Chapter 5122-25 Certification

5122-25-01 Applicability.

(A) The provisions of the rules contained in this chapter are applicable to each agency providing mental health services that are funded by, or funding is being sought by, a community mental health board; is subject to department licensure according to section 5119.22 of the Revised Code; or that voluntarily requests certification. Any service contact(s) provided by an agency that is paid for in whole or in part by any community mental health board shall be subject to the provisions of this chapter.

(B) These rules do not diminish or enhance the authority of community mental health boards to administer the community mental health system pursuant to the Ohio Revised Code, and applicable federal law.

R.C. 119.032 review dates: 04/14/2009 and 04/14/2014

Promulgated Under: 119.03

Statutory Authority: 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.61(A), 5119.611(C)

Prior Effective Dates: 10-1-2003

5122-25-02 Accreditation.

(A) An agency seeking certification for one or more of the following services may attain appropriate behavioral health accreditation prior to submitting an application for certification:

(1) Behavioral health counseling and therapy service as defined in rule 5122-29-03 of the Administrative Code;

(2) Mental health assessment service as defined in rule 5122-29-04 of the Administrative Code;

(3) Pharmacologic management service as defined in rule 5122-29-05 of the Administrative Code;

(4) Partial hospitalization service as defined in rule 5122-29-06 of the Administrative Code;

(5) Crisis intervention mental health service as defined in rule 5122-29-10 of the Administrative Code;

(6) Community psychiatric supportive treatment (CPST) service as defined in rule 5122-29-17 of the Administrative Code; and/or

(7) Intensive home based treatment (IHBT) service as defined in rule 5122-29-28 of the Administrative Code.

(B) Behavioral health accreditation referenced in paragraph (A) of this rule shall be obtained from one or more of the following accrediting bodies:

(1) "The Joint Commission;"

(2) "The Commission on Accreditation of Rehabilitation Facilities;" and/or

(3) "The Council on Accreditation ."

(C) The department may:

(1) Add the names of other accrediting bodies to those listed in paragraph (B) of this rule if it determines that such bodies meet its accreditation requirements.

(2) Likewise, the department may delete the names of accrediting bodies from those listed in paragraph (B) of this rule if it determines that such bodies no longer meet its accreditation requirements.

(a) An agency accredited by a body the department chooses to delete from those listed in paragraph (B) of this rule shall remain certified until its current accreditation expires. If an agency wishes to retain certification after that time, it must attain accreditation from a body recognized by the department.

(D) An agency granted deemed status in accordance with rule 5122-25-03 of the Administrative Code shall maintain its accreditation throughout its term of certification. Should an agency choose to not submit a renewal application to its accrediting body, the agency shall immediately notify the department and will be subject to a full certification survey.

(E) The agency shall inform the department, appropriate community mental health boards, and local client advocacy groups in writing of its accreditation survey date(s) at least thirty days prior to the beginning of a scheduled accreditation survey, or when the agency is given less than thirty days notice of a scheduled survey, within seven days of receiving notice from the accrediting body. An agency undergoing an unannounced or unscheduled accreditation survey shall inform the department within seven days after the conclusion of the unannounced or unscheduled accreditation survey.

Effective: 07/01/2013
R.C. 119.032 review dates: 04/16/2013 and 07/01/2018
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(E)
Rule Amplifies: 5119.61(A) , 5119.611(E)
Prior Effective Dates: 10/1/2003, 3/25/2004. 11/15/2004, 7/1/2005, 1/9/2006, 8/23/2007, 7/1/2009

5122-25-03 Deemed status and reciprocity.

(A) The department shall accept, as evidence of compliance with Chapters 5122-26 to 5122-29 of the Administrative Code, the agency's appropriate behavioral health accreditation by any of the following accrediting bodies: "The Joint Commission"; "The Commission on Accreditation of Rehabilitation Facilities"; and/or "The Council on Accreditation."

(1) The following certification standards are exempted from the above statement:

(a) Rule 5122-26-13 of the Administrative Code (incident notification);

(b) Rule 5122-26-19 of the Administrative Code (uniform cost reporting);

(c) Rule 5122-26-19.1 of the Administrative Code (actual uniform cost report (AUCR) agreed-upon procedures and report submission requirement) ; and

(d) Rule 5122-29-33 of the Administrative Code (health home service for persons with serious and persistent mental illness). This paragraph shall no longer be exempted from deemed status effective January 1, 2017.

(B) The department shall accept an agency's accreditation/certification/recognition as required by paragraph (F) of rule 5122-29-33 of the Administrative Code in lieu of promulgating standards for the provision of integrated physical health and behavioral health care as part of the health home service for persons with serious and persistent mental illness rule.

(C) An agency applying for deemed status by the department must submit the following:

(1) A copy of the certificate or license awarded by the accrediting body;

(2) A copy of the accreditation award notification letter; and

(3) A copy of each of the accrediting body's survey reports and any modifications made to the survey report.

(D) The department may also accept as documentation of the agency's compliance with certification standards, in whole or in part, official report(s) that the agency complies with comparable licensure and/or certification requirements of another state department.

(E) An agency must notify the department within ten days of any change to its accreditation, licensure and/or certification status, by providing a copy of the accreditation status change notification.

(1) Should an agency's accreditation, licensure and/or certification status be granted as or modified to probation, stipulations, conditional, provisional, deferral, preliminary denial or other similar status, the department may ask for additional documentation until such time as full accreditation status is restored. Full accreditation status means the accrediting body has issued an accreditation decision of "accredited" or "accreditation" without additional conditions or modifiers other than three-year or one-year accreditation.

(2) Should an agency's accreditation, licensure and/or certification status be denied, suspended or revoked by the accrediting and/or licensing/certifying body, the department shall withdraw deemed status and the agency shall be subject to a full certification survey and/or proposal to revoke certification in accordance with Chapter 119. of the Revised Code.

(F) The department may conduct surveys and/or review documentation of a sample of agencies having achieved appropriate behavioral health accreditation in order to evaluate whether the accreditation processes used by the organizations are consistent with service delivery models the director considers appropriate for mental health services. The department will communicate to an accrediting organization any identified concerns, trends, needs, and recommendations. The department shall have access to all records necessary to evaluate the accrediting body processes, but may not conduct a survey or request documentation under this paragraph for the purpose of determining compliance with certifications standards.

Effective: 10/01/2012
R.C. 119.032 review dates: 07/17/2012 and 09/30/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611 , 5119.612
Rule Amplifies: 5119.61(A) , 5119.611 , 5119.612
Prior Effective Dates: 1/1/2004, 7/22/2004, 7/1/2005, 1/9/2006, 11/24/2011

5122-25-04 Certification procedure.

(A) Any agency subject to or seeking certification shall apply to the department by filing an application.

(1) An agency that has received accreditation and is applying for deemed status from the department according to rule 5122-25-03 of the Administrative Code shall file an application that includes:

(a) Identifying information including:

(i) Legal name as filed with the Ohio secretary of state, including any fictitious name ("doing business as") if applicable;

(ii) Address(es) and telephone number(s) at which the applicant operates and address for legal notice and correspondence;

(iii) Name and e-mail address of executive director, chief executive officer or president; and

(iv) Name and e-mail address of designated agency contact person who shall be the primary contact on behalf of the agency;

(v) A list of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification; and

(vi) A description of the agency's purpose, mission and goals if an agency is applying for its first certification.

(b) Corporate information including the following upon request of the department. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website:

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

(ii) If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state, of registration to do business in Ohio.

(c) For any site which has not been approved or accredited by the agency's accrediting body, copies of approved physical inspections, either initial or renewal, for each building owned or leased, including:

(i) 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 shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;

(ii) Annual approved fire inspection, which shall be free of deficiencies, by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce; and

(iii) Water supply and sewage disposal inspection for facilities in which 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) Documentation of any existing waivers or variances from the department regarding the certification standards, and justification if the agency is seeking their renewal.

(e) Notification if the agency uses seclusion and/or restraint or major aversive behavioral interventions in accordance with rule 5122-26-16 of the Administrative Code.

(f) If an agency is seeking certification for other mental health services as defined in rule 5122-29-27 of the Administrative Code, that are funded in whole or in part by a community mental health board, and for which there are no specific certification standards, the name of the service, a brief description of the service, and a letter of approval from the community mental health board shall be submitted.

(g) The documentation required in rule 5122-25-03 of the Administrative Code, unless it has already been submitted and deemed status approved by the department.

(h) Documentation for consideration by ODMH of reciprocity with another state department's licensing, certification/licensure or approval requirements, in accordance with rule 5122-25-03 of the Administrative Code.

(i) Documentation requested by ODMH for any service not included under the deemed status provision of rule 5122-25-03 of the Administrative Code.

(2) An agency that is not requesting deemed status by the department according to rule 5122-25-03 of the Administrative Code shall file an application that includes, but is not limited to:

(a) Identifying information including:

(i) Legal name as filed with the Ohio secretary of state, including any fictitious name ("doing business as") if applicable:

(ii) Address(es) and telephone number(s) at which the applicant operates and address for legal notice and correspondence;

(iii) Governing structure;

(iv) Agency budget;

(v) Table of organization;

(vi) Name and e-mail address of executive director, chief executive officer, or president;

(vii) Name and e-mail address of designated agency contact person who shall be the primary contact on behalf of the agency

(viii) List of qualified providers according to Chapter 5122-29 of the Administrative Code and the services they provide;

(ix) List of services according to Chapter 5122-29 of the Administrative Code to be provided during the term of certification; and

(x) A list of subcontracts with other agencies or organizations that provide mental health services.

(b) Corporate information including the following upon request of the department. Before requesting this information, the department shall first attempt to obtain the information from the Ohio secretary of state website:

(i) A copy of the applicant's articles of incorporation and all amendments;

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

(iii) If an out-of-state corporation, a copy of the certificate from the Ohio secretary of state, of registration to do business in Ohio.

(c) Copies of approved physical inspections, either initial or renewal, for each building owned or leased, including:

(i) 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 shall be required for any major change in the use of space that would make the facility subject to review under different building code standards;

(ii) Annual approved fire inspection by a certified fire authority, or where there is none available, by the division of the state fire marshal of the department of commerce; and

(iii) Water supply and sewage disposal inspection for facilities in which 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) Documentation of any existing waivers or variances from the department regarding the certification standards, and justification if the agency is seeking their renewal.

(e) Notification if the agency uses seclusion and/or restraint or major aversive behavioral interventions in accordance with rule 5122-26-16 of the Administrative Code; and

(f) Documentation for consideration by ODMH of reciprocity with another state department's licensing, certification/licensure or approval requirements, in accordance with rule 5122-25-03 of the Administrative Code.

(g) If an agency is seeking certification for other mental health services as defined in rule 5122-29-27 of the Administrative Code, that are funded in whole or in part by a community mental health board, and for which there are no specific certification standards, the name of the service, a brief description of the service, and a letter of approval from the community mental health board shall be submitted.

(B) Upon receipt of an application, the department shall review the materials to determine if they are complete. If an application is incomplete, the department shall notify the applicant of corrections or additions needed, and/or may return the materials to the applicant. Incomplete materials, including failure to pay the full certification fee, shall not be considered an application for certification, and return of the materials or failure to issue a certificate shall not constitute a denial of an application for certification.

(C) Following the department's acceptance of materials as a complete application, or while awaiting final payment of the full certification fee in accordance with rule 5122-25-08 of the Administrative Code, the department shall determine whether the applicant's services and activities meet certification standards. The process for such a determination consists of the following:

(1) For an agency applying for deemed status, the department shall review the application materials, and issue the certification without further evaluation of the services, except that the department may conduct an on-site survey or otherwise evaluate the agency for cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the department.

(2) For an agency that has not been granted deemed status by the department according to rule 5122-25-03 of the Administrative Code, the department may schedule and conduct an on-site survey of and/or otherwise evaluate the applicant's services and activities. At least thirty days before a scheduled survey date, the applicant shall:

(a) Notify appropriate community mental health boards and local client advocacy groups in writing of the ODMH survey date; and

(b) Post notices of the ODMH survey date and of the opportunity for the public to participate in a public information interview during the survey. Such notices shall be posted in public areas, on bulletin boards near major entrances, and in treatment or residential areas of the applicant.

(D) The department may conduct an on-site survey or otherwise evaluate an agency applying for or granted deemed status at any time based on cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the director.

The department may conduct an on-site survey or otherwise evaluate an agency not applying for deemed status at the time of initial application or renewal in accordance with paragraph (C)(2) of this rule, at other times with appropriate notice, or at any time based on cause, including complaints made by or on behalf of consumers and confirmed or alleged deficiencies brought to the attention of the director.

The department shall have access to all records necessary to verify compliance with certification standards applicable to the agency and may conduct interviews with staff, others in the community, and clients with client permission. When scheduling surveys, the department shall notify the appropriate mental health boards(s) and invite their participation, pursuant to division (A)(3) of section 340.03 of the Revised Code. Exit interviews with agency staff shall be conducted during routine initial and renewal on-site surveys.

(E) An applicant that fails to comply with any or all of the certification standards applicable to the agency shall receive a written statement from the department citing items that are not in compliance.

(1) This statement shall describe the deficiencies, actions needed for correction, and a time frame for the agency to submit a written plan of correction.

(2) The agency's plan of correction shall describe the actions to be taken and shall specify a time frame for correction of deficiencies.

(F) If an agency adds a service or activity subject to certification during the term of certification, the agency shall submit:

(1) For an agency applying for deemed status, the documentation required in rule 5122-25-03 of the Administrative Code. Upon determination by the department that the agency has obtained appropriate behavioral health accreditation, the department will certify the agency to provide that service or activity.

(2) For an agency not requesting deemed status, a description of the service or activity and the list of qualified providers. Upon determination by the department that the service or activity is in compliance with certification standards, including conducting an on-site survey, if indicated, the department will certify the agency to provide that service or activity.

(G) If an agency adds a new location during the term of certification, the agency shall submit either the documentation required in paragraph (A)(1)(c) or paragraph (A)(2)(c) of this rule, or evidence that the site has been approved by its accrediting body. Upon determination by the department that the site is in compliance with certification standards, the department will certify the agency to provide any or all of its certified services at that location.

(H) Each agency shall submit an application for certification renewal no fewer than sixty days prior to the expiration of the current certificate.

Effective: 10/01/2012
R.C. 119.032 review dates: 07/17/2012 and 09/30/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611 , 5119.612
Rule Amplifies: 5119.61(A) , 5119.611 , 5119.612
Prior Effective Dates: 1/1/2004, 7/1/2009, 11/24/2011

5122-25-05 Provisions of certification.

(A) The department may issue one of three types of certificates to an agency, based upon its findings per paragraphs (C) to (F) of rule 5122-25-04 of the Administrative Code:

(1) A probationary certificate, which shall replace a full certificate during the term of probation, and which shall expire within one hundred twenty days of the date of issuance, to be used when:

(a) Serious deficiencies are found during the department's determination of an agency's compliance with the certification standards; or

(b) The agency's documented corrective action(s) is not approved by the department.

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

(3) A full certificate specifying the term of certification, which shall be three calendar years from the date of issuance by the department. This certificate shall remain in effect until it is renewed, terminated or revoked. It shall automatically terminate sixty days after the department notifies the agency of its failure to file an application for certification.

(a) The department shall issue a full certificate within thirty days of:

(i) Receipt of complete application materials; or

(ii) Receipt of an acceptable plan of correction, as determined by ODMH, for an initial or renewal certification; or.

(B) A probationary, interim and full certificate is renewable, except that an interim certificate may be renewed only twice.

(C) The certificate shall be site specific to each service and is not transferable to any other agency, agency site, building, corporation, or other entity.

(D) The agency shall notify the department immediately of any services, sites and/or activities added or closed/terminated since the most recent certification.

(E) An agency's certification extends to all services for which it is certified, and at all locations for which it is certified to provide services.

Effective: 11/24/2011
R.C. 119.032 review dates: 07/28/2011 and 11/24/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61 , 5119.611(A)
Rule Amplifies: 5119.61 , 5119.611(A)
Prior Effective Dates: 10/1/03, 7/1/09

5122-25-06 Waivers and variances.

(A) The department may grant a waiver or variance from any certification standard, or portion thereof, for a period of time determined by the department, but that shall not exceed the expiration date of the current certificate. However, requests for waivers and variances that would adversely affect the quality of services or the health and safety of clients will not be granted.

(B) An agency shall submit a written request to the department for a waiver or variance. The written request shall state clearly the rationale and need for the requested waiver or variance.

(1) Within thirty days of receipt of the written request, the department shall:

(a) Provide a specific response to the request; or

(b) Provide an estimate to the agency of the timeframe in which the department will be able to provide a specific response to the request.

R.C. 119.032 review dates: 12/30/2011 and 12/30/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 10-1-2003, 1-9-06

5122-25-07 Denial, revocation, and termination of certification.

(A) The director may deny or revoke certification for one or more of the following reasons:

(1) The agency fails to comply with any certification standard for which it has not been deemed and/or granted reciprocity, per rule 5122-25-03 of the Administrative Code;

(2) Upon the second renewal of an agency's probationary certificate issued in accordance with paragraph (A)(1) of rule 5122-25-05 of the Administrative Code; or

(3) The agency:

(a) Loses accreditation as specified in paragraphs (A) and (B) of rule 5122-25-02 of the Administrative Code; or

(b) Fails to remain in compliance with comparable licensure and/or certification requirements of another state department for which it has received reciprocity, per paragraph (C) of rule 5122-25-03 of the Administrative Code; or

(c) If the agency or principal in the agency has been convicted of medicaid fraud.

(B) The denial of an application for certification or the revocation of certification is subject to appeal under Chapter 119. of the Revised Code.

(C) A certificate shall be considered terminated and invalid if the agency fails to reapply, voluntarily relinquishes the certificate, or goes out of business.

(D) Certificates shall be returned to the department upon denial, termination, revocation, or upon voluntarily discontinuing operation of the agency.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: RC 5119.61(A) , 5119.611(C) , 5119.01(H)
Rule Amplifies: RC 5119.61(A) , 5119.611(C) , 5119.01(H)
Prior Effective Dates: 10/1/03

5122-25-08 Fees.

(A) Each agency shall pay a fee covering a three-year term of certification of the agency and its services.

(1) Fees shall be calculated based on the total amount of funds the agency receives for all mental health services covered in whole or in part by a contract with the community mental health board. The department shall assess fees for interim, probationary or full certification according to the schedule listed below:

Board contract for mental health services Three year certification fee

$0 through $40,000 $180

$40,001 through $100,000 $360

$100,001 through $200,000 $480

$200,001 through $400,000 $600

$400,001 through $800,000 $900

$800,001 through $1,600,000 $1800

$1,600,001 through $3,000,000 $3600

over $3,000,000 $4200

(2) An agency seeking certification by the department that does not have a contract with the mental health board shall be assessed a fee of three hundred seventy-five dollars.

(3) An agency not currently certified by the department and seeking initial certification shall be assessed a fee of five thousand dollars.

A minimum of twenty-five hundred dollars of the initial certification fee shall be paid at the time of application. The remainder shall be paid in full within six months of submitting an application for initial certification, and prior to the department conducting an on-site survey or approving certification.

(B) The fee for an agency that has applied for or are is accredited by one of the accrediting bodies listed in paragraph (B) of rule 5122-25-02 of the Administrative Code shall be waived, with the exception of an agency not currently certified by the department and seeking initial certification, or an agency whose deemed status has been revoked in accordance with paragraph (D) of rule 5122-25-03 of the Administrative Code.

(1) For an agency that has applied for accreditation, proof of application and fee paid to the accrediting body shall be submitted.

(2) For an accredited agency, documentation of accreditation shall be submitted as required in rule 5122-25-03 of the Administrative Code.

(3) An agency whose deemed status has been revoked in accordance with paragraph (D) of rule 5122-25-03 of the Administrative Code shall be assessed a pro-rated certification fee:

(a) The initial assessed fee shall be equal to one-third of the certification fee that is established in the fee schedule in paragraph (A)(1) of this rule.

(b) The department shall assess a fee equal to one-third of the certification fee that is established in the fee schedule in paragraph (A)(1) of this rule for each subsequent year that the agency's deemed status remains revoked.

(C) The certification fee must be paid by the agency into the sale of goods and services fund created pursuant to section 5119.16 of the Revised Code.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: RC 5119.01(H) , 5119.61(A) , 5119.611(C)
Rule Amplifies: RC 5119.01(H) , 5119.61(A) , 5119.611(C)
Prior Effective Dates: 10/1/03