local certified building inspector or, where none is available, by the chief of the bureau of building code compliance in the Ohio department of commerce.

(4) The inpatient psychiatric service provider is to be inspected annually by a certified fire authority or, where none is available, by the division of state fire marshal in the Ohio department of commerce. Copies of annual inspections are to be maintained by the inpatient psychiatric service provider for a period of at least three years or until the next on-site licensure survey.

(5) The inpatient psychiatric service provider's food service is to be inspected annually by the authorized local municipal county health department. Copies of annual inspections are to be maintained by the inpatient psychiatric service provider for a period of at least three years or until the next on-site licensure survey.

(6) If the inpatient psychiatric service provider's water supply and sewage disposal is not part of a municipal system, it is to comply with applicable state or local regulations, rules, codes, or ordinances.

(B) Each inpatient psychiatric service provider is to provide an environment that is clean, safe, aesthetic, and therapeutic. Appropriate space, equipment, and facilities are to be available to provide services.

(1) If smoking is permitted, a separate, enclosed area is to be used for smoking;

(2) Each patient's sleeping room is to have all of the following:

(a) A window, with an operable covering for privacy, that has a view to the outdoors;

(b) A minimum of one hundred net square feet of usable floor space per bed for single occupancy, and a minimum of eighty net square feet of usable floor space per bed for multi-occupancy;

(d) A degree of privacy from other patients if there is more than one bed in the room.

(3) Child/adolescent patients are not to share the same sleeping room with adult patients.

(4) For all patients, a safe and secure storage area for personal belongings accessible to the patient is to be provided. Personal belongings that may pose safety issues for patients may be placed in a safe and secure storage area accessible to patients through a request of staff.

(5) Each inpatient psychiatric service provider is to provide common patient areas that adequately meet patient needs and program mandates.

(a) There is to be a minimum of eighty total square feet of usable social space per licensed bed to include:

(i) A patient lounge area totaling at least thirty square feet per licensed bed, including separate smoking and non-smoking areas if smoking is permitted in the lounge area;

(ii) A patient activity area totaling at least thirty square feet per licensed bed which may include indoor recreation areas;

(iii) Dining room facilities to meet patient needs;

(iv) A patient kitchen area to include a sink, a refrigerator, and cooking facilities as appropriate to patient need; and

(v) A patient laundry area.

(6) Patient lounge, activity, and dining areas are to be shared spaces as appropriate to patient need. Child/adolescent patients are to be provided the use of a patient lounge area appropriate for their use separate from adult use of patient lounge areas.

(7) There are to be private areas to include all of the following:

(a) A private area for visitation from family members, significant others, or other persons;

(b) A private area for telephone use;

(d) Private areas to include places and times for personal privacy.

(8) Each inpatient psychiatric service provider is to provide an environment that is accessible to persons with disabilities and make reasonable accommodations in accordance with all applicable federal, state and local laws and regulations.

(9) Each inpatient psychiatric service provider is to develop policies and procedures regarding services designed to assist deaf/hard of hearing persons as well as persons for whom English is not the primary language.

(a) Services are to be provided at such a level so that the patient and patient's family or significant others are not denied the benefits of participation in the inpatient psychiatric service provider's treatment program. Services will comply with all applicable state and federal guidelines regarding the maintenance of patient confidentiality. As applicable, such services are to consist of but are not to be limited to availability of all of the following:

(i) Qualified interpreters with demonstrated ability or certification;

(ii) Telecommunication devices for the deaf or hard of hearing; and

(iii) Television closed caption capability.

(b) Such services are to be available to patients and their family members or significant others who are receiving services. Specifically for emergency services, the inpatient psychiatric service provider is to have policies and procedures that address the need for immediate accessibility to qualified interpreters, telecommunication devices for the deaf/hard of hearing, and other assistance with communication.

(c) Direct care staff and treatment team members are to be trained in issues relating to barriers to traditional verbal/English communication.

(d) Services to assist patients and families of patients or significant others are to be available at no charge to the patient, family, or significant others.

(10) Each inpatient psychiatric service provider is to implement a falls prevention program that is monitored through its quality improvement process.

(C) Each inpatient psychiatric service provider is to have a sufficient number of professional, administrative, and support staff to meet both census needs and patient needs.

(1) Staffing for all services is to reflect the volume of patients, patient acuity, and the level of intensity of the services provided to ensure that desired outcomes of care are achieved and negative outcomes are avoided.

(2) Staffing of any organized patient activity (e.g., rehabilitation therapy services or nursing services provided to groups of patients) is to be sufficient to ensure safety and may be dependent on the type, duration, and location of the activity and the immediate accessibility of other staff.

(3) For nursing services:

(a) A 1:4 minimum nursing staff-to-patient ratio is to be maintained as an overall average in any four week period with the exception of night hours when patients are sleeping.

(b) For reasons of safety, at least two staff members are to be present at all times.

(d) A registered nurse is to be available for direct patient care when needed.

(D) Each inpatient psychiatric service provider is to meet all applicable medicare conditions of participation (including 42 C.F.R. 482.13(e)), TJC, ACHC, or DNV standards for seclusion and restraint in addition to complying with all of the following provisions:

(1) The following are not to be used under any circumstances:

(a) Behavior management interventions that employ unpleasant or aversive stimuli such as the contingent loss of the regular meal, the contingent loss of bed, and the contingent use of unpleasant substances or stimuli such as bitter tastes, bad smells, splashing with cold water, and loud, annoying noises;

(b) Any technique that obstructs the airway or impairs breathing;

(d) Any technique that restricts the individual's ability to communicate;

(e) Any technique that causes an individual to be retraumatized based on an individual's history of traumatic experiences;

(f) Weapons and law enforcement restraint devices, as defined by CMS in appendix A of its interpretive guidelines to 42 C.F.R. 482.13(e) and found in " CMS State Operations Manual, Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals,"July 21, 2023, revision, used by any hospital staff or hospital-employed security or law enforcement personnel, as a means of subduing a patient to place that patient in patient restraint/seclusion; and

(g) Chemical restraint; and

(h) Prone restraint.

(2) Position in physical or mechanical restraint.

An individual is to be placed in a position that allows airway access and does not compromise respiration. Hospital staff are not authorized to utilize prone restraint.

(3) The inpatient psychiatric service provider is to identify, educate, and approve staff members to use seclusion or restraint. Competency of staff in the use and documentation of seclusion or restraint methods is to be routinely evaluated. The results of evaluations are to be maintained by the inpatient psychiatric service provider for a minimum of three years for each staff member identified.

Staff are to have appropriate training prior to utilizing seclusion or restraint, and, at a minimum, annually thereafter. The exception to annual training is a first aid or CPR training/certification program of a nationally recognized certifying body, e.g., the american red cross or american heart association, when that certifying body establishes a longer time frame for certification and renewal.

(a) Staff are to be trained in and demonstrate competency in the safe application of all seclusion or restraint interventions he or she is authorized to perform;

(b) Staff are to be trained in and demonstrate competency in choosing the least restrictive intervention based on an individualized assessment of the patient's behavioral and/or medical status or condition;

(c) Staff are to be trained in and demonstrate competency in recognizing and responding to signs of physical distress in clients who are being secluded or restrained;

(d) Staff are to be trained and certified in first aid and CPR;

(e) Staff are to be trained in and demonstrate competency in recognizing and responding to signs of physical distress in clients who are being secluded or restrained;

(f) Staff authorized to take vital signs and blood pressure are to be trained in and demonstrate competency in taking them and understanding their relevance to physical safety and distress;

(g) Staff are to be trained in and demonstrate competency in assessing circulation, range of motion, nutrition, hydration, hygiene, and toileting needs; and

(h) Staff are to be trained in and demonstrate competency in helping a client regain control to meet behavioral criteria to discontinue seclusion or restraint.

(4) The presence of advance directives or client preferences addressing the use of seclusion or restraint is to be determined and considered, as well as documented in the medical record. If the inpatient psychiatric service provider will be unable to utilize seclusion or restraint in a manner in accordance with the patient's directives or preferences, the provider is to notify the patient, give the rationale, and document such in the ICR

(5) In each patient's medical record, upon admission and upon any relevant changes in the patient's condition, any perceived medical or psychiatric contraindications for the possible use of seclusion or restraint is to be documented. The specific contraindication is to be described and is to take into account the following which may place the patient at greater risk for such use:

(a) Gender;

(b) Chronological and developmental age;

(d) Culture, race, ethnicity, and primary language;

(e) History of physical, sexual abuse, or psychological trauma;

(f) Medical and other conditions that might compromise physical well-being, e.g., asthma, epilepsy, obesity, lung and heart conditions, an existing broken bone, pregnancy, and drug/alcohol use;

(g) Physical disabilities; and

(h) Psychiatric condition.

(6) Orders are to be written only by an individual with specific clinical privileges/authorization to order seclusion and restraint, granted by the inpatient psychiatric service provider, and who is a:

(a) Psychiatrist or other physician; or

(b) Physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

Countersignatures to telephone orders for seclusion or restraint are to be signed within twenty-four hours by an individual with specific clinical privileges/authorization to order seclusion and restraint, granted by the hospital, and who is a psychiatrist or other physician, physician assistant, certified nurse practitioner, or clinical nurse specialist.

(7) Following the conclusion of each incident of seclusion or restraint, the patient and staff are to participate in a debriefing.

(a) The debriefing is to occur within twenty-four hours of the incident unless the client refuses, is unavailable, or there is a documented clinical contraindication.

(b) The following are to be invited to participate unless such participation is clinically contraindicated and the rationale is documented in the clinical record:

(i) For a child/adolescent client, the family, or custodian or guardian.

(ii) For an adult client, the client's family or significant other when the client has given consent, or an adult client's guardian, if applicable.

(8) As part of the inpatient psychiatric service provider's performance improvement process, a periodic review and analysis of the use of seclusion and restraint is to be performed.

(9) The inpatient psychiatric service provider is to maintain an ongoing log of its seclusion and restraint utilization for departmental review. A log is to be maintained for department review of each incident of mechanical restraint, seclusion, and physical restraint, and for time-out exceeding sixty minutes per episode. The log is to include, at minimum, the following information:

(a) The person's name or other identifier;

(b) The date, time, and type of method utilized, i.e., seclusion, physical restraint, mechanical restraint, or time-out. The log of physical and mechanical restraint is to also describe the type of intervention as follows:

(i) For mechanical restraint, the type of mechanical restraint device used;

(ii) For physical restraint, the type of hold or holds; and

If restraint is necessary as a means of safely transporting an individual to seclusion, either a separate order for restraint and a separate order for seclusion is needed or, alternatively, one order may be used that delineates a separate restraint and a separate seclusion.

If the restraint or seclusion episode is concluded, and the patient's behavior necessitates initiating another restraint or seclusion, then a new order needs to be obtained, even if the ending time of the original order has not passed.

(10) Plan to reduce seclusion and restraint.

(a) A inpatient psychiatric service provider that utilizes seclusion or restraint is to develop a plan designed to reduce its use. The plan is to include attention to the following strategies:

(i) Identification of the role of leadership;

(ii) Use of data to inform practice;

(iii) Workforce development;

(iv) Identification and implementation of prevention strategies;

(v) Identification of the role of clients (including children), families, and external advocates; and

(vi) Utilization of the post seclusion or restraint debriefing process.

(b) A written status report is to be prepared annually and reviewed by leadership.

(E) Pursuant to rule 5122-14-14 of the Administrative Code, the hospital is to notify the department of all of the following:

(1) Each instance of physical injury to a patient that is restraint-related, e.g., injuries incurred when being placed in seclusion and/or restraint or while in seclusion or restraint, with the exception of injury that is self-inflicted, i.e., a patient banging his/her own head;

(2) Each death that occurs while a person is restrained or in seclusion;

(3) Each death occurring within twenty four hours after the person has been removed from restraint or seclusion; and

(4) Each death where it is reasonable to assume that a person's death may be related to or is a result of such seclusion or restraint.

(F) Staff actions commonly known as therapeutic, supportive, or directional touch, utilized to direct an individual to another area without the use of force and which do not restrict an individual's freedom of movement, are not considered restraint and are not subject to the provisions of paragraph (D) of this rule.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-11 Patient rights, participation and education.

(A) In addition to the definitions appearing in rule 5122-14-01 of the Administrative Code, the following definitions apply to this rule:

(1) "Patient rights specialist" means the individual designated by the inpatient psychiatric service provider with responsibility for assuring compliance with the patient rights and grievance procedure rule.

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

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

(4) "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.

(B) Each patient has the following rights, as well as the additional rights listed in paragraph (C) of this rule:

(1) Regarding access to patient rights and financial information:

(a) The right to be informed within twenty-four hours of admission of the rights described in this rule and to request a written copy of these rights;

(b) The right to receive information in language and terms appropriate for the patient's understanding; and

(2) Regarding personal liberty:

(a) In accordance with existing federal, state, and local laws and regulations, the right to be treated in a safe treatment environment, with respect for personal dignity, autonomy, and privacy;

(b) The right to receive services that are appropriate and respectful;

(d) The right to participate in any appropriate and available service that is consistent with an individual service/treatment plan, regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation;

(e) The right to reasonable assistance, in the least restrictive setting; and

(f) The right to reasonable protection from physical, sexual, or emotional abuse or harassment.

(3) Regarding the development of service/treatment plans:

(a) The right to a current individualized treatment plan (ITP) that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, as available, either directly or by referral; and

(b) The right to actively participate in periodic ITP reviews with the staff including services necessary upon discharge.

(4) Regarding declining or consenting to services:

The right to give full informed consent to services prior to commencement and the right to decline services absent an emergency.

(5) Regarding restraint or seclusion:

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

(6) Regarding privacy:

(a) The right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non-hospital surveyors, contractors, construction crews, or others; and

(b) The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies, or photographs, or other audio and visual recording technology. This right does not bar a hospital from using closed-circuit monitoring to observe seclusion rooms or common areas, but closed circuit monitoring is not to be utilized in patient bedrooms and bathrooms.

(7) Regarding confidentiality:

(a) The right to confidentiality unless a release or exchange of information is authorized and the right to request to restrict treatment information being shared; and

(b) The right to be informed of the circumstances under which the hospital is authorized or intends to release, or has released, confidential information without written consent for the purposes of continuity of care as permitted by division (A)(7) of section 5122.31 of the Revised Code.

(8) Regarding grievances:

The right to have the grievance procedure explained orally and in writing; the right to file a grievance with assistance if requested; and the right to have a grievance reviewed through the grievance process, including the right to appeal a decision.

(9) Regarding non-discrimination:

The right to receive services and participate in activities free of discrimination 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 not permitted by local, state or federal laws.

(10) Regarding reprisal for exercising rights:

The right to exercise rights without reprisal in any form including the ability to continue services with uncompromised access. No right extends so far as to supersede health and safety considerations.

(11) Regarding opinions:

The right to have the opportunity to consult with independent specialists or legal counsel, at one's own expense.

(12) Regarding conflicts of interest:

No inpatient psychiatric service provider employee may be a person's guardian or representative if the person is currently receiving services from said provider.

(13) The right to have access to one's own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual patient for clear treatment reasons in the patient's treatment plan. If access is restricted, the treatment plan is to also include a goal to remove the restriction.

(14) The right to be informed in advance of the reasons for discontinuance of service provision, and to be involved in planning for the consequences of that event.

(15) The right to receive an explanation of the reasons for denial of service.

(C) In addition to the rights listed in paragraph (D) of this rule, each consumer residing in an inpatient psychiatric hospital is to have the following rights and be informed of such rights:

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

(2) The right to retain personal property and possessions, including a reasonable sum of money, consistent with the person's health, safety, service/treatment plan, and developmental age.

(3) Regarding the development of service/treatment plans, the right to formulate advance directives, submit them to hospital staff, and rely on practitioners to follow them within the parameters of the law.

(4) Regarding labor of patients, the right to not be compelled to perform labor that involves the operation, support, or maintenance of the hospital or for which the hospital is under contract with an outside organization. Privileges or release from the hospital are not to be conditioned on the performance of such labor.

(5) Regarding declining or consenting to services:

(a) The right to consent to or refuse the provision of any individual personal care activity and/or mental health services/treatment interventions; and

(b) The right, when on voluntary admission status, to decline medication, unless there is imminent risk of physical harm to self or others; or

(c) The right when hospitalized by order of a probate or criminal court to decline medication after being given the opportunity to give informed consent, unless there is imminent risk of harm to self or others, or through an order by the committing court (e.g., persons admitted for a competency evaluation under division (G)(3) of section 2945.371 of the Revised Code or admitted for a sanity evaluation under division (G)(4) of section 2945.371 of the Revised Code).

(6) Regarding privacy, dignity, free exercise of worship, and social interaction:

The right to enjoy freedom of thought, conscience, and religion, including religious worship within the hospital and receipt of services or sacred texts that are within the reasonable capacity of the hospital to supply. However, no patient is to be coerced into engaging in any religious activities.

(7) Regarding private conversation and access to phone, mail, and visitors:

(a) The right to communicate freely with and be visited at reasonable times by the patient's family members, significant others, legal guardian, and private counsel or personnel of the legal rights service and, unless prior court restriction has been obtained, to communicate freely with and be visited at reasonable times by a personal physician or psychologist;

(b) The right to communicate freely with others, unless specifically restricted in the patient's service/treatment plan for reasons that advance the person's goals, including the following:

(i) The right of an adult to reasonable privacy and freedom to meet with visitors, guests, or surveyors, and make and/or receive phone calls; or the right of a minor to meet with inspectors, and the right to communicate with family, guardian, custodian, friends, and significant others outside the hospital in accordance with the minor's individualized service/treatment plan;

(ii) The right to have reasonable access to telephones to make and receive confidential calls, including a reasonable number of free calls if unable to pay for them and assistance in calling if requested and needed. The right of a minor to make phone calls is to be in accordance with the minor's individualized service/treatment plan.

(c) The right to have ready access to letter-writing materials, including a reasonable number of stamps without cost if unable to pay for them, and to mail and receive unopened correspondence and assistance in writing if requested and needed subject to the hospital's rules regarding contraband. The right of a minor to send or receive mail is also subject to directives from the minor's parent or legal custodian when such directives do not conflict with federal postal regulations.

(8) Notification to family or physician:

The right to have a physician, family member, or representative of the person's choice notified promptly upon admission to a hospital.

(D) Each inpatient psychiatric service provider is to provide a patient rights specialist to safeguard patient rights. The patient rights specialist or the specialist's designee is to meet all of the following criteria and fulfill all of the following responsibilities:

(1) Be appropriately trained and knowledgeable in the fundamental human, civil, constitutional, and statutory rights of psychiatric patients including the role of the Ohio protection and advocacy system (disability rights Ohio);

(2) Ensure that the patient, and as appropriate, the patient's family members, significant others, and legal guardian, are informed about patient rights, in understandable terms, upon admission, and throughout the hospital stay. Treatment staff are to work with the patient to assist them in understanding and exercising patient rights. For any person who is involuntarily detained, the inpatient psychiatric service provider will, immediately upon being taken into custody, inform the person orally and in writing of their rights described in division (C) of section 5122.05 of the Revised Code;

(3) Be accessible in person during normal business hours and during evenings, weekends, and holidays as needed for advocacy issues. The name, title, location, hours of availability, and telephone number of the patient rights specialist along with a copy of the patient rights and grievance procedure as set forth in this rule is to be posted in an area available to the patient and made available to the patient's legal guardian, if any, as well as the patient's family and significant others upon their request. In addition, the patient rights and grievance procedure as set forth in this rule, as well as the telephone number of the patient rights specialist, is to be posted on the provider's web site;

(4) Assist and support patients, their family members, and significant others in exercising their legal rights and representing themselves in resolving complaints. This is to include providing copies of the inpatient psychiatric service provider's policies and procedures relevant to patient rights and grievances upon request, and assistance with the grievance procedure. This is to also include assistance in obtaining services of the Ohio protection and advocacy system (disability rights Ohio) in accordance with sections 5123.60 and 5123.601 of the Revised Code, and assistance in obtaining access to or services of outside agencies or resources upon request;

(5) Not be a member of the patient's treatment team and not have clinical management or care responsibility for the patient for whom he or she is acting as the patient rights advocate; and

(6) Maintain a log available for department review of patient grievances, including all allegations of denial of patient rights as identified by patients, family members of patients, significant others or other persons.

(E) Each inpatient psychiatric service provider is to ensure that its staff members are knowledgeable about patient rights and referral of patients to the patient rights advocate.

(F) Each inpatient psychiatric service provider is to ensure that patients and families of patients participate in an advisory capacity related to programming and relevant policies and procedures.

(G) Each inpatient psychiatric service provider is to ensure that patient and family education is an interdisciplinary and coordinated process, as appropriate to the patient's treatment plan, consistent with patient confidentiality and documented in the medical record. Education is to incorporate appropriate members of the treatment team, types of materials, methods of teaching, community educational resources, as well as special devices, interpreters, or other aids to meet specialized needs.

(H) Each inpatient psychiatric service provider is to obtain the informed consent of a patient or when appropriate, a guardian, for all prescribed medications that have been ordered, except in an emergency, and for those medical interventions specified in division (A) of section 5122.271 of the Revised Code.

(1) Each inpatient psychiatric service provider is to ensure that the patient and legal guardian, when legally appropriate, receives written and/or oral information in a language and format that may be standardized and that is understandable to the person receiving it.

(a) Information is to include the anticipated benefits and side effects of the intervention, including the anticipated results of not receiving the intervention, and of alternatives to the intervention.

(b) Persons served are to be given the opportunity to ask questions, seek additional information, and provide input before the intervention or medication is administered or dispensed.

(c) Documentation is to be kept in the patient's medical record regarding the patient's participation in this process, including the patient's response, objections, and decisions regarding the medication or medical intervention. Such documentation may be accomplished through a notation from an appropriate professional staff person, signature of the patient or guardian, or other mechanism.

(2) For purposes of informed consent specific to medication, each psychiatric inpatient service provider is to ensure that the patient and parent or legal guardian when legally appropriate receives written and/or oral information from a physician, registered nurse, or pharmacist.

Last updated April 24, 2024 at 8:36 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-12 Program, specialty services and discharge planning requirements.

(A) Each inpatient psychiatric service provider is to have a written comprehensive plan of service that will be reviewed annually and revised if necessary.

(B) The comprehensive plan of service is to include all of the following:

(1) A description of services provided;

(2) A description of any affiliation or agreements with other agencies or entities;

(3) A description of the population served including age groups and other relevant characteristics of the patient populations;

(4) Criteria for admission, continued stay, and discharge; and

(5) A description of how patients and family members of patients are to participate in an advisory role with respect to the inpatient service.

(1) Limit admissions to those persons whose principal diagnosis and focus of treatment upon admission is a mental disorder according to the latest edition of the American psychiatric association's diagnostic and statistical manual of mental disorders (DSM), except that persons whose principal diagnosis and focus of treatment is a substance abuse disorder, detoxification for substance abuse, a chronic dementing organic mental disorder, or intellectual disability are to be excluded. This does not preclude admissions for which the above named excluded diagnoses may be a secondary diagnosis;

(a) To support best clinical practice of concurrent integrated treatment for persons with co-occurring of mental illness and substance abuse, an inpatient psychiatric service provider may co-locate both psychiatric and substance abuse and/or detox registered beds in the same physical area, and may use staff who are cross-trained in both treatment disciplines to provide integrated services.

(b) Until September 30, 2024, the total number of psychiatric beds and the total number of detox (medical/surgical) beds and/or substance abuse beds are to remain as registered with the Ohio department of health.

(c) Patients are to be admitted to the appropriate bed based upon their principal diagnosis and focus of treatment. However, this would not preclude integrated concurrent treatment for a co-occurring disorder.

(2) Include any applicable age limits, diagnostic categories, and other criteria necessary to ensure that each admission is the least restrictive alternative available and consistent with each patient's treatment needs;

(3) Specify procedures and timelines for responding to an application for voluntary admission; and

(4) Assure that the inpatient psychiatric service provider will accept patients on a civil commitment and that it has the clinical competence to treat these patients:

(a) Utilizing the same criteria applied to voluntary patients, and

(b) According to admission criteria applied to voluntary patients.

The inpatient psychiatric service provider is to assure that it will provide such patients access to its full range of available services.

(D) Discharge criteria is to include, but not be limited to, achievement of treatment goals, or that the patient is to be transferred to a more appropriate treatment facility. A civilly committed patient is to be discharged when the patient no longer meets the criteria for civil commitment, however such patients are to have the right to apply for voluntary admission status at any time pursuant to division (G) of section 5122.15 of the Revised Code.

(E) The primary function of each inpatient psychiatric service provider is to provide diagnostic and treatment services for persons with a primary diagnosis of mental illness. Such services are to be culturally relevant and sensitive and take into consideration any relevant patient history of trauma and/or abuse.

(F) Clinical services are to be provided by an interdisciplinary treatment team working together.

(1) All members of the treatment team who have specific treatment responsibilities are to have either appropriate clinical privileges and be qualified by training or experience and demonstrated competence or be supervised by a clinically privileged practitioner.

(2) Each inpatient psychiatric service provider is to specify in policy and procedures the roles and responsibilities of team members in identifying and meeting the clinical needs of patients in relationship to goals and programs.

(3) Each inpatient psychiatric service provider is to assure and provide for the staffing of team members to meet the clinical needs of each patient as identified in the patient's treatment plan.

(G) Each professional discipline will:

(1) Identify special skills needed to render specific patient care and treatment services.

(2) Participate in the development of criteria for qualifications of its staff members, which are to include education, experience, and licensure or certification mandates.

(H) Each inpatient psychiatric service provider is to provide or make provision for the services specified in this paragraph in order to promote recovery and meet the comprehensive needs of each patient. Such services may be provided by any qualified individual, unless otherwise specified in these rules and/or regulated by professional licensure and scope of practice.

(1) Medical services are to be:

(a) Under the direction of a psychiatrist; and

(b) Include availability of a psychiatrist for consultation twenty-four hours a day, seven days a week, either in person or by telephone.

Medical services, including dental, are to meet the comprehensive physical and psychiatric treatment needs of each patient as identified in the patient's treatment plan.

(2) Dietetic services, including availability of a licensed dietitian.

(3) Emergency services, which are to be available and accessible through a written plan for psychiatric emergencies for both persons receiving inpatient treatment from the inpatient psychiatric service provider and for any persons presenting themselves as in need of and requesting emergency treatment.

(a) If the inpatient psychiatric service provider maintains an emergency room or emergency service, it will not refuse emergency care to individuals presenting with potentially life or health-threatening psychiatric situations.

(b) If the inpatient psychiatric service provider does not maintain an emergency room or emergency service, it will provide emergency care on site until an individual presenting with a potentially life or health-threatening psychiatric situation is transferred to a more appropriate provider.

(4) Nursing services, which are to be under the direction or supervision of a full time registered nurse who has a bachelor's or master's degree in nursing and four years psychiatric nursing experience. It is preferred that the individual hold voluntary certification in psychiatric and mental health nursing by the American nurses credentialing association. This mandate applies to those individuals hired into this position after January 1, 2000.

Psychiatric nursing experience is the treatment and care of persons whose principal diagnosis and focus of treatment is a psychiatric disorder; the experience can include working as a registered nurse on a psychiatric inpatient unit or in an outpatient setting with individuals who have a primary psychiatric diagnosis. Psychiatric nursing experience does not include either of the following:

(a) Experience derived from caring for individuals in a nursing home, whose principal diagnosis is often a chronic dementing organic mental disorder; or

(b) For a nurse hired or after July 1, 2024, experience derived from working in a hospital medical unit, emergency department, or other healthcare setting where individuals do not have a primary psychiatric diagnosis.

(5) Pastoral services are to be offered by the inpatient psychiatric service provider's clergy or the provider is to arrange for pastoral services from family or community clergy;

(6) Patient education services are to be readily accessible at all reasonable hours and include current reading and resource materials for education and leisure to meet the needs of the patients;

(7) Pharmaceutical services are to meet both of the following mandates:

(a) Be under the direction of a pharmacist with a current license.

(b) Operate in accordance with Chapters 3715., 3719., and 4729. of the Revised Code regarding operation of pharmacies, storage, and dispensing of drugs;

(8) Physical rehabilitation services are to be under the direction of qualified staff;

(9) Psychological services are to be under the direction of a licensed psychologist;

(10) Psycho-social services are to meet all of the following mandates:

(a) Be provided by qualified staff;

(b) Be staffed by at least one person who is licensed either as a professional counselor, professional clinical counselor, independent social worker, or a social worker; and

(11) Rehabilitation therapy services are to meet all of the following mandates:

(a) Be provided by qualified staff;

(b) Be staffed by at least one rehabilitation therapist as defined in rule 5122-14-01 of the Administrative Code;

(d) Be provided by rehabilitation therapy staff with diverse skills to meet the needs of all patients; and

(12) Substance abuse diagnostic and treatment services for all patients who have a secondary problem of substance use disorder are to be provided by an individual licensed or certified by the Ohio chemical dependency professionals board under Chapter 4758. of the Revised Code or by an individual licensed or certified by the counselor, social worker, and marriage and family therapist board under Chapter 4757. of the Revised Code whose scope of practice includes the diagnosis and treatment of substance use disorders.

(I) Each inpatient psychiatric service provider is to develop special programs to include, but not be limited to, the following groups whenever the annual average daily census for that group is six or more patients:

(1) Adults age sixty-five and older;

(2) Patients with a secondary diagnosis of substance use disorder; and

(3) Patients with a secondary diagnosis of developmental disability or pervasive developmental disorder.

(J) Written policies and procedures and program descriptions are to document that patient needs, based on at least age and diagnosis, will be met for all patient groups in paragraph (I) of this rule.

(1) Inpatient psychiatric service providers that provide services for adults sixty-five years of age and older are to develop written policies and procedures regarding services to meet the special needs of such patients. These needs include vision, hearing, dietary, physical, cognitive, functional living skills and psychiatric needs, and the needs of the patients' family members. Special attention is to be given to problems associated with utilization of medication including polypharmacy. Diagnostic and treatment services are to be provided by a psychiatrist with clinical privileges in geriatric psychiatry. Consultation with an occupational therapist or an occupational therapy assistant in collaboration with an occupational therapist are to be available as appropriate to each patient's needs.

(2) Services for patients who have a secondary problem of substance abuse are to include specialized diagnostic assessments, group and/or individual therapy, education, linkage to self help groups, and referrals for post discharge substance abuse treatment, if appropriate.

(3) Inpatient psychiatric service providers that provide services for patients with a secondary diagnosis of intellectual disability or developmental disability are to adhere to treatment standards in accordance with Chapters 5122. and 5123. of the Revised Code or equivalent standards and as appropriate to the psychiatric services provided.

(K) Inpatient psychiatric service providers authorized to serve children and adolescents are to provide for the educational, recreational, developmental, social, and functional needs of these patients and for the treatment needs of these patients' families.

(1) For all children twelve years of age or less, diagnostic and treatment services are to be provided by a child and adolescent psychiatrist, or by a psychiatrist in consultation with a child and adolescent psychiatrist within seventy-two hours of admission.

(2) For all children thirteen through seventeen years of age, diagnostic and treatment services are to be provided by a child and adolescent psychiatrist, a psychiatrist with clinical privileges in adolescent psychiatry, or by a psychiatrist in consultation with a child and adolescent psychiatrist within seventy-two hours of admission.

(3) Each inpatient psychiatric service provider is to provide rehabilitation therapy services to each patient as appropriate to the patient's needs and as indicated in the patient's treatment plan, including at least five hours per week of active physical activities.

(4) Each inpatient psychiatric service provider is to provide a a patient with at least two hours per week of family therapy or other family interventions as appropriate to patient need and indicated on the patient's treatment plan.

(5) Each inpatient psychiatric service provider is to provide a patient with at least five hours per week of services intended to assist the patient in maintaining his/her educational and intellectual development, consistent with the patient's treatment plan.

(a) If the admission is longer than ten days, the inpatient psychiatric service provider with the consent of the parent/adult student is to notify the school district where the provider is located of the need for services and provide appropriate physical space so that the patient can access or continue individualized education plan IEP services provided by the school district.

(b) If educational needs and/or eligibility for special education services under Chapter 3323. of the Revised Code are identified during the admission, the inpatient psychiatric service provider is to communicate this to the patient's home school upon parent or guardian request with appropriate consent.

(L) If a psychiatric intensive care unit is provided the following additional standards are to be met:

(1) The psychiatric intensive care unit is to be directed and staffed according to the special needs of its patients;

(2) Written policies and procedures are to describe criteria for the use of psychiatric intensive care and any special procedures used; and

(3) Psychiatric intensive care units are to be designed and equipped to facilitate safe and effective care of patients.

(M) Inpatient psychiatric service providers that accept individuals into an observation or treatment status for periods of less than twenty-four hours are to develop policies and procedures regarding all of the following:

(1) Conditions under which individuals are accepted and released;

(2) The provision of patient rights information; and

(3) The provision of after hospitalization care.

(N) Prior to or within twenty-fours hours of admission of each patient, appropriate community resources and needs relative to the patient's treatment are to be identified. These community resources and needs may include or pertain to professionals who have rendered prior treatment to the patient, referral sources, courts, schools, employers, religious affiliation, community psychiatric supportive treatment services, and discharge planning.

(O) All identified community resources, when appropriate to patient need and with permission of the patient, are to be contacted to participate in treatment planning for discharge. Such efforts and involvement will be documented in the medical record.

(P) If a patient is likely to be referred to a community mental health agency upon discharge, the inpatient psychiatric service provider with permission from the patient is to invite participation by the community psychiatric supportive treatment providers from the local community mental health agencies in team meetings and planning for discharge.

(Q) The inpatient psychiatric service provider is to make arrangements for each patient for post discharge services as specified in the patient's treatment plan.

(1) Each inpatient psychiatric service provider is to provide an appropriate discharge plan for patients, or the inpatient psychiatric service provider is to arrange for each of these patients, as necessary, to receive mental health services from other mental health providers, consistent with patient choice and acceptance.

(a) The inpatient psychiatric service provider is to provide interim post discharge services for up to two weeks post discharge, unless the post discharge provider assumes responsibility for the provision of mental health services prior to the end of the interim two-week period. This is to include an appointment for medication management as needed. Such interim post discharge services are to include a crisis management plan, which may include a mechanism to contact a physician, interim medication management, referral to or provision of a support group or individual supportive services, or a mechanism to contact an emergency services provider.

(b) The inpatient psychiatric service provider is to determine, in collaboration with the patient and post discharge provider, that the post discharge provider has the appropriate services the patient has been identified as needing, including the provision of in-depth patient education regarding the nature and management of the patient's illness/disorder.

(2) As part of discharge planning and prior to discharge, the inpatient psychiatric service provider is to make all reasonable efforts to ensure that the patient has an appointment, as appropriate, with one or more mental health service providers not later than two weeks post discharge if it has been concluded that these services are mandated within two weeks.

(3) For children/adolescents, each inpatient psychiatric service provider is to make provision for coordination of psycho-educational treatment and recommended aftercare with the patient's local school and any existing individualized education plan from the patient's local school.

(4) The clinical treatment team is to develop a discharge plan with active participation by the patient. The parent, guardian, or family is also to participate, where appropriate, according to the treatment plan and, if needed, with permission of the patient. If the patient is a minor in the custody of an agency, that agency is to participate in the development of the discharge plan.

(5) A copy of the relevant portions of the post discharge plan is to be given to the patient, or as appropriate, the patient's guardian, and is to be made available, with the patient's permission, to the person or agency that will assume primary responsibility for implementation of the discharge plan.

(R) When utilization patterns indicate problems or opportunities for improvement in the larger community system in which the inpatient psychiatric service provider is located, the inpatient psychiatric service provider is to discuss these issues with the relevant boards of alcohol, drug addiction, and mental health services. Such discussions are to be documented.

Last updated April 24, 2024 at 8:37 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-13 Medical records, documentation and confidentiality.

(A) Each inpatient psychiatric service provider is to maintain a complete medical record for each individual patient.

(B) A medical record is to include all of the following:

(1) Patient demographic information, including indication of legal status as a voluntary or involuntary patient;

(2) All legal documents, including, as appropriate, an application for voluntary admission signed and dated by the patient, written requests for release pursuant to section 5122.03 of the Revised Code, and all legal documents pertaining to civil commitment and guardianship.

For patients with a guardian, the inpatient psychiatric service provider is to make an effort to obtain all needed consent forms signed and dated by the guardian. If the guardian is unable to provide written consent, the provider may obtain and document verbal consent of the guardian as long as two individuals document, in writing, that each witnessed the guardian provide the verbal consent.

(3) The reason for admission including presenting problems, precipitating factors, and initial diagnosis;

(4) Previous hospitalizations;

(5) Reports of all patient assessments and examinations;

(6) An individualized treatment plan that includes criteria for discharge and meets mandates in section 5122.27 of the Revised Code;

(7) All medical orders;

(8) Documentation of the patient's progress and other significant patient events that could impact treatment;

(9) Appropriate, complete, signed, and dated consents for treatment and release of confidential information;

(10) A discharge summary completed within thirty days after discharge and signed by the attending or treating physician; and

(11) A post discharge plan.

(D) Each inpatient psychiatric service provider is to be responsible for conducting a complete assessment of each patient including a consideration of the patient's strengths and needs and the types of services to meet those needs in the least restrictive environment consistent with treatment needs.

(1) The assessments are to include, as appropriate to patient need: physical, laboratory, emotional, behavioral, social, recreational, cognitive, functional living skills, educational, legal, vocational, nutritional, cultural, religious, income support, housing needs, and other community support and discharge planning needs.

(2) Each inpatient psychiatric service provider is to define in writing the scope of assessments to be performed by each clinical discipline not otherwise specified in this chapter, consistent with the discipline's scope of practice, state licensure laws, applicable regulations, certification, or registration.

(E) Written assessments of each patient are to be provided and dated by the respective interdisciplinary team members as soon as possible after admission and prior to the development of the treatment plan mandated within twenty-four hours of admission unless otherwise specified in this rule.

(1) For new admissions if assessments are available from prior evaluations and/or admissions within the past six months, each assessment is to be reviewed, revised as necessary, dated, and signed by a member of the respective discipline as soon as possible after admission and prior to the development of the treatment plan.

(2) The following mandated patient assessments are to be completed within twenty-four hours of a patient's admission:

(a) A medical history and physical examination is to be completed by a physician. If the patient's condition does not permit completion of the examination, each part of the examination is to be completed as soon as the patient's condition permits it. If a physician was responsible for the completion of a medical history and physical examination within thirty days of the current course of treatment and the patient's condition remains consistent with the results of that examination, a signed copy of this history and examination may suffice. The medical history and physical examination may be conducted by a physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

(i) The history and physical examination is to include a basic neurological examination that includes an examination of the cranial nerves, sensory and motor functions, coordination, and deep tendon reflexes.

(ii) If the patient is a child, adolescent, or person with an intellectual or developmental disability, the history and physical examination is to include evaluations of motor development and functioning, sensorimotor functioning, speech, hearing and language functioning, visual functioning, immunization status, and oral health and oral hygiene.

(b) A psychiatric examination, including mental status examination, is to be competed by a psychiatrist or a physician with specific clinical privileges to conduct such an examination. Alternatively, the psychiatric examination may be conducted by a physician assistant, certified nurse practitioner, or clinical nurse specialist authorized in accordance with his or her scope of practice and as permitted by applicable law or regulation.

(c) An assessment of each patient's nursing care needs to be completed by a registered nurse. As part of the nursing assessment, the registered nurse is to conduct a screening of each patient's nutritional status unless otherwise assessed by a registered dietitian.

(d) An assessment for functional and rehabilitation needs is to be completed. The assessment may include an evaluation of the patient's activities of daily living; community living skills; social, leisure and vocational skills; self care and self control abilities; physical/sensori-motor capabilities; speech, language, oral, and pharyngeal sensor-motor competencies; and auditory and vestibular competencies.

(e) An emotional and behavioral assessment. The assessment is to include an evaluation of the patient's history of emotional, behavioral, substance-abuse problems or treatment, and physical or sexual abuse.

(f) A psycho-social assessment. The assessment is to include the following information about the patient, as appropriate:

(i) Environment and home;

(ii) Leisure and recreation;

(iii) Work history;

(iv) Spirituality;

(v) Childhood history;

(vi) Military service history;

(vii) Financial status;

(viii) Usual social, peer-group, and environmental setting;

(ix) Sexual orientation; and

(x) Family circumstances, including the constellation of the family group, the current living situation, and social, ethnic, cultural, emotional, and health factors. The psychosocial assessment includes determining the need and extent for family participation.

(g) In programs serving children and adolescents, an assessment is to be performed that includes an evaluation of all of the following:

(i) The impact of the child's or adolescent's condition on the family and the family's impact on the child or adolescent;

(ii) The child's or adolescent's legal custody status, when applicable;

(iii) The child or adolescent's growth and development, including physical, emotional, cognitive, educational, nutritional, and social development;

(iv) The child's or adolescent's play and daily activities needs; and

(v) The family's or guardian's expectations for and involvement in the child's or adolescent's assessment, initial treatment, and continuing care.

(F) Each patient is to have a written individualized treatment plan that is responsive and timely to the treatment needs of the patient based on information provided by the patient and the patient's family and assessments by the clinical treatment team. The initial treatment plan and subsequent revisions are to be developed with the active participation of the patient, and through collaborative efforts of the clinical team. As appropriate and with patient consent, family members and significant others are also to participate. Such patient, family, and clinical treatment team collaboration is to be documented in the treatment plan. A patient's inability or refusal to participate in treatment planning and the patient's reasons for such are to also be documented in the treatment plan. The patient, and as appropriate parent or guardian, is to have the right to be informed of changes in the treatment plan including a change in assignment of the primary therapist or attending physician.

(1) The initial treatment plan is to be developed with the active participation of the patient and implemented within twenty-four hours of admission through collaborative efforts by the interdisciplinary clinical treatment team.

(2) The initial treatment plan and any subsequent revisions to the plan are to do all of the following:

(a) Reflect the patient's clinical needs, condition, functional strengths, and limitations.

(i) The patient's perceptions of his or her needs are documented, as are the families' perceptions when appropriate and available.

(ii) Justification is documented when identified needs are not addressed;

(b) Specify goals for achieving emotional and/or physical health as well as maximum growth and adaptive capabilities.

(i) Treatment plan goals are based on assessments of the patient and, as appropriate, the family.

(ii) Treatment plan goals are linked to living, learning, and work activities.

(iii) Treatment goals identified by the patient and actions the patient agrees to or requests to take, and the patient's involvement in and expressed concerns about the treatment plan are documented;

(d) Specify target dates or time-frames for completion of goals and steps;

(e) Specify services and interventions to be provided to achieve patient goals and indicate the staff persons and/or discipline responsible for provision of services;

(f) Specify frequency of services; and

(g) Specify criteria for discharge.

(3) The initial treatment plan is to be reviewed, updated, and/or revised within seventy-two hours of a patient's admission. All subsequent updates to the plan are to occur at least every seven days for the first month of hospitalization, at least monthly thereafter, and as appropriate to patient needs.

(G) The discharge summary completed within thirty days after discharge is to include all of the following:

(1) An assessment of the patient's condition on admission;

(2) An assessment of the patient's condition upon discharge and reason for discharge;

(3) A description of diagnostic and treatment services received by the patient, with reference to interventions identified on the treatment plan, and the patient's response;

(4) All recommendations made to the patient;

(5) Medications prescribed upon discharge; and

(6) Initial and final diagnosis, both physical and psychiatric, according to the American psychiatric association's latest edition of the diagnostic and statistical manual of mental disorders (DSM), which is to be recorded in full without the use of either symbols or abbreviations.

(H) A discharge plan is to be developed with each patient and is to do all of the following:

(1) State all appropriate recommendations and specific plans to include, but not be limited to, psychiatric, medical, case management, housing, vocational, financial, educational needs, other community support needs, and community resources available to meet these needs;

(2) Identify specific resources and state recommendations for continued, ongoing patient and family education regarding the nature and management of the patient's illness or disorder;

(3) Specify persons or agencies responsible for each recommended intervention or service;

(4) Specify the time frame for initiation of each recommended intervention or service;

(5) Specify a crisis management plan as described in paragraph (Q)(1)(a) of rule 5122-14-12 of the Administrative Code; and

(6) Be signed and dated by the patient, or as appropriate parent or guardian, and by each member(s) of the clinical treatment team responsible for reviewing the plan with the patient. A patient's inability or refusal to sign or participate in discharge planning and the patient's reasons for such is to be documented in the plan.

(I) The patient's treatment plan and medical record are to be available to the patient and family members in accordance with section 5122.31 of the Revised Code.

(J) The inpatient psychiatric service provider is to have written policies and procedures regarding the release of information and confidentiality of oral or written patient information in compliance with section 5122.31 of the Revised Code.

Last updated April 24, 2024 at 8:37 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Ohio Adm.Code 5122-14-14 Incident notification and risk management.

(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also mandates the agency to review and analyze all incidents so that it might identify and implement corrective measures designed to prevent recurrence and manage risk.

(B) Definitions

(1) "Incident" means an event that poses a danger to the health and safety of patients and/or staff and visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the hospital.

(2) "Reportable incident" means an incident that needs to be submitted to the department, including incidents that are then to be forwarded by the department to disability rights Ohio. As referenced in division (E) of section 5119.36 of the Revised Code, "major unusual incident" has the same meaning as "reportable incident."

(3) "Six month reportable incident" means an incident type of which limited information is to be reported to the department. A six month reportable incident is not the same as a reportable incident.

(4) "Six month incident data report" means a data report that is to be submitted to the department.

(C) The inpatient psychiatric service provider is to develop an incident reporting system to include a mechanism for the review and analysis of all reportable incidents such that clinical and administrative activities are undertaken to identify, evaluate, and reduce risk to patients, staff, and visitors. The inpatient psychiatric service provider is to identify in policy other incidents to be reviewed and analyzed.

(1) An incident report is to be submitted in written form to the inpatient psychiatric service provider's chief executive officer or designee within twenty-four hours of discovery of the incident.

(2) As part of the inpatient psychiatric service provider's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in policy, is to be performed.

(3) The inpatient psychiatric service provider is to maintain an ongoing log of its reportable incidents for departmental review.

(D) Any person who has knowledge of an instance of abuse or neglect of a child or adolescent, or alleged or suspected abuse or neglect of a child or adolescent, or of an alleged crime committed against a child or adolescent that would constitute a felony is to immediately notify the appropriate public children's services agency or law enforcement authorities in accordance with section 2151.421 of the Revised Code.

Even if the person has knowledge of an alleged crime against a child or adolescent committed by another child or adolescent, the person is to immediately notify law enforcement authorities.

(E) Any person who has knowledge of an instance of abuse or neglect of an elderly person, or alleged or suspected abuse or neglect of an elderly person, or of an alleged crime committed against an elderly person that would constitute a felony is to immediately notify the appropriate law enforcement and county department of job and family services authorities in accordance with section 5101.63 of the Revised Code.

(F) Each inpatient psychiatric service provider is to submit reportable incidents and six month reportable incidents as defined by and in accordance with the schedule included in appendix A to this rule.

(G) Each reportable incident is to be reported electronically through the web enabled incident reporting system (WEIRS) as mandated by the department, and is to be forwarded to the department within twenty-four hours of its discovery, exclusive of weekends and holidays. The WEIRS form is to include identifying information about the inpatient psychiatric service provider, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations specified in 45 C.F.R. 164.514(b)(2).

(1) The inpatient psychiatric service provider is to file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved patients, staff, and visitors.

(2) The inpatient psychiatric service provider is to notify the patient's parent, guardian, or custodian, if applicable, within twenty-four hours of discovery of a reportable incident and document such notification.

(a) Notification may be made by phone, mailing, faxing or e-mailing a copy of the incident form, or other means according to inpatient psychiatric service provider policy and procedures.

(b) When notification does not include sending a copy of the incident form, the inpatient psychiatric service provider is to inform the parent, guardian, or custodian, of his or her right to receive a copy and forward a copy within twenty-four hours of receiving a request for a copy. The inpatient psychiatric service provider is to document compliance with the provisions of this paragraph.

(H) Each inpatient psychiatric service provider is to submit a six month incident data report to the department utilizing the form in WEIRS.

The six month data report is to be submitted according to the following schedule:

(1) The six month data report for the period of January first to June thirtieth of each year is to be submitted no later than July thirty-first of the same year; and

(2) The six month data report for the period of July first to December thirty-first of each year is to be submitted no later than January thirty-first of the following year.

(I) The department may initiate follow-up and further investigation of a reportable incident or six month reportable incident as deemed necessary and appropriate, or may request such follow-up and investigation by the inpatient psychiatric service provider and/or regulatory or enforcement authority.

View Appendix

Last updated April 24, 2024 at 8:37 AM

History

Effective: April 24, 2024
Promulgated Under: 119.03

Chapter 5122-21 Preadmission Screening and Annual Review

Ohio Adm.Code 5122-21-03 Pre-admission screening and resident review (PASRR) for nursing facility applicants and residents with serious mental illness.

(A) Purpose:

This rule sets forth a process for a state-contracted vendor and the Ohio department of mental health and addiction services to respectively evaluate and determine whether an individual with indications of serious mental illness (SMI) requires those services provided in a medicaid-certified nursing facility (NF), and if so whether that individual needs specialized services for mental illness that exceed NF services.

(B) Applicability:

This rule applies to individuals who have indications of SMI and are seeking admission into a NF, and for NF residents with indications of SMI who are seeking to continue residing in a NF. It also applies to individuals seeking readmission to a NF after having transferred from a NF to a hospital or unit that is licensed or certified by the department, and to individuals with indications of SMI who are transferring from one NF to another NF, with or without an intervening hospital stay.

(1) An 'administrative letter' is a communication device in which the state declines to reconsider a previously issued PASRR determination to the individual or guardian. An administrative letter is not a new PASRR determination, thus it does not carry appeal rights.

(2) 'Adverse determination' means a determination made in accordance with rules 5160-3-15, 5160-3-15.1, 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does not require the level of services provided by a NF. This includes any PASRR determination issued by the department that allows a time-limited approval, such as a categorical, time specified, or an extension.

(3) 'Assessor' means a professional possessing a clinical licensure approved by the department's medical director to complete the level II PASRR evaluation.

(4) 'Attending Physician' means the physician whom an individual, or the family of an individual, has assigned primary responsibility for the treatment of care of the individual, or if the individual or the individual's family has not assigned responsibility, the physician who has accepted responsibility.

(5) 'Business day' means a day of the week, excluding Saturday, Sunday, or a legal holiday as defined in section 1.14 of the Revised Code.

(6) "Board of alcohol, drug addiction, and mental health services" or "board" means the body 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; which have the same duties as described in section 340.03 of the Revised Code,

(7) 'Categorical determination' means a presumptive pre-admission screen (PAS) approval issued without the completion of a face to face assessment for an individual diagnosed with developmental disabilities (DD) or SMI.

(8) 'Department' means the Ohio department of mental health and addiction services.

(9) 'Developmental disability' (DD) has the same meaning defined in rule 5123-14-01 of the Administrative Code.

(10) 'DODD' means the Ohio department of developmental disabilities.

(11) 'Evaluation' also known as an assessment or a level II evaluation as defined in rule 5160-3-15 of the Administrative Code, includes a face to face interview between an assessor and the individual, their guardian, or authorized representative, if applicable. The purpose of an evaluation is to assess the individual's need for the level of services provided in a NF, and to assess whether the individual would need specialized services for mental illness if approved for NF services.

(12) 'Extension' is a time-limited approval for up to ninety days of additional stay in a NF, following a previously issued specified-period or extension approval, granted in accordance with rule 5160-3-15.2 of the Administrative Code. An extension is given solely to allow for effective discharge planning.

(13) 'Guardian' has the same meaning as in section 2111.01 of Revised Code.

(14) 'Hospital exemption' (exempted hospital discharge) means the same as defined in rule 5160-3-15 of the Administrative Code.

(15) 'Indefinite approval is an approval that permits a NF to admit an individual diagnosed with SMI. Individuals admitted to a NF under an indefinite approval will be required to adhere to all PASRR requirements related to NF residents.

(16) 'Individual' in this rule means a person regardless of payment source, who is seeking admission, readmission, or transfer to a medicaid-certified NF or a facility in the process of becoming medicaid-certified NF.

(17) 'Level I' means the same as defined in rule 5160-3-15 of the Administrative Code.

(18) "Level II' means the combination of the disability-specific PASRR evaluation and the determination issued by DODD and/or the department.

(19) 'Level II determination' or "determination" in this rule means the department's finding of whether an individual diagnosed with SMI requires the level of services provided in a NF, and whether the individual requires specialized services for mental illness if found to require NF services.

(20) 'Long-term resident' means the same as defined in rule 5160-3-15 of the Administrative Code.

(21) 'Nursing facility' (NF) has the same meaning as in section 5111.20 of Revised Code. A long-term care facility that has submitted an application packet for medicaid certification to the Ohio department of medicaid (ODM) is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health (ODH) and shall be treated as NF for purposes of this rule.

(22) 'Pre-admission screening' refers to the level I screening as defined in paragraph (B)(15) of rule 5160-3-15 of the Administrative Code.

(23) 'Psychiatric unit or hospital' refers to those facilities that are licensed or operated by the department.

(24) 'Reviewer' refers to a licensed mental health clinician who reviews the PASRR screen, supporting documents, the level II assessment, and the summary report to issue the state's determination of whether the individual requires NF services. If the determination is yes, then the reviewer indicates whether the individual needs specialized services for mental illness. If it is determined that the individual is not in need of NF services, then the reviewer may recommend community service that may address the individual's needs.

(25) 'Rule-out' means a determination made by the department that the individual is not subject to further review. An individual may be ruled-out at any time during the PASRR assessment when it is determined that the individual:

(a) Does not have SMI, even though the individual was diagnosed with mental illness.

(b) Has a primary diagnosis of dementia (including Alzheimer's disease or a related disorder);

(d) The individual has physician-ordered end-of-life services.

(26) 'Serious mental illness' (SMI) includes the following criteria regarding diagnosis, level of impairment and recent treatment:

(a) Diagnosis - The individual does not have dementia for which the treatment is considered primary, but has a major mental disorder diagnosable under the most recent edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM); and this mental disorder includes, but is not limited to, one of the following: schizophrenia, mood, delusional (paranoid), panic or other severe anxiety disorder, somatic symptom disorder, personality disorder, other psychotic disorder, or a mental disorder other than developmental disability that may lead to a chronic disability diagnosable under the DSM.

(b) Level of impairment - within the past six months, due to the mental disorder, the individual has experienced functional limitations on a continuing or intermittent basis in major life activities that would be appropriate for the individual's developmental stage.

(c) Recent treatment - the treatment history indicates that the individual has experienced at least one of the following:

(i) Psychiatric treatment more intensive than counseling and/or psychotherapy performed on an outpatient basis more than once within the past two years.

(ii) Within the last two years, due to the mental disorder, experienced an episode of significant disruption to the usual living arrangement, for which supportive services were required, or which resulted in intervention by housing or law enforcement officials; or

(iii) Is admitted to a psychiatric unit at the time of seeking NF services.

(27) 'Significant change in condition' means the same as is defined in rule 5160-03-15 of the Administrative Code.

(28) 'Specialized services for mental illness' mean those services specified by the PASRR determination for an individual diagnosed with SMI, which are arranged by the department and may be provided under the behavioral health services as described in rules 5160-8-05 and 5160-27-02 of the Administrative Code, which combined with services by the nursing facility, results in the continuous and aggressive implementation of an individualized plan of care in accordance with 42 C.F.R. 483.120, as in effect January 1, 2019.

(29) 'Specified determinations' is a time-limited approval that may be issued to a NF resident for a stay of up to one hundred eighty days, for the completion of prescribed therapies for which a NF is certified to provide, or to allow for effective discharge planning.

(D) The process by which the department receives referrals for determinations is:

(1) All individuals who are seeking admission into a NF, or who are seeking to continue residing in a NF after a RR triggering event, are required by federal and state regulations to undergo a level one PASRR screen to identify whether the individual possesses indications of SMI or DD

(2) All individuals identified in paragraph (D)(1) of this rule who are identified with indications or suspicion of SMI or DD during a level one PASRR screen are referred to the department or DODD, as appropriate, for a level II determination as set forth by this rule.

(E) Evaluation process:

The level II evaluation includes a face to face interview between the assessor and the individual with indication of SMI who is seeking admission into or to continue residing in a NF; and a review of the individual's medical or NF records to determine the individual's functional level. It may also include the assessor interviewing other professionals and any court-appointed guardian who might have in-depth knowledge of the individual.

(1) The required components of a level II evaluation are:

(a) The assessor will determine the need for and arrange for translation service to ensure the individual's or guardian's full participation throughout the evaluation.

(b) The assessor will inquire of the the individual or guardian whether there are family members or significant others who should be asked to participate in the evaluation. If yes, then the assessor will arrange to interview these individuals, if available.

(c) A comprehensive history and physical examination. The following areas must be included (if not previously addressed):

(i) Complete medical history;

(ii) Review of all body systems;

(iii) Specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes;

(iv) In the case of abnormal findings which are the basis for a NF placement, additional evaluations conducted by appropriate specialists;

(v) A comprehensive drug history including current or immediate past use of medications that could mask or mimic symptoms of mental illness; and,

(vi) A psychosocial evaluation of the person, including current living arrangements and medical and support systems;

(d) A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of general intellectual functioning, memory functioning, orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia degree of reality testing (presence and content of delusions), and hallucinations;

(e) A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment determines whether this level of services can be provided to the individual in an alternative community setting or whether the level of services needed is such that NF placement is required. The focus must be placed on whether the individual can perform the activities of daily living if given the opportunity. A refusal to perform the activity does not constitute an inability. The functional assessment must address at least the following:

(i) Self-monitoring of health status;

(ii) Self-administering and scheduling of medical treatment, including medication compliance;

(iii) Self-monitoring of nutritional status;

(iv) Handling money;

(v) Dressing appropriately; and,

(vi) Bathing and, grooming.

(f) Assessment for the need of specialized services, as defined in paragraph (C)(28) of this rule.

(2) The evaluation concludes with the submission of a written assessment summary in which the assessor reports their findings to the department, along with supporting documents acquired during the review of the individual's records.

(3) Personnel requirements related to the evaluation process are:

(a) The professionals approved to complete the history and physical examination must be in accordance with those listed in rule 5160-3-15 of the Administrative Codes.

(b) In addition to those licensed clinicians listed in rule 5160-3-15.1 of the Administrative Code, individuals with the following licenses or credentials are eligible to be level II assessors for individuals with indications of SMI:

(i) Licensed independent marriage and family therapist;

(ii) Psychology intern;

(iii) Psychology fellow;

(iv) Psychology assistant;

(v) Psychologist;

(vi) Physician;

(vii) Registered nurse;

(viii) Licensed social worker;

(ix) Licensed independent social worker;

(x) Professional counselor; or,

(xi) Professional clinical counselor

(4) Level II evaluations may be moved to desk reviews, instead of a face to face interview between the assessor and the individual with indication of SMI who is seeking admission into or to continue residing in a NF, at the discretion of the department during the COVID-19 state of emergency declared by the governor.

(F) Pre-admission screen (PAS) determination process:

(1) A level II PAS determines whether the individual requires the level of services provided by a NF, based on a comprehensive analysis of all data; the review considers the most inclusive (least restrictive) placement and the need for specialized services for mental illness if NF services are required.

(2) Individualized determinations are performed on all individuals seeking NF services, except those individuals whose admission into a NF are based on categorical determination to require the level of services provided by a NF.

(3) A categorical determination presumes that the individual meets the criteria for NF services, and is defined in paragraph (C)(7) of this rule. A categorical determination does not indicate whether the individual requires specialized services for mental illness, and approves the individual to be admitted into a NF for limited periods as defined in the following categories:

(a) An 'emergency NF stay' is a temporary admission to a NF pending further assessment in emergency situations requiring protective services, with placement in a NF not to exceed seven days, in accordance with rule 5160-3-15 of the Administrative Code. The individual must be admitted to a NF within twenty-four hours of determination or immediately following discharge from a hospital, for a period of no more than seven days; or

(b) A 'respite admission' permits the individual to be admitted into a NF for up to fourteen days, in accordance with rule 5160-3-15 of the Administrative Code. The individual must be admitted to a NF within sixty days of determination for respite of no more than fourteen days and does not need specialized services for mental illness.

(4) Non-residents located within Ohio who are seeking admission to a medicaid-certified NF will be subject to the same standards as Ohio residents who are seeking NF services. If these individuals show indications of SMI upon completing the PASRR screen they will be scheduled for a level II evaluation and will be issued a determination from the department.

The department will not assess non-residents located in Ohio seeking admission into out-of-state NFs.

(G) Resident review (RR) determination process:

(1) A RR determines whether the individual who is already a NF resident requires the level of services provided by a NF, based on a comprehensive analysis of all data; the review considers the most inclusive (least restrictive) placement and the need for specialized services for mental illness if NF services are required.

(2) Individualized determinations are made on all NF residents seeking to continue residing in a NF.

(3) A resident review determination may conclude the following:

(a) The NF resident does require NF services. The determination would also indicate whether the resident requires specialized services for mental illness. If so, the determination would list the services that would meet the resident's needs.

(b) The NF resident does not require ongoing NF services but would benefit from a specified period (short-term) stay in the NF to allow for the completion of prescribed therapies. In this case, the determination would also indicate whether the NF resident requires specialized services for mental illness.

(c) The NF resident does not require NF services and is within an approved specified period and found to require an extension of the short-term stay to allow for effective discharge planning directly related to the resident's complex needs. In this case, the determination would also indicate whether the NF resident requires specialized services for mental illness.

(d) The NF resident does not require NF services, and is issued a PASRR determination requiring a transition to a more inclusive community option. In this case, the determination would make recommendations for needed supports, including behavioral health services and supports that may address the individual's needs during discharge planning, transition, and to sustain the individual in the community. The NF administration is required to issue a thirty-day notice to discharge the resident, according to rule 3701-61-03 of the Administrative Code.

(H) A determination that an individual needs specialized services for mental illness shall result in the aggressive implementation of an individualized plan of care approved by the medical director of the department or designee that:

(1) Is developed and supervised by an interdisciplinary team which includes a physician, trained mental health professionals and, as appropriate, other professionals;

(2) Prescribes specific therapies and treatment activities for an individual exhibiting symptom of SMI which necessitates supervision by trained mental health personnel;

(3) Is available in the community; and is time limited and directed toward diagnosing and reducing the individual's behavioral symptoms that necessitated intervention, improving the individual's level of independent functioning, and achieving a functioning level that permits an optimal quality of life.

(I) Notification:

(1) The department notifies the following entities or individuals when it issues a determination of findings in response to an individual who was suspected of possessing SMI and seeking NF services.

(a) The individual seeking NF services or court-appointed guardian.

(b) The NF administration.

(d) The discharging hospital, except if the individual utilized the hospital exemption.

(2) The notice of findings includes the following information and is distributed to hospital discharge planners, NF administrations, individuals located in the community, or court-appointed guardians:

(a) A determination as to whether the individual was found to require NF level of services.

(b) A determination as to whether the individual requires specialized services for mental illness, if the individual was found to require NF services, and provides recommendations for community behavioral health services to individuals who were not found to require the level of services provided in a NF.

(c) Identifies the placement option that is the most inclusive in which the individual can access needed supports and services, that is consistent with the determination for the need for the level of NF services.

(d) Discharge arrangements, if applicable; and

(e) Appeal rights as outlined in paragraph (J) of this rule.

(3) The department will notify the community behavioral health boards of all instances when one of its residents applied to be admitted into or to continue residing in a NF. This will occur via the electronic board reporting function that is maintained within the department's PASRR data management system.

(a) The purpose of the board notification is to inform an individual's community of residence that the individual might benefit from access to community behavioral health services.

(b) The notification also presents the board with an opportunity to deter its resident from unnecessary institutionalization, or to facilitate effective discharge planning to allow the NF resident to transition to the community when the NF placement is inappropriate, or the NF resident chooses to reside in the community.

(4) Turnaround times:

(a) The department shall meet the national standard of issuing a determination on the annual average of seven to nine business days (approximately fourteen calendar days) from the point of receiving a referral.

(b) The department shall expedite issuing determinations associated with individuals being discharged from psychiatric units or hospitals that are licensed or operated by the department at the time of application. The department shall issue an expedited determinations within an average of forty-eight hours from the point of receiving a referral from an individual admitted to a psychiatric unit or hospital.

(5) Possible outcomes for a PASRR determination for an individual diagnosed with SMI seeking NF services:

(a) Yes NF/no specialized services

(b) Yes NF/yes specialized services

(J) Appeal rights:

(1) The individual or the court-appointed guardian may appeal an adverse PASRR determination issued by the department within the timeframes set forth in rule 5101:6-6-01 of the Administrative Code.

(2) The department may conduct an informal reconsideration of an adverse determination when notified by the bureau of state hearings (BSH) of a scheduled hearing, or upon a request from the individual and or court-appointed guardian to submit additional information.

(3) The department will work collaboratively with relevant staff at DODD to jointly reconsider an adverse determination issued to an individual diagnosed with SMI and DD.

(K) PASRR-compliance:

(1) The department will monitor the utilization of hospital exemptions associated with individuals who possess a diagnosis of mental illness.

(2) The department will monitor the following types of time-specified determinations for individuals diagnosed with SMI:

(a) A categorical emergency NF admission, as defined in paragraph (F)(3)(a) of this rule.

(b) A categorical respite admission, as defined in paragraph (F)(3)(b) of this rule.

(d) An extension, as defined in paragraph (C)(12) of this rule.

(3) Reporting instances of a failure to comply with PASRR requirements:

(a) All identified instances in which the department concludes that a NF administration failed to comply with PASRR requirements will be referred to ODM.

(b) Residents diagnosed with mental illness admitted to or retained in a NF who receive an adverse PASRR determination will be referred to the appropriate board of alcohol, drug addiction, and mental health services, on a case by case basis, for possible assistance with accessing needed community supports.

History

Effective: November 21, 2020
Promulgated Under: 119.03

Chapter 5122-22 Supplemental Services Fund

Ohio Adm.Code 5122-22-01 Trusts for supplemental services.

(A) Purpose

The purpose of this rule is to define those supplemental services that may be provided through a trust and to establish standards for the maintenance and distribution to a beneficiary of assets of a trust authorized by section 5815.28 of the Revised Code.

(B) Applicability

This rule applies to the maintenance and distribution of assets from trusts authorized by section 5815.28 of the Revised Code for Ohio residents with mental illness who depend on public assistance for subsistence and for the payment of rehabilitative, supplemental services without jeopardizing the beneficiaries' public assistance.

(1) "Ascertainable standard" means a standard in a trust instrument requiring the trustee to provide for the care, comfort, maintenance, welfare, education, or general well-being of the beneficiary.

(2) "Department" means the Ohio department of mental health and addiction services.

(3) "Disability" has the same meaning as in section 5815.28 of the Revised Code.

(4) "Guardian" means a guardian of the person, limited guardian, interim guardian, or emergency guardian pursuant to the appointment of the probate court under Chapter 2111. of the Revised Code.

(5) "Supplemental services" means services specified in paragraph (D) of this rule that are provided to an individual with a disability in addition to services that individual is eligible to receive under programs authorized by federal or state law.

(6) "Supplemental services fund" means the fund created in the state treasury pursuant to section 5119.51 of the Revised Code.

(7) "Supplemental services trust" means a trust created pursuant to section 5815.28 of the Revised Code for the purpose of providing supplemental services to an individual with a mental disability.

(8) "Protective service" means performance of the duties of a guardian, trustee, or conservator with respect to a person with mental illness.

(9) "Conservator" means a conservator of the person pursuant to an appointment by a probate court under Chapter 2111. of the Revised Code.

(10) "Board" means a board of alcohol, drug addiction, and mental health services.

(D) Supplemental services

(1) Supplemental services are expenditures, items, or services that meet the following criteria:

(a) The services are in addition to services an individual with a disability is eligible to receive under programs authorized by federal or state law or regulations and the services do not supplant services that would otherwise be available without the existence of the trust;

(b) The services are in addition to basic necessities like essential food, clothing, shelter, education, and medical care and the services are in addition to other items provided pursuant to an ascertainable standard; and

(c) The services are paid for with funds distributed pursuant to a trust that meets the standards in section 5815.28 of the Revised Code or with funds distributed from the supplemental services fund created in section 5119.51 of the Revised Code and the services would not be available without payment from the trust or fund.

(2) Supplemental services that meet the criteria outlined in paragraph (D)(1) of this rule may include, but are not limited to, the following:

(a) Reimbursement for attendance at or participation in recreational or cultural events;

(b) Travel and vacations;

(d) Items beyond necessary food and clothing (e.g., funds for dining out occasionally, for special foods periodically delivered, or for an article of clothing such as a coat which is extra but desirable because it is newer, more stylish, etc.);

(e) Cosmetic, extraordinary, experimental, or elective medical or dental care, if not available through other third party sources;

(f) Visiting friends or companionship;

(g) Exercise equipment or special medical equipment if not available through other third party sources;

(h) The cost differential between a shared room and a private room;

(i) Equipment such as telephones, cable television, televisions, radios, and other sound equipment, as well as cameras for private use by the individual;

(j) Membership in clubs such as book clubs, health clubs, and record clubs;

(k) Subscriptions to magazines and newspapers;

(l) Small, irregular amounts of personal spending money, including reasonable funds for the occasional purchase of gifts for family and friends, or for donations to charities or churches;

(m) Advocacy;

(n) Services of a representative payee or conservator if not available through other third party sources;

(o) Guardianship or other protective service listed in paragraph (C)(9) of this rule;

(p) Someone other than mental health community support staff members to visit the individual periodically and monitor the services the individual receives;

(q) Intervention or respite when the person is in crisis if not available through other third party sources;

(r) Vocational rehabilitation or habilitation, if not available through other third party sources;

(s) Reimbursement for attendance at or participation in meetings, conferences, seminars, or training sessions;

(t) Reimbursement for the time and expense for a companion or attendant necessary to enable the individual to access or receive supplemental services including, but not limited to, travel and vacations and attendance at meetings, conferences, seminars, or training sessions;

(u) Items that medicaid and other governmental programs do not cover or have denied payment or reimbursement for, even if those items include basic necessities such as physical or mental health care or enhanced versions of basic care or equipment (e.g., wheelchair, communication devices), and items that are not included for payment by the per diem of the facility in which the beneficiary lives; and

(v) Other expenditures used to provide dignity, purpose, optimism, and joy to the beneficiary of a supplemental services trust.

(3) Supplemental services also specifically include expenses for burial and related services for an individual, not otherwise paid for, and in an amount not to exceed four thousand five hundred dollars. Such burial services may be purchased by the trustee in an irrevocable prepaid burial contract while the beneficiary is alive or paid by the trustee after the death of the beneficiary.

(E) Standards for maintenance of the trust

(1) Upon creation of the trust, the trustee is to notify the director's office of the department of the creation of the trust, the situs of the assets, the probate court or court of common pleas that exercises jurisdiction over the trust, and the case/docket number of the case in that court.

(2) It is not necessary for the trustee to submit reports to the department concerning the status of the trust or distributions made from the supplemental services trust until the death of the beneficiary of the trust. The trustee is to make such reports as otherwise mandated by statute or the relevant court.

(3) The trust may confer discretion upon the trustee and may contain specific instructions or conditions governing the exercise of the trustee's discretion.

(4) The department is not to impose any limitation as to the suitability of placing trust assets into different types of investments beyond that established by the trust instrument itself and any further mandates imposed by the court that has jurisdiction over the trust.

(5) Multiple trusts for the same beneficiary may be combined for purposes of administrative convenience pursuant to section 1339.67 of the Revised Code. Reformation of the trust is to be at the discretion of the court that has jurisdiction over the trust and in accordance with applicable law.

(6) The limitation imposed upon the amount of the trust by section 5815.28 of the Revised Code applies only to the initial funding of the trust. Trust assets, including interest, may be retained and accumulated beyond the amount of the statutory limitation imposed at the time of the creation of trust.

(7) If the trust is funded to the maximum amount of the statutory limitation in section 5815.28 of the Revised Code at the time of its creation, the person who created the trust (i.e., the settlor) is not to later add subsequent or periodic additional amounts to the trust by other arrangements such as other trust instruments or policies of insurance unless the original trust assets are entirely depleted, and then no more than the amount of the original trust corpus.

(8) Parties other than the settlor who have no obligation to support the beneficiary may add funds to an established supplemental services trust by means of gift, bequest, or otherwise without limitation as to amount. Such funds, once added, are not later subject to withdrawal by the party that provided those funds.

(9) The trustee is to carry a bond or other form of insurance payable from trust assets to guarantee against any possible loss of trust assets unless specifically waived by the settlor or waived by law. The bond or other insurance is to be equal to the value of the trust assets.

(10) The trustee is not to commingle assets of a supplemental services trust with his own assets or with the assets of any other person or entity. However, trust assets or more than one supplemental services trust for more than one beneficiary, or trust assets from more than one trust created by the same settlor, may be combined as long as a bookkeeping system or computer records can be used to determine the amounts of principal and interest available and earned by each beneficiary or each trust at any time upon reasonable notice.

(11) Trusts that existed prior to the enactment of section 5815.28 of the Revised Code are not deemed to qualify as a supplemental services trust.

(F) Standards for distribution of the trust

(1) During the lifetime of the beneficiary, the trustee is to do all of the following:

(a) Avoid any expenditures that would jeopardize the beneficiary's eligibility for medicaid, supplemental security income (SSI), or other forms of public assistance;

(b) Expend trust assets only for supplemental services as defined in this rule;

(c) Whenever possible, pay directly for the supplemental services and not give funds directly to the beneficiary to make such payments. However, the trustee may distribute small, irregular amounts of personal spending money directly to the beneficiary, especially when the beneficiary is capable of managing small amounts of cash or is learning about the use of money pursuant to the individual's individual treatment plan;

(d) Attempt to obtain a written denial of payment from medicaid or other third party payor when there is a doubt whether a particular service qualifies as a supplemental service; and

(e) When a provider of housing is receiving a per diem payment for items or services which otherwise might qualify as a supplemental service, attempt to ascertain the unavailability of other funds for that purpose prior to making an expenditure.

(2) The beneficiary of a supplemental services trust is not to have any authority to compel the trustee under any circumstances to furnish the beneficiary with minimal or other maintenance or support, to make payments from principal or income, or to convert trust assets into cash, whether pursuant to an ascertainable standard or otherwise.

(3) Upon the death of the beneficiary, the trustee is to do all of the following:

(a) Notify the court that has jurisdiction over the trust and the director's office of the department of the death of the beneficiary;

(b) Ensure that burial expenses for the beneficiary have been paid to the extent allowed in paragraph (D)(3) of this rule;

(c) Submit a portion (at least fifty per cent) of the remaining trust assets pursuant to the terms of the trust to the state treasurer for deposit to the supplemental services fund for individuals with mental illness or disability;

(d) Notify the director's office of the department that such payment has been made to the state treasurer and the amount of such payment; and

(e) Distribute the remaining trust assets pursuant to the terms of the trust and the direction of the court that has jurisdiction over the trust.

(4) The trustee is to have the authority to pay all taxes, assessments, costs, and other expenses arising in connection with the administration of the trust estate, including reasonable compensation to the trustee, its agents, and attorneys upon approval by the court that has jurisdiction over the trust.

(G) In the event it is determined by a state or federal court, the social security administration, the United States department of health and human services, or another federal agency that any expenditures from a supplemental services trust would render a beneficiary ineligible for supplemental security income (SSI), medicaid, or similar programs and thus defeat the purpose of this rule and the enabling legislation, the trustee is to terminate the trust and distribute the trust assets in a manner that ensures the beneficiary's continued eligibility for supplemental security income (SSI), medicaid, or similar programs. In such event, the trustee is is mandated to submit an amount equal to the disbursements made on behalf of the beneficiary for medical care by the state from the date the trust vests, but not more than fifty per cent of the trust corpus to the state treasurer for deposit to the supplemental services fund.

(H) Distribution of funds from the supplemental services fund.

(1) Two months prior to the end of each fiscal year, the department, after consulting with the boards of alcohol, drug abuse and mental health services, provider organizations, and constituent organizations that represent consumers of mental health services and their families, will determine whether sufficient funds exist in the supplemental services fund created in section 5119.51 of the Revised Code to justify distribution. If the department determines that there are sufficient funds in the supplemental services fund, the department will distribute those funds or a portion thereof to boards of alcohol, drug abuse, and mental health services according to an allocation formula determined by the department.

(2) A board that receives funds from the supplemental services fund will distribute those funds only for supplemental services as defined in paragraph (D) of this rule and pursuant to the standards for distribution as delineated in paragraph (F) of this rule.

(3) Eligibility for distribution is not to be determined upon the basis of living environment, age, or marital status. In order to be eligible for payment by a board under this rule, the individual is to reside in the county served by the board and is eligible to receive services from the board.

(4) An individual who is a beneficiary of a supplemental services trust established pursuant to this rule is not eligible for payments by a board under the supplemental services fund unless the supplemental services trust funds have been totally expended. Unless the allocation of a board is less than two thousand dollars, no more than one-tenth of a board allotment from the supplemental services fund is to be expended for the benefit of any one individual unless specifically approved by the board.

(5) Requests for distributions may be submitted by an eligible individual, or on behalf of an eligible individual by the individual's guardian, family member, advocate, community support program worker, or other interested party.

(6) The board is not mandated to make payments under this rule that exceed the amount of funds received from the supplemental services fund.

(7) No administrative costs may be taken by the department, a board, or its contract agency from the allocation of supplemental services funds.

(8) The board is to submit a written annual report to the department on forms provided by the department by the fifteenth of August of each year after the fiscal year in which funds were received from the supplemental services fund, or for years in which there was a carry-over from funds received in prior fiscal years. A board that received an allocation from the supplemental services fund but failed to submit the mandated report is not eligible for subsequent allocations until the report is submitted.

(9) The board is to provide information to persons, families, and agencies in the community to make them aware of the supplemental services program.

(10) The state treasurer may receive and accept funds for deposit into the supplemental services fund by way of gift, bequest, or otherwise in addition to funds received pursuant to the operation of sections 5815.28 and 5119.51 of the Revised Code. All assets will be distributed from the supplemental services fund pursuant to this rule, no matter what their source.

Last updated August 15, 2023 at 8:21 AM

History

Effective: August 15, 2023
Promulgated Under: 119.03

Chapter 5122-24 Certification Definitions

Ohio Adm.Code 5122-24-01 Certification definitions.

(A) Purpose

The purpose of this rule is to provide definitions for key words and phrases used in the department's certification standards for community behavioral health services and recovery supports.

(B) Applicability

The following definitions apply to Chapters 5122-24 to 5122-29 of the Administrative Code, unless otherwise specified in one of those chapters:

(1) "Abuse" means any act or absence of action inconsistent with human rights which results or could result in physical injury to an individual served, unless the act is done in self defense or occurs by accident; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against an individual served under that chapter; insulting or coarse language or gestures directed toward an individual served which subjects the individual served to humiliation or degradation; or depriving an individual served of real or personal property by fraudulent or illegal means. For children, "abuse" is as described in section 2919.22 of the Revised Code; "abused child" has the same meaning as in section 2151.031 of the Revised Code.

(2) "Acceptability" means the way in which the provider ensures that its services and activities are sensitive to the individual needs of people, and that the provider addresses issues of freedom of choice, and of ethnic, racial, gender and cultural characteristics. "Acceptability" includes seeking out the advice of individuals being served, or of populations who may not be receiving sufficient services as reflected by a comparison of community demographics and the demographics of individuals served by the provider, in order to understand how acceptability varies within the general population.

(3) "Accessibility" means the ability for individuals served to enter, approach, communicate with, or make use of the services of a provider, including but not limited to the need for bilingual staff, minority-specific programming, staffing patterns that reflect community demographics and adequacy of hours of operation.

(4) "Activity" means an action performed by a provider that does not constitute a certifiable service or support as defined in paragraph (B)(11) of this rule, and therefore does not have a cost per unit, but that is reimbursable by the department, either as an activity, e.g., research, or as a portion of the unit cost of services, e.g., administrative.

(5) "Administer" means the direct application of a single drug to the body of a client either by injection, inhalation, ingestion or any other means. The complete act of administration entails the following:

(a) Removal of an individual dose from a previously dispensed, properly labeled container;

(b) Verification of drug dose with the practitioner's order;

(d) Properly recording the time, date, and dose given in the client's integrated clinical record.

(6) "Administrative supervision" means to monitor the administrative aspects of a service or group of services within a provider.

(7) "Admission" means a provider's decision to offer direct services to an individual, and includes opening an individual client record for the individual at the time of the first admission to the provider.

(8) "Alcohol and drug addiction services" has the same meaning as in section 5119.01 of the Revised Code.

(9) "Appropriateness" means actions, treatment, or service that promote empowerment, dignity, and self-worth as defined by the individual served in consultation with the individuals providing the service or support.

(10) "Board of alcohol, drug addiction, and mental health services" or "board" has the same meaning as in section 5119.90 of the Revised Code.

(11) "Certifiable services or supports" and "certifiable services and supports," depending on the context, means the alcohol and drug addiction services, mental health services, and recovery supports that the department certifies that are specified in Chapter 5122-29 of the Administrative Code.

(12) "Certificate" means the official document containing the department's written authorization to the provider to operate specific services or supports or activities.

(13) "Certification" means the written authorization from the department for a provider to operate specific certifiable services or supports and provide activities according to Chapters 5122-24 to 5122-29 of the Administrative Code.

(14) "Certification standards" means the prerequisites as stated in Chapters 5122-24 to 5122-29 of the Administrative Code with which a provider must comply in order to receive certification by the department to provide certifiable services and supports, as well as activities listed in section 340.09 of the Revised Code. These services, supports, and activities are those included in the provider's contract with the Ohio department of medicaid, the provider's contract or sub-contract with the board of alcohol, drug addiction, and mental health services, or for which a non-contract provider has voluntarily applied to operate.

(15) "Client" means an individual admitted by a provider for certifiable services or supports or who receives certifiable services or supports from a provider. "Individuals," "individuals receiving services or supports," "individuals being served," "individuals served," or "consumer" have the same meaning as "client." The terms include all categories of individuals of all ages, unless specified.

(16) "Community behavioral health services" means alcohol and drug addiction services or mental health services, or both, as defined in section 5119.01 of the Revised Code.

(17) "Community behavioral health services provider" means a community addiction services or community mental health services provider, or both, as defined in section 5119.01 of the Revised Code.

(18) "Community support system" means an array of services, supports, and activities that provides prevention, treatment, and support services and is referred to in division (A)(2) of section 340.011 of the Revised Code. This array includes all of the following:

(a) Location of individuals in need of certifiable services or supports to inform them of available services, supports, and benefit mechanisms;

(b) Assistance for clients to obtain services necessary to meet basic human needs for food, clothing, shelter, medical care, personal safety, and income;

(c) Mental health or addiction care, including, but not limited to outpatient, day treatment, and, where appropriate, inpatient care;

(d) Emergency services and crisis intervention;

(e) Assistance for clients to obtain vocational services and opportunities for jobs;

(f) Provision of services designed to develop social, community, and personal living skills;

(g) Access to a wide range of housing and the provision of residential treatment and support;

(h) Support, assistance, consultation, and education for clients receiving certifiable services and supports, those clients' families and friends, and others;

(i) Recognition and encouragement of families, friends, and neighborhood networks, especially networks that include racial and ethnic minorities, churches, community organizations, and meaningful employment as natural supports for clients receiving certifiable services or supports;

(j) Grievance procedures and protection of the rights of clients receiving certifiable services or supports; and

(k) Case management, which includes continual individualized assistance and advocacy to ensure that needed services are offered and procured.

(19) "Consent" means agreement to participate in a research or treatment procedure on the basis of the subject's understanding of its nature and possible risks and benefits.

(20) "Crisis" means a situation with a high stress level, for either an individual or a system, and where usual coping methods do not succeed in resolving the issues presented by the precipitating event. A crisis is usually short in duration, lasting less than eight to twelve weeks.

(21) "Culturological assessment" means the systematic appraisal or examination of individuals, groups and communities as to their cultural beliefs, values and practices to determine explicit needs and intervention practices within the cultural context of the people being evaluated. "Culturological assessment" includes the following domains:

(a) Patterns of life style;

(b) Specific cultural values/norms;

(d) Worldview and ethnocentric tendencies;

(e) General features that client perceives similar to other cultures;

(f) Health and life care rituals and rites of passage to maintain health;

(g) Folk and professional health/illness systems utilized;

(h) Degree of cultural change and acculturation noted;

(i) Caring behaviors;

(j) Cultural restrictions;

(k) Spiritual needs; and

(l) Family.

(22) "Department" means the Ohio department of behavioral health.

(23) "Destruction" means the act of making a drug unusable.

(24) "Director" means the chief executive and administrative officer of the Ohio department of behavioral health.

(25) "Dispense" has the same meaning as in rule 4729:1-1-01 of the Administrative Code. Only those individuals authorized by the state board of pharmacy may dispense medications.

(26) "Distribute" means the general system of moving drugs from a supplier to final destination, whether administered to an individual served, stored, returned to supplier or destroyed.

(27) "Emergency" means a situation that is a matter of life or death or of extreme drastic loss of an individual's ability to manage a potentially dangerous situation where the goal is avoidance of loss and minimization of risks.

(28) "Executive director" means the individual responsible for the day-to-day operation of a provider. The executive director, as defined by this paragraph, may be referred to by other titles, such as "chief executive officer."

(29) "Federally-qualified health center" and "federally-qualified health center look-alike" have the same meanings as in section 3701.047 of the Revised Code.

(30) "Grievance" means a formal request for further review of any unresolved written complaint or a complaint containing allegations of the denial, exercise or violation of the rights of individuals served. A grievance may be initiated either verbally or in writing by an individual served, client, ex-client, or any other individual or provider acting on behalf of an individual served.

(31) "Group practice" means two or more individuals to which all of the following apply:

(a) The individuals have formed a corporation under Chapter 1701. of the Revised Code, a limited liability company under Chapter 1706. of the Revised Code, a non-profit corporation under Chapter 1702. of the Revised Code, a professional association under Chapter 1785. of the Revised Code, or a partnership or limited partnership under Chapter 1776. or 1782. of the Revised Code;

(b) The primary purpose of the entity they have formed under paragraph (B)(31)(a) of this rule is for providing the professional services of any one or more of the following practitioners, and such practitioners may also employ or contract with others to support the provision of the professional services:

(i) Physicians who are licensed or otherwise legally authorized to practice medicine and surgery or osteopathic medicine and surgery under Chapter 4731. of the Revised Code;

(ii) Physician assistants as defined in section 1.64 of the Revised Code;

(iii) Clinical nurse specialists or certified nurse practitioners, as defined in section 1.64 of the Revised Code, including psychiatric-mental health advanced practice registered nurses;

(iv) Psychologists who are licensed or otherwise legally authorized to practice psychology under Chapter 4732. of the Revised Code;

(v) Licensed professional clinical counselors, independent social workers, independent marriage and family therapists, or marriage and family therapists who are licensed or otherwise legally authorized for their respective practices under Chapter 4757. of the Revised Code;

(vi) Licensed independent chemical dependency counselor-clinical supervisors or licensed independent chemical dependency counselors regulated under Chapter 4758. of the Revised Code.

(c) Each practitioner who is a member of the group practice provides substantially the full range of services the same type of practitioner would routinely provide if practicing as a sole practitioner, except that the practitioners do so through the joint use of shared office space, facilities, equipment, and personnel;

(d) The overhead expenses of the group are the responsibility of each individual member of the group in accordance with methods previously determined by members of the group.

(32) "Hazardous materials" means any substance considered to be potentially harmful to humans, including, but not limited to, toxic chemicals or flammable substances.

(33) "ICR" means individual client record as described in Chapter 5122-27 of the Administrative Code.

(34) "Individual with serious emotional disturbance" means an individual who is under twenty-two years of age who meets criteria that is a combination of duration of impairment, intensity of impairment, and diagnosis.

(a) Criteria:

(i) Under twenty-two years of age;

(ii) Marked to severe emotional/behavioral impairment;

(iii) Impairment that seriously disrupts family or interpersonal relationships; and

(iv) May involve the services of other youth-serving systems (e.g., education, human services, juvenile court, health, intellectual disabilities, youth services, and others).

(b) Marked-to-severe behavioral impairment is defined as impairment that is at or greater than the level implied by any of the following criteria in most social areas of functioning:

(i) Inability or unwillingness to cooperate or participate in self-care activities;

(ii) Suicidal preoccupation or rumination with or without lethal intent;

(iii) School refusal and other anxieties or more severe withdrawal and isolation;

(iv) Obsessive rituals, frequent anxiety attacks, or major conversion symptoms;

(v) Frequent episodes of aggressive or other antisocial behavior, either mild with some preservation in social relationships or more severe requiring considerable constant supervision; or

(vi) Impairment so severe as to preclude observation of social functioning or assessment of symptoms related to anxiety (e.g., severe depression or psychosis).

(i) Requiring assistance or intervention by police, courts, educational system, mental health system, social service, human services, and/or children's services;

(ii) Preventing participation in age-appropriate activities;

(iii) In which community (home, school, peers) is unable to tolerate behavior; or

(iv) In which behavior is life-threatening (e.g., suicidal, homicidal, or otherwise potentially able to cause serious injury to self or others).

(35) "Individual with severe mental disability" or "individual with serious mental illness" means an individual, eighteen years of age or older, who currently, or at any time during the past year, has had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria that has resulted in functional impairment substantially interfering with or limiting one or more major life activities. Major life activities include activities of daily living such as eating, bathing, or dressing; instrumental activities of daily living, such as maintaining a household, managing money, getting around the community, or taking prescribed medications; or functioning in social, family, or vocational/educational contexts.

(36) "Intervention" means a procedure that is intended to produce a change in behavior, cognition, and/or physiological or biochemical process.

(37) "ITP" means individualized treatment plan as described in rule 5122-27-03 of the Administrative Code.

(38) "Mental health services" has the same meaning as in section 5119.01 of the Revised Code.

(39) "Misconduct" means any act that may affect, interrupt or interfere with the performance of official duties and that is illegal or a wrongful performance or omission of a legal duty.

(40) "Neglect" means a purposeful or negligent disregard of duty by an employee or staff member. Such duty is one that is imposed on an employee or staff member by statute, rule, or professional standards and which is owed to the individual served by that employee or staff member.

(41) "Orientation" means a process designed to improve or enhance an employee's knowledge about his or her job responsibilities and physical environment to increase awareness of the expectations, choices, resources, and constraints that affect job performance and adjustment.

(42) "Outcomes" means the impact on the system or individual served.

(43) "Parent" means either parent of a minor, except that if one parent has sole custody, "parent" means the parent with sole custody. "Parent" also includes a guardian or custodian as defined in section 2151.011 of the Revised Code.

(44) "Person," as specified in section 1.59 of the Revised Code, includes an individual, corporation, business trust, estate, trust, partnership, and association.

(45) "Personally furnish" has the same meaning as in rule 4729:8-1-01 of the Administrative Code. Only those individuals authorized by the state board of pharmacy may personally furnish drugs for use outside a prescriber's practice setting.

(46) "Physician" (DO or MD) means an individual authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.

(47) "Plan" means a written document related to a service or activity that describes goals and objectives, assigns responsibility for implementation, establishes outcome measures, and assigns responsibility for monitoring and reporting results.

(48) "Policy" means a written statement developed by a provider that gives specific direction regarding how the provider intends to operate, either administratively or programmatically. Policies are developed to ensure that provider staff perform their duties in a consistent manner and that the public can expect that all services and activities will be conducted according to the policy statement.

(49) "Practitioner" means an individual eligible to provide a service in accordance with Chapter 5122-29 of the Administrative Code.

(50) "Prescribe" means the professional judgment of selecting a specific drug, dosage and schedule of administration appropriate to the therapeutic needs of an individual served.

(51) "Principal" means an individual who has controlling authority or is in a leading position, (e.g., executive director, chief financial officer, or chief clinical officer); a principal may also be an owner, partner, or member of the governing body of the provider.

(52) "PRN order" (pro re nata order) means a written practitioner's order for a medication, treatment, or procedure which is only carried out when an individual served manifests a specific, previously defined clinical or behavioral characteristic.

(53) "Procedure" means a written set of instructions describing the step-by-step actions to be taken by provider staff in implementing the policies of the provider.

(54) "Psychiatrist" (DO or MD) means a physician who has satisfactorily completed a residency training program in psychiatry approved by the residency review committee of the accreditation council for graduate medical education of the American medical association, the committee on postgraduate education of the American osteopathic association, or the American osteopathic board of neurology and psychiatry a physician who has been recognized as of July 1, 1989, as a psychiatrist by the Ohio state medical association or Ohio osteopathic association, on the basis of formal training and five or more years of medical practice limited to psychiatry or a physician working under a temporary license and completing a residency in psychiatry.

(55) "Recovery" means the personal process of change in which Ohio residents strive to improve their health and wellness, resiliency, and reach their full potential through self-directed actions.

(56) "Recovery supports" has the same meaning as in section 5119.01 of the Revised Code.

(57) "Referral" means a recommendation to seek or request certifiable services or supports and/or evaluation between agencies in order to assess or meet the needs of individuals served. Referral, as used in "information and referral service," means the act of assisting an individual gain access to certifiable services or supports of a community behavioral health services provider.

(58) "Resiliency" means a dynamic process which takes into account the interaction of risk and protective factors, contextual conditions, as well as the individual's traits and abilities.

(59) "Self-administration" means an individual taking medication independently.

(60) "Significant others" means individuals who are significant and important to the well-being of an individual served, as identified by the individual served.

(61) "Standard" means a stated level of performance for a service or activity expressed as an accepted and adhered-to practice.

(62) "Stock supply" means a volume of medications that are not dispensed, or not labeled with the specific name of an individual served, and has the same meaning as "limited stock supply."

(63) "Student" means an individual enrolled in an approved, certified or accredited educational program and who may provide certifiable services or supports as part of his/her practicum, internship, or field placement, and with appropriate supervision according to the obligations of the educational institution, applicable licensing board standards, and in coordination with applicable provider policies and procedures.

(64) "Supervise" means to monitor, instruct and be accountable for provider staff in their performance of clinical services to individuals served according to the policies of the provider. "Supervise" has the same meaning as "clinical supervision."

(65) "Termination" means the decision to no longer provide services to an individual served by the provider.

(66) "Transfer" means a provider's recommendation to discontinue providing one or more services to an individual and to begin providing another service(s) in the same provider.

(67) "Variance" means written permission granted by the department to a provider to meet a modified requirement of a rule in the Administrative Code.

(68) "Waiver" means written permission granted by the department to a provider to be exempted from a rule or specific provision of a rule in the Administrative Code.

Last updated August 3, 2026 at 8:23 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Chapter 5122-25 Certification

Ohio Adm.Code 5122-25-01 Applicability.

(A) Statement of applicability

In general, the rules in this chapter apply to any person or government entity that provides or seeks to provide one or more certifiable services or supports, including (1) a person or government entity that operates or seeks to operate an opioid treatment program, (2) a person or government entity that operates or seeks to operate a class one residential facility as defined in section 5119.34 of the Revised Code, and (3) a board of alcohol, drug addiction, and mental health services that is, under section 340.037 of the Revised Code, approved by the director to provide any certifiable service or support. Paragraph (B) of this rule contains the exemptions from that general rule and paragraph (C) of this rule sets forth the specific standard that applies to federally-qualified health centers (FQHCs) and FQHC look-alikes.

A person or government entity to whom this chapter applies is referred to as a "provider."

(B) Exemptions

All of the following are exempt from the provisions of this chapter:

(1) In accordance with division (B) of section 5119.35 of the Revised Code, an individual who holds a valid license, certificate, or registration issued by this state authorizing the practice of a health care profession that includes the performance of any service that is required to be certified as described in this section, regardless of whether the service is performed as part of a sole proprietorship, partnership, or group practice.

(2) In accordance with division (B) of section 5119.35 of the Revised Code, an individual who provides any service that is required to be certified as described in this section as part of an employment or contractual relationship with a hospital outpatient clinic that is accredited by an accreditation agency or organization approved by the director of behavioral health.

(3) A person or government entity where a rule specifically exempts that person or government entity from the rule obligation.

(C) Specific standard applicable to federally-qualified health centers (FQHCs) and federally-qualified health center look-alikes (FQHC look-alikes)

(1) An FQHC or FQHC look-alike is subject to the rules in this chapter when the FQHC or FQHC look-alike provides or seeks to provide one or more of the following certifiable services or supports as part of the FQHC or FQHC look-alike designation as "out of scope":

(a) Mental health day treatment as described in rule 5122-29-06 of the Administrative Code.

(b) Forensic evaluation service as described in rule 5122-29-07 of the Administrative Code.

(d) Residential and withdrawal managements substance use disorder services as described in rule 5122-29-09 of the Administrative Code.

(e) Substance use disorder qualified residential treatment program (QRTP) for youth as described in rule 5122-29-09.1 of the Administrative Code.

(f) Crisis intervention service as described in rule 5122-29-10 of the Administrative Code.

(g) Employment service as described in rule 5122-29-11 of the Administrative Code.

(h) Driver intervention program as described in rule 5122-29-12 of the Administrative Code.

(i) SUD case management services as described in rule 5122-29-13 of the Administrative Code.

(j) Mobile response and stabilization service as described in rule 5122-29-14 of the Administrative Code.

(k) Peer support services as described in rule 5122-29-15 of the Administrative Code.

(l) Peer run organization as described in rule 5122-29-16 of the Administrative Code.

(m) Community psychiatric supportive treatment as described in rule 5122-29-17 of the Administrative Code.

(n) Therapeutic behavioral health services and psychosocial rehabilitation as described in rule 5122-29-18 of the Administrative Code.

(o) Prevention services as described in rule 5122-29-20 of the Administrative Code.

(p) Supplemental behavioral health services as described in rule 5122-29-27 of the Administrative Code.

(q) Intensive home-based treatment (IHBT) service as described in rule 5122-29-28 of the Administrative Code.

(r) Assertive community treatment as described in rule 5122-29-29 of the Administrative Code.

(2) An FQHC or FQHC look-alike is not subject to the rules in this chapter when the FQHC or FQHC look-alike provides or seeks to provide one or more of the following certifiable services or supports as part of the FQHC or FQHC look-alike designation as "in scope, other activities," including the provision of medication-assisted treatment as defined in section 340.01 of the Revised Code and the prescribing of one or more psychotropic drugs as defined in section 5119.19 of the Revised Code:

(a) General services as described in rule 5122-29-03 of the Administrative Code.

(b) Consultation service as described in rule 5122-29-19 of the Administrative Code.

Last updated August 3, 2026 at 8:23 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-02 Certification procedure - initial application.

(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.

(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 5122-25-03 Certification procedure - update application.

(A) This rule specifies the procedure a provider is to follow when the provider seeks to update its certification of certifiable services or supports with the department at any time before renewal (i.e., in the midst of a certification term). Reasons for submitting an update application could include a provider seeking to add a certifiable service or support to, or remove a certifiable service or support from, the menu of services or supports the provider provides; changing locations; adding locations; or changing its executive director, chief executive officer, or similar title. In this circumstance, the provider is to submit an "update application" through the department's licensure and certification tracking system. An update application will be an abbreviated version of the application for initial certification described in rule 5122-25-02 of the Administrative Code.

(B) Upon receipt of an update application, the department will review the application 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 certification is not a refusal to certify.

A provider that fails to respond to a request to submit corrections or additions to an update application within forty-five days is automatically considered to have withdrawn the application. If the provider desires to attempt the update again, the provider is to file a new update application.

A provider that seeks to add a certifiable service or support to the menu of services or supports the provider provides by submitting an update application to the department is to have attained provisional, preliminary, inaugural, conditional, or full accreditation for that service or support not later than the date of application if the department determines that the service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section. The department may then determine whether the provider qualifies for interim certification under the circumstances described in paragraph (A)(2)(a) of rule 5122-25-06 of the Administrative Code or full certification under the circumstances described in paragraph (B)(2)(a) of rule 5122-25-07 of the Administrative Code.

(1) The director may conduct an on-site review of a provider submitting an update application if the director needs additional information to determine whether the standards specified in section 5119.36 of the Revised Code and any rules adopted under that section are satisfied with respect to the reason or reasons for which the provider is submitting the update application. Otherwise, if the director determines that the standards specified in section 5119.36 of the Revised Code and any rules adopted under that section are satisfied without the need for additional information, the director may issue the certification without further evaluation of the services and supports.

(2) If the provider is seeking to add one or more services or supports to the menu of services or supports the provider provides and the director has determined that national accreditation does not exist for at least one of the services or supports the provider is seeking to add, 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.

(3) In addition to an on-site review conducted under paragraph (C)(1) or (C)(2) 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.

(4) Regardless of whether the department is conducting an on-site review under paragraph (C)(1), (C)(2), or (C)(3) 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.

Last updated August 3, 2026 at 8:26 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-04 Certification procedure - renewal application.

(A) This rule specifies the procedure a provider is to follow when applying for renewal certification of one or more certifiable services or supports.

(B) A provider is to submit an application for renewal 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 for renewal. A provider is to submit an application for renewal certification not less than one hundred twenty days before the expiration of the current certificate.

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

(1) A renewal 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.

(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 or 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;

(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 provider provides mental health services, substance use disorder services, or recovery supports.

(j) A list of the certifiable services or supports 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 accrediting organization accrediting each service and 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.

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

(l) Notification if the provider uses seclusion and restraint as defined in rule 5122-26-16 of the Administrative Code.

(m) Any other information the department requests for purpose of determining that the provider's services or 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.

(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 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 certification fee specified in rule 5122-25-12 of the Administrative Code.

(5) Documentation of any existing waivers or variances from the certification standards, issued by the department, and justification for such waivers or variances if the provider is seeking renewal of them.

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

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

(8) A copy of each accreditation award notification letter issued by a national accrediting organization, if applicable.

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

(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 a renewal application, 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 certification 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 renewal 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.

A provider that fails to respond to a request to submit corrections or additions to an application for renewal 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 renewal 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, in accordance with division (A) of section 5119.36 of the Revised Code, will 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 specified 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 of the Revised Code and any rules adopted under that section are satisfied without the need for additional information, the director may issue the certification without further evaluation of the services and 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 the provider under section 340.036 of the Revised Code. It is up to the department's discretion as to whether the department will notify the provider in advance of such an on-site review.

(b) The director is obligated, however, to conduct an on-site review of the provider under both of the following circumstances:

(i) The provider seeks renewal prior to October 1, 2025, and the provider has not yet attained accreditation from a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code to provide each service or support listed in the application for which the director has determined that national accreditation exists for such services or supports. The director is to conduct such an 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 the provider under section 340.036 of the Revised Code.

(ii) The director has determined 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. 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.

If the department determines it will conduct an on-site review under this paragraph or paragraph (D)(1)(b)(i) of this rule, the department is to send the provider a letter confirming the date of the on-site review and provide a copy of that letter to the applicable board. At least thirty days before a scheduled on-site review, the provider is to post notices of the on-site review date and the opportunity for the public to participate in a public information interview during the on-site review. The notices are to be posted in the provider's public areas, on bulletin boards near major entrances of provider's facility, and in the treatment or residential areas of provider's facility.

(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. 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. In conducting such an on- site review, the director 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 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

A provider that fails to respond to a request to submit a plan of correction within ninety days is to automatically be considered to have withdrawn its application. If the provider desires to seek renewal certification again and the provider's certificate has not expired or terminated, the provider is to file a new application for renewal certification.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-05 Determination of certification status by department.

Following the department's receipt of an application for initial certification or renewal certification, or an update application where the provider is seeking to add, during a certification term, one or more certifiable services or supports to the menu of services or supports it provides, the department will analyze each service or support for which certification has been applied for and determine whether that service or support qualifies for interim certification or full certification.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-06 Interim certification.

(A) The department may determine that a provider qualifies for interim certification of a certifiable service or support at the following times and under the following circumstances:

(1) After the provider has applied for initial certification

(a) When the department determines that the service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has applied for initial certification in accordance with rule 5122-25-02 of the Administrative Code and has attained provisional, preliminary, or conditional accreditation for that service or support from a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(b) When the department determines that the service or support is not one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has applied for initial certification in accordance with rule 5122-25-02 of the Administrative Code.

(2) After the provider has filed an update application

(a) When the department determines that the service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted an update application in accordance with rule 5122-25-03 of the Administrative Code (because the provider is seeking to add a new service to the menu of services the provider provides) and the provider has attained provisional, preliminary, or conditional accreditation for that service or support from an accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(b) When the department determines that the service or support is not one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted an update application in accordance with rule 5122-25-03 of the Administrative Code (because the provider is seeking to add a new service to the menu of services the provider provides).

(3) After the provider has applied for certification of an additional service or support in an application for renewal certification

(a) When the department determines that the additional service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted a renewal application in accordance with rule 5122-25-04 of the Administrative Code and has attained provisional, preliminary, or conditional accreditation for the additional service or support from an accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(b) When the department determines that the additional service or support is not one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted a renewal application in accordance with rule 5122-25-04 of the Administrative Code.

(4) Emergency situations

When the department determines that an emergency situation exists or there is an administrative reason necessitating the granting of interim certification of a service or support to a provider who already provides at least one other certifiable service or support.

(B) An interim certification allows a provider to provide a service or support for a limited period of time specified in paragraph (D) of this rule while the provider works to meet all standards for full certification or, as determined by the department, during the period of the emergency situation or other administrative reason.

A certificate is valid only at the locations specified on the certificate. Residential and withdrawal management substance use disorder services provided in accordance with rule 5122-29-09 and driver intervention program provided in accordance with rule 5122-29-12 of the Administrative Code are site specific, meaning that a provider is to request certification at each specific location. All other currently certified services or supports may be provided at any certified location.

A certificate is not transferable to any other location, provider site, or building and is valid only for the provider named in the application. The certificate is not transferable to or assumable by any other person or government entity, including any person or government entity that purchases the provider's corporate or managing entity or enters into any similar purchase agreement. A provider is not to grant the use of its certification to another person or government entity.

(C) The department will grant interim certification for a service or support only after it has determined all of the following:

(1) That the provider has submitted a complete and compliant application for initial certification pursuant to the procedure in rule 5122-25-02 of the Administrative Code, a complete and compliant update application pursuant to the procedure in rule 5122-25-03 of the Administrative Code, or a complete and compliant application for renewal certification pursuant to the procedure in rule 5122-25-04 of the Administrative Code, as applicable, and the application materials comply with Chapters 5122-26 to 5122-29 of the Administrative Code.

(2) If national accreditation is mandated for the particular service or support under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section, that the provider has received preliminary, provisional, or conditional national accreditation for that service or support from a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(3) That the provider demonstrates readiness to meet the clinical documentation obligations of Chapter 5122-27 of the Administrative Code by (a) having an electronic health record system that can meet the standards in that chapter or (b) providing samples of paper forms.

(4) That the provider has adequate staff and equipment to provide the particular service or support determined in accordance with Chapter 5122-29 of the Administrative Code.

(5) That if the provider was subject to an on-site review as described in rule 5122-25-02, 5122- 25-03, or 5122-25-04 of the Administrative Code, that the provider corrected all deficiencies identified in the department's written statement of noncompliance.

(6) That the department has not been notified under section 5119.367 of the Revised Code or is not otherwise aware that the provider, any owner or principal of the provider, or any subsidiary of the provider or owner has been the subject of an adverse action, as defined in that section, during the three-year period immediately preceding the date of application.

(7) That the provider has obtained the permits and inspections specified in paragraph (G) of rule 5122-26-12 of the Administrative Code for each building in Ohio that the provider owns or leases and at which the provider intends to provide one or more certifiable services or supports, except if the building is owned or leased by a school as defined in section 5709.07 of the Revised Code.

(D) An interim certificate terminates on the date that is one hundred eighty days from the date of issuance.

(E) An interim certificate may be extended for a single one hundred eighty-day period.

(F) If a provider is unable to attain full certification at the end of an extension period granted under paragraph (E) of this rule, the interim certificate terminates. In extenuating circumstances, however, at the discretion of the director, the director may consider granting the provider emergency administrative certification under rule 5122-25-09 of the Administrative Code. If the applicant desires to seek initial certification again, the provider is to file a new application for initial certification.

(G) An interim certificate also terminates under the following circumstances:

(1) The provider voluntarily relinquishes the certificate;

(2) The provider is unable to obtain full national accreditation; or

(3) The department revokes the certificate in accordance with rule 5122-25-11 of the Administrative Code.

(H) A provider is to produce the certificate for review on the request of a client or the department.

(I) A provider is to immediately notify the department and the applicable board of alcohol, drug addiction, and mental health services in writing of any changes in its operations that affect the provider's continued compliance with the department's certification standards.

(J) Through an update application submitted in accordance with rule 5122-25-03 of the Administrative Code, a provider is to notify the department of a change in its executive director, chief executive officer, or similar title, including the name, telephone number, and electronic mail address of the replacement individual.

(K) A provider is to notify the department, in writing, of any planned changes to the ownership of the provider. Owners are individuals or corporations with a five percent or more ownership or controlling interest. The notification is to be made at least thirty days before the effective date of the ownership change and include ownership information specified by the department.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-07 Full certification.

(A) As used in this rule, "full accreditation," with respect to a particular certifiable service or support, means a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code that the department has identified on its national accreditation webpage has issued an accreditation decision of "accredited" or "accreditation" without additional conditions or modifiers other than three-year or one-year accreditation.

(B) The department may determine that a provider qualifies for full certification of a certifiable service or support during the following times and circumstances:

(1) After the provider has applied for initial certification

(a) When the department determines that the service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has applied for initial certification in accordance with rule 5122-25-02 of the Administrative Code and attained full accreditation for that service or support from a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(2) After the provider has filed an update application

(a) When the department determines that the service or support is one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted an update application in accordance with rule 5122-25-03 of the Administrative Code (because the provider is seeking to add a new service or support to the menu of services or supports the provider provides) and the provider has attained full accreditation for that service or support from a national accrediting organization specified in division (B)(3) of section 5119.36 of the Revised Code.

(b) When the department determines that the service or support is not one for which national accreditation is mandated under division (B)(1) of section 5119.36 of the Revised Code and rules adopted under that section and the provider has submitted an update application in accordance with rule 5122-25-03 of the Administrative Code (because the provider is seeking to add a new service or support to the menu of services or supports the provider provides).

(3) When the provider is transitioning from interim to full certification

When the provider was previously issued an interim certificate under rule 5122-25-06 of the Administrative Code and the provider is able to demonstrate to the department that it has achieved all standards in paragraph (C) of this rule.

(C) A provider maintains full certification when the provider successfully renews full certification in accordance with the procedure in rule 5122-25-04 of the Administrative Code.

The department will issue full certification for a service or support only after it has determined all of the following:

(1) That the provider has submitted a complete and compliant application for initial certification pursuant to the procedure in rule 5122-25-02 of the Administrative Code or a complete and compliant update application pursuant to the procedure in rule 5122-25-03 of the Administrative Code, as applicable, and the application materials comply with Chapters 5122-26 to 5122-29 of the Administrative Code.

(3) That the provider demonstrates clinical readiness to meet the documentation obligations of Chapter 5122-27 of the Administrative Code by (a) having an electronic health record system that can meet the standards in that chapter or (b) providing samples of paper forms.

(4) That the provider has adequate staff and equipment to provide the particular service or support determined in accordance with Chapter 5122-29 of the Administrative Code.

(5) That if the provider was subject to an on-site review as described in rule 5122-25-02, 5122- 25-03, or 5122-25-04 of the Administrative Code, that the provider has corrected all deficiencies identified in the department's written statement of noncompliance.

(6) That the department has not been notified under section 5119.367 of the Revised Code or is not otherwise aware that the provider, any owner or principal of the provider, or any subsidiary of the provider or owner has been the subject of an adverse action, as defined in section 5119.367 of the Revised Code, during the three-year period immediately preceding the date of application.

(D) If the provider possesses national accreditation for the certifiable service or support, the department is to issue full certification not later than thirty days after the department determines that it has received a complete and compliant application or an acceptable plan of correction from the provider. If the provider does not possess national accreditation for the certifiable service or support, the department would issue interim certification to the provider as specified in rule 5122-25-06 of the Administrative Code.

(E) Full certification allows a provider to provide a service or support until the full certification expires or is otherwise terminated or revoked by the department, whichever is earlier.

(1) Full certification expires on the date specified by the department which is not to be later than three years from the date of issuance.

(2) Full certification terminates sixty days after the department notifies the provider of its failure to file a complete and compliant application or an acceptable plan of correction or when a provider voluntarily relinquishes its certification or goes out of business.

(3) Full certification is revoked on the date specified by the department pursuant to rule 5122- 25-11 of the Administrative Code.

(F) A certificate is valid only at the locations specified on the certificate. Residential and withdrawal management substance use disorder services provided in accordance with rule 5122-29-09 of the Administrative Code and driver intervention service provided in accordance with rule 5122-29-12 of the Administrative Code are site specific, meaning that a provider is to request certification at each specific location. All other currently certified services or supports may be provided at any certified location.

(G) A provider is to produce the certificate for review on the request of a client or the department.

(H) A provider is to immediately notify the department and the applicable board of alcohol, drug addiction, and mental health services in writing of any changes in its operations that affect the provider's continued compliance with the department's certification standards.

(I) Through an update application submitted in accordance with rule 5122-25-03 of the Administrative Code, a provider is to notify the department of a change in its executive director, chief executive officer, or similar title, including the name, telephone number, and electronic mail address of the replacement individual.

(J) A provider is to notify the department, in writing, of any planned changes to the ownership of the provider. Owners are individuals or corporations with a five percent or more ownership or controlling interest. The notification is to be made at least thirty days before the effective date of the ownership change and include ownership information specified by the department.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-08 Probationary certification.

(B) The department may issue probationary certification when the provider has full certification and at least one of the following is true:

(1) The department has identified serious deficiencies during its review of a provider's compliance with certification standards or the provider's documented corrective action is not approved by the department; or

(2) When a national accrediting organization has modified the provider's accreditation status from full accreditation to another accreditation status, except for losing accreditation.

(D) Probationary certification may be extended for a single one hundred twenty-day period.

(E) If a provider is unable to return to full certification or loses national accreditation at the end of an extension period granted under paragraph (D) of this rule, the probationary certification terminates. At this point, the provider may voluntarily relinquish the certificate or the department may revoke the certificate in accordance with 5122-25-11 of the Revised Code.

(F) Nothing in this rule limits the department's ability to bring an administrative hearing prior to issuing probationary certification or an extension thereof under this rule.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-09 Emergency administrative certification.

The department may issue emergency administrative certification in emergency situations or for administrative reasons determined by the department. Emergency administrative certification will be issued for a duration of up to ninety days. Subsequent administrative certification periods are at the discretion of the department. The emergency administrative certification expires on the date determined by the department unless a subsequent emergency administrative certificate is issued. Before the certification expires, the department will notify the provider of its options which will vary depending on the circumstances that precipitated the issuance of the emergency administrative certification.

Last updated August 3, 2026 at 8:27 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-10 Waivers and variances.

(A) The department may grant a waiver or variance from any certification standard in rules, or portion thereof, for a period of time determined by the department. The period of time is not, however, to exceed the expiration date of the current certification. Requests for waivers and variances that would adversely affect the quality of services, client rights, or the health and safety of clients will not be granted. The department will not grant a waiver or variance from any statutory mandate.

(B) A waiver or variance is to be requested by an individual provider in writing using the form prescribed for this purpose available on the department's website.

(1) Provide, in writing, a specific response to the request; or

(2) Provide, in writing, an estimate to the provider of the timeframe in which the department will be able to provide a specific response to the request.

(D) Once a waiver or variance has expired as described in paragraph (A) of this rule, a provider may submit a request for a new waiver or variance by following the procedure in paragraph (B) of this rule. That procedure is to be followed regardless of whether the new waiver or variance request is or is not identical to a prior waiver or variance request the provider has been granted. All other paragraphs of this rule apply with respect to the department's review and determination on the new waiver or variance request.

(E) The department's refusal to grant a waiver or variance, in whole or part, is final and not subject to an adjudication under Chapter 119. of the Revised Code.

Last updated August 3, 2026 at 8:28 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-11 Refusal and revocation of certification.

(A) The director may refuse to certify certifiable services and supports, refuse to renew certification, or revoke certification if any of the following applies to the provider:

(1) The provider is not in compliance with the rules in this chapter or Chapters 5122-24, 5122-26, 5122-27, 5122-28, or 5122-29 of the Administrative Code;

(2) The provider has been cited for a pattern of serious noncompliance or repeated violations of statutes or rules during the current certification period or any previous certification period;

(3) The provider has been found to be in violation of section 5119.36 or 5119.396 of the Revised Code;

(4) The provider submits false or misleading information as part of a certification application, renewal, on-site review, or investigation or submits false or misleading information to the department of medicaid or a board of alcohol, drug addiction or mental health services;

(5) The provider does not have adequate staff and equipment to provide the certifiable services or supports;

(6) The provider, whether through its directors, officers, employees, agents, or contractors, falsifies client records in any way;

(7) The provider becomes aware of an employee falsifying information on client records which have been billed to the department of medicaid or the department of medicaid's contractor and fails to pay back the funds within thirty days or notify the department of medicaid within thirty days;

(8) The provider is aware of an employee who has abused or neglected a client and has failed to take appropriate disciplinary action to correct the situation;

(9) The department has been notified under section 5119.367 of the Revised Code, or is aware that the provider, any owner or principal of the provider, or any subsidiary of the provider or owner has been the subject of an adverse action, as defined in that section, taken during the three-year period immediately preceding the date of notification or date of becoming aware of the adverse action;

(10) The provider misuses or fails to properly account for the disbursement of local, state, or federal funds;

(11) The provider fails to provide timely access to its records as requested by the department;

(12) The provider has not fulfilled the certification fee prerequisite, unless exempt from the fee;

(13) If applicable, the provider does not possess current and appropriate accreditation for the services for which it seeks certification or has been providing services; or

(14) The provider altered or modified its certificate.

(B) The department's refusal to certify certifiable services or supports, refusal to renew certification, or decision to revoke certification is subject to appeal under Chapter 119 of the Revised Code.

(C) If the director proposes to take action under section 5119.36 of the Revised Code or this rule on an initial or renewal application, the director is to notify the board of alcohol, drug addiction, and mental health services serving the alcohol, drug addiction, and mental health service district in which the certifiable services or supports will be or were provided, and provide the board an opportunity to respond with respect to that initial or renewal application.

(D) Any provider that has had its certification revoked pursuant to this rule is not eligible to apply to the department for certification for at least five years from the date of revocation without the written consent of the department. Any provider with a principal or subsidiary who was a principal or subsidiary of another organization that had its certification revoked is not eligible to apply to the department for certification for at least five years from the date of revocation without the written consent of the department.

(E) Any person or government entity for which the department has refused to certify certifiable services and supports or has refused to renew certification pursuant to this rule is not eligible to apply to the department for certification for at least three years from the date of refusal without the written consent of the department. Any provider, any owner or principal of the provider, or any subsidiary of the provider or owner that had its certification refused is not eligible to apply to the department for certification for at least three years from the date of refusal without the written consent of the department.

(F) The date on which certification was refused or revoked is the date specified by the department in writing to the provider. On and after such date, the provider is not to provide certifiable services.

(G) Not later than thirty days after the issuance of a final order for disciplinary action, the department shall provide notice of that action to the applicable board of alcohol, drug addiction, and mental health services.

Last updated August 3, 2026 at 8:28 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-25-12 Certification fees.

(A) Initial certification

A provider applying for initial certification of one or more certifiable services or supports, pursuant to the procedure in rule 5122-25-02 of the Administrative Code, is to pay the following at the time of submitting the application for initial certification to the department:

(1) A base application fee of one thousand dollars, regardless of the number of services and supports for which certification is sought.

(2) For each service or support for which national accreditation does not exist for the service or support, as determined by the department, a per service or support fee of two hundred dollars.

A provider does not owe a per service or support fee for each service or support for which the department determines that national accreditation exists for the service or support.

(B) Update certification

A provider that seeks to add one or more certifiable services or supports to the menu of services and supports it provides, pursuant to the procedure in rule 5122-25-03 of the Administrative Code, is to pay the following at the time of submitting the update application:

(1) A base application fee of two hundred fifty dollars.

(2) For each service or support for which national accreditation does not exist for the service or support, as determined by the department, a per service or support fee of two hundred dollars.

A provider does not owe a per service or support fee for each service or support for which the department determines that national accreditation exists for the service or support.

A provider applying for renewal certification of one or more certifiable services and supports, pursuant to the procedure in rule 5122-25-04 of the Administrative Code, is to pay the following at the time of submitting the application for renewal certification:

(1) A base application fee of five hundred dollars.

(2) For each service or support for which national accreditation does not exist for the service or support, as determined by the department, a per service or support fee of two hundred dollars.

A provider does not owe a per service or support fee for each service or support for which the department determines that national accreditation exists for the service or support.

(D) If any certification application is denied for being incomplete, a new application may be submitted but the provider may have to pay a new certification fee in accordance with this rule. The department may waive the new certification fee at its discretion.

(E) If the department notifies a provider that the application materials are non-compliant, the provider may submit an application corrective action plan with no penalty. If the department notifies a provider that the resubmitted documentation is non-compliant, the provider may again submit an application corrective action plan with no penalty. If the department notifies a provider that a third application plan of correction is needed, the provider will incur a two hundred fifty dollar resubmission fee. The department may waive this fee at its discretion if the application only needs minor corrections. Each subsequent notification of a non-compliant application and application plan of correction prerequisite will incur a five hundred dollar resubmission fee. The department may waive this fee at its discretion if the application only mandates minor corrections.

(F) Any certification fee paid by a provider pursuant to the rule is to be paid into the sale of goods and services fund created pursuant to section 5119.45 of the Revised Code.

Last updated August 3, 2026 at 8:28 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Chapter 5122-26 Policies and Procedures for the Operation of Mental Health Services Agencies

Ohio Adm.Code 5122-26-01 Purpose.

The purpose of this chapter is to state the obligations for written policies and procedures for providers that provide certifiable services or supports.

Last updated August 3, 2026 at 8:25 AM

History

Effective: August 1, 2026
Promulgated Under: 119.03

Ohio Adm.Code 5122-26-02 Applicability.