Chapter 5122-1 General Provisions

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.

Replaces: 5122-1-01

Effective: 06/06/2011
Promulgated Under: 111.15
Statutory Authority: 5119.01
Rule Amplifies: 5119.01
Prior Effective Dates: 5-8-1990, 2-1-2000, 1-14-2008

5122-1-02 Public hearings and method of notice.

(A) Public hearings

(1) The department shall conduct a public hearing for all administrative rules filed in compliance with Chapter 119. of the Revised Code.

(a) Any person affected by the proposed action of the department concerning such rules may appear and be heard in person. The person, the person's attorney, or both, may present the person's position, arguments, or contentions, orally or in writing, offer and examine witnesses, and present evidence tending to show that the proposed rule, amendment, or rescission, if adopted or effectuated, will be unreasonable or unlawful.

Persons unable to attend the hearing may present their positions, arguments, or contentions in writing. Such written materials must be received by the department no later than the day of the public hearing in order to be included in the hearing record.

(b) At the hearing, the testimony shall be recorded. The department will not routinely transcribe the recording unless a person requests transcription of all or part of the record and agrees to reimburse the department for the costs of the transcription. The department reserves the right to require the requesting person to pay in advance all or part of the cost of the transcription.

(B) Method of notice for public hearings

(1) At least thirty days before the public hearing, the department shall prepare a notice of public hearing which includes all of the following:

(a) A statement of the department's intent to propose, amend, or rescind rules;

(b) A general statement of the subject matter to which the proposed rules, amendments, or rescissions relate;

(c) The reason or purpose for adopting, amending, or rescinding the rule(s);

(d) A statement that a copy of the rule(s) shall be available for review at the department's central office; and

(e) The date, time, and place of the hearing.

(2) The department shall provide a copy of the public notice to any person who requests it and pays a reasonable fee, not to exceed the cost of copying and mailing.

(3) At least thirty days before the public hearing, the department shall submit the notice of public hearing to the legislative service commission for publication in the register of Ohio.

Effective: 02/17/2012
R.C. 119.032 review dates: 11/30/2011 and 02/17/2017
Promulgated Under: 119.03
Statutory Authority: 119.03
Rule Amplifies: 119.03
Prior Effective Dates: 3/25/2004

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.

Effective: 01/24/2011
Promulgated Under: 111.15
Statutory Authority: 5119.01
Rule Amplifies: 5122.31
Prior Effective Dates: 9/30/02, 12-10-2005, 5-26-2008

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.

Effective: 09/18/2010
Promulgated Under: 111.15
Statutory Authority: 340.09 , 5119.01 , 5119.06
Rule Amplifies: 340.09 , 5119.01 , 5119.06
Prior Effective Dates: 4-24-1978, 7-1-1980, 6-2-1990, 9-24-1998, 9/30/2002, 12/10/2005, 1-14-2008

5122-1-28 Industrial and entertainment funds.

[This rule designated an internal management rule]

(A) The purpose of this rule shall be to provide guidance to all ODMH regional psychiatric hospital employees involved in creating and maintaining industrial and entertainment funds for the entertainment and benefit of clients.

(B) This rule shall be applicable to all employees of ODMH hospitals.

(C) Process:

(1) The chief executive officer of each hospital under the managing responsibility of the Ohio department of mental health shall take the necessary action to insure that an industrial and entertainment fund is established.

(2) All monies received by a hospital which are designated for entertainment and benefit of the patients, including profits from the commissary fund operations, shall be deposited into the industrial and entertainment fund and be used only for the entertainment and benefit of patients.

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

(D) Income: Income for the industrial and entertainment fund shall be derived from, but not be limited to, the following sources:

(1) Donations;

(2) Vending machine commissions;

(3) Monies from occupational and/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 5119.36 of the Revised Code.

(8) Profits generated by hospital commissaries in accordance with division (B) of section 5119.36 of the Revised Code.

(E) Disbursements:

Disbursements may be made from the industrial and entertainment fund only for items which exclusively benefit patients and for which no appropriated or patient funds are available. Disbursements shall 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 and/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) Film 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.

(F) Other disbursements:

Disbursements in the amount of one thousand dollars or less may be made with the approval of the chief executive officer or his designee. Expenditures in excess of one thousand dollars shall have prior approval from central office. Approval shall be secured in advance by submitting "a request for approval to purchase form DMH-FIS-005" as follows:

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

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

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

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

Effective: 03/08/2009
Promulgated Under: 111.15
Statutory Authority: 111.15 , 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 7-27-1990, 2-1-2000, 12-10-2005

5122-1-29 Operation of ODMH regional psychiatric hospital commissaries.

(A) The purpose of this rule shall be to establish procedures for the funding and operation of hospital commissaries under the managing responsibility of the division of hospital services which is operated by the Ohio department of metal health (ODMH).

(B) The provisions of this rule shall apply to all hospitals under the managing responsibility of ODMH.

(C) Process:

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

(2) Hours of operation of commissaries shall be established by the chief executive officer of the hospital 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 and/or wages of all commissary employees shall be paid from appropriated funds. A state employee must be accountable for the day-to-day operation of the commissary. All volunteers must be covered by a fidelity bond.

(4) The recording of transactions of the commissaries shall be directly supervised by the business office of each hospital and shall be subject to audit by the internal audit group of legal services located in ODMH central office, and the auditor of state.

(D) Operation:

(1) A cash register shall be used to record all cash sales at the time of transaction.

(2) Form "DMH-FIS-032" shall be used to substantiate all charge sales. Fund transfers for all non-cash sales shall be made within one day of the actual transactions.

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

(4) Commissary invoices shall 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 shall be completed. "A-2 forms" shall be completed daily and turned into the business office monthly for approval and storage. All other generally accepted accounting practices shall be implemented in maintaining proper financial records.

(5) Commissary revenue over and above operating costs shall be considered profits. Commissary prices shall 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 shall be paid into the industrial and entertainment fund of the hospital to be used to benefit the patients. Profits shall 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 shall be no rescission.

(6) Apparent merchandise shrinkage shall 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 shall gain personally from the operation of the commissary. There shall 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 the office of support services of the ODMH or from local suppliers.

(9) Items purchased locally shall be obtained at the lowest prices available and informal bidding procedures shall be used whenever possible. 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 shall have prior approval from ODMH central office. Approval shall be secured in advance by submitting a "Request for approval to purchase form DMH-FIS-005" as follows:

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

(b) The form, accompanied by at least three letterhead bids, shall be forwarded to the deputy director of hospital services for approval.

(i) A vendor's refusal to bid shall be acceptable as a bid.

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

(c) Upon ODMH central office approval, the copy of the certificate of approval shall be returned to the initiating hospital. The certificate shall be retained by the hospital according to the ODMH retention schedule.

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

(a) All merchandise for resale;

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

(c) Equipment;

(d) Repair and maintenance of equipment;

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

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

(g) Check printing charges.

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

Effective: 03/08/2009
Promulgated Under: 111.15
Statutory Authority: 111.15 , 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 12-17-1979, 7-1-1980, 2-17-1986, 3-4-1991, 2-1-2000, 12-10-2005

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.

Effective: 04/09/2013
Promulgated Under: 111.15
Statutory Authority: 111.15
Rule Amplifies: 3501.05 , 5122.301
Prior Effective Dates: 4/3/1995, 2/1/2000, 12/10/2005, 6/1/2008, 6/6/2011