5122-14-03 Licensure procedure.

(A) The purpose of this rule is to state various licensure procedures including application, renewal, correction of deficiencies or non-compliance, and determination of the number of licensed beds.

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

(C) Definitions applying to this rule are those appearing in rule 5122-14-01 of the Administrative Code.

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

(1) The application shall consist of, at minimum:

(a) Completed application form;

(b) Approved building inspection or certificate of occupancy report;

(c) Approved fire inspection report;

(d) Non-refundable annual licensure fee;

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

(f) Comprehensive plan of service;

(g) Proof of psychiatric bed registration as reported annually to the Ohio department of health, as applicable;

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

(i) Completed self-survey checklist; and

(j) 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 shall equal the total number of licensed beds for the inpatient psychiatric service provider.

(2) The proposed inpatient psychiatric service provider shall 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 rules 5122-14-01 to 5122-14-14 of the Administrative Code.

(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 requirements stated in paragraphs (D)(1) to (D)(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:

(a) Implementation of policies and procedures; and

(b) Documentation of being in compliance with licensure rules 5122-14-01 to 5122-14-14 of the Administrative Code.

(E) For inpatient psychiatric service provider(s) holding a current license, annual renewal of full licensure shall be based on receipt and approval by the department of:

(1) Completed application form which assures that the private inpatient psychiatric service provider remains in compliance with licensure rules 5122-14-01 to 5122-14-14 of the Administrative Code;

(2) All substantial changes in written policies and procedures specific to inpatient psychiatric service provider treatment and licensure rules 5122-14-01 to 5122-14-14 of the Administrative Code to be submitted to the department when the inpatient psychiatric service provider does not receive an on-site survey;

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

(4) 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) Non-refundable annual licensure fee;

(6) 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 shall equal the total number of licensed beds for the inpatient psychiatric service provider;

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

(8) A thirty-day notice shall be given whenever possible by the department to the inpatient psychiatric service provider prior to the expiration of the annual license.

(F) Renewal of full licensure shall require an on-site survey of the inpatient psychiatric service provider every three years, or as determined by the department, to be conducted by a designee of the department to assure compliance with licensure rules 5122-14-01 to 5122-14-14 of the Administrative Code. A thirty-day notice shall be given whenever possible by the department to the inpatient psychiatric service provider prior to such a survey.

(G) The department shall provide to an inpatient psychiatric service provider a written communication identifying any deficiencies or non-compliance with licensure rules 5122-14-01 to 5122-14-14 of the Administrative Code 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 shall 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 shall 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 shall fully implement its plan of correction within the timeframes specified by the department.

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

(1) Licensed beds shall be registered annually with the Ohio department of health, pursuant to section 3701.07 of the Revised Code.

(2) Any change in the location or the total number of licensed beds shall require prior approval from the department.

(3) The number of licensed beds shall refer to the actual number of set up and staffed beds available for immediate patient occupancy, or which 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 the psychiatric hospital's or inpatient unit(s)' physical facilities, these beds once available for patient occupancy may be licensed upon application by the inpatient psychiatric service provider to the department.

(b) The total number of licensed beds shall not 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 shall notify the department in writing so that its license can be terminated. The inpatient psychiatric service provider shall also notify the department of health, as applicable.

(I) An inpatient psychiatric service provider may be visited at any time by a designee of the department to determine compliance with rules 5122-14-01 to 5122-14-14 of the Administrative Code.

Effective: 07/01/2011
R.C. 119.032 review dates: 03/21/2011 and 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.20
Rule Amplifies: 5119.20
Prior Effective Dates: 10-12-1978, 1-1-1991, 1-1-2000