Chapter 5122-26 Policies and Procedures for the Operation of Mental Health Services Agencies

5122-26-01 Purpose.

The purpose of this chapter is to state the requirements for policies and procedures for operation of agencies that provide mental health services and activities.

R.C. 119.032 review dates: 11/29/2010 and 11/29/2015
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91

5122-26-02 Applicability.

The provisions of the rules contained in this chapter are applicable to each agency subject to certification by the department.

R.C. 119.032 review dates: 11/29/2010 and 11/29/2015
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91, 10/1/03

5122-26-03 Governing body and governance.

(A) Each agency shall have a leadership structure. The leadership structure shall identify who is responsible for:

(1) Governance;

(2) Agency administration, i.e. planning, management and operational activities; and

(3) Provision of clinical services.

(B) Each corporation for non-profit shall have a governing body. For the purposes of this rule, governing body shall have the same meaning as governing board. The governing body shall guide, plan and support the achievement of the agency's mission, vision and goals. The governing body shall develop written by-laws, a code of regulation, or policies for the following:

(1) Selection of members of the governing body . The composition of the governing body shall reflect the demographics of the community it serves.

(2) The number of members of the governing body needed for a quorum;

(3) Terms of office for the members of the governing body; and

(4) Provisions guarding against the development of, and prohibiting the existence of, a conflict of interest between a governing body member and the agency.

(C) The governing body shall:

(1) Provide for orientation of its new members, including providing information about governing structure, duties, responsibilities and operations of the organization;

(2) Provide financial oversight and approve the annual budget and plan for services;

(3) Conduct meetings of the governing body at least quarterly, which shall include:

(a) Review an annual summary of quality assurance and risk management activities and document governing body actions taken as a result of this review; and

(b) Review an annual summary of client rights activities and document governing body actions taken as a result of this review.

(4) Maintain minutes of meetings of the governing body including, but not limited to:

(a) Date, time and place of the meeting;

(b) Names of members who attended; and

(c) Topics discussed and actions taken.

(5) Establish procedures for selecting the chief executive officer or executive director;

(6) Establish duties and responsibilities of the executive director;

(7) Select the executive director;

(8) Conduct an annual review and evaluation of the executive director;

(9) Identify responsibility for leadership in the absence of the executive director;

(10) Establish, review and update as necessary the agency's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the agency's national accrediting body, if applicable, or a minimum of every five years;

(11) Ensure adequate malpractice and liability insurance protection for its corporate membership, governing body, advisory board if applicable, agency and agency staff, and review such protection annually;

(12) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of mental health services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other agency bodies, to:

(a) Persons who are receiving or have received mental health services, and their family members; and

(b) Persons who collectively represent a wide range of community interests and demographic characteristics of the service district in categories such as race, ethnicity, primary spoken language, gender and socio-economic status;

(13) Ensure that the hours of operation for services and/or activities accommodate the needs of persons served, their families and significant others; and

(14) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.

(D) A government agency shall identify its governance structure for the purpose of meeting the requirements of this rule. Each agency which is not a corporation for non-profit and therefore not subject to the provisions of paragraphs (B) and (C) of this rule shall have a written description of its governance structure, and identify whether the owner shall assume sole responsibility for the activities required in this rule, or whether the agency is governed by a governing body, board of directors, or other governance body. Agency governance shall:

(1) Provide financial oversight and develop an annual budget and plan for services;

(2) At least annually:

(a) Review an summary of quality assurance and risk management activities and document governing body actions taken as a result of this review; and

(b) Review client rights activities and document governing body actions taken as a result of this review;

(3) Establish duties and responsibilities of the executive director;

(4) Select the executive director;

(5) Conduct an annual review and evaluation of the executive director;

(6) Identify responsibility for leadership in the absence of the executive director;

(7) Establish, review and update as necessary the agency's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the agency's national accrediting body, if applicable, or a minimum of every five years;

(8) Ensure adequate malpractice and liability insurance protection for its corporate membership, advisory board if applicable, agency and agency staff, and review such protection annually;

(9) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of mental health services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other agency bodies, to

(a) Persons who are receiving or have received mental health services, and their family members; and

(b) Persons who collectively represent a wide range of community interests and demographic characteristics of the surrounding community, such as race, ethnicity, primary spoken language, gender, and socio-economic status;

(10) Ensure that the hours of operation for services and/or activities accommodate the needs of persons served, their families and significant others; and

(11) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.

(E) Each agency shall maintain a written table of organization or organization chart which documents the lines of responsibility of:

(1) Governing body, if applicable;

(2) Executive director;

(3) Administrative leadership; and

(4) Clinical oversight.

Replaces: 5122-26-03, 5122-26-05

Effective: 07/01/2011
R.C. 119.032 review dates: 01/04/2011 and 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 5/10/79, 1/1/91, 4/18/91

5122-26-04 Policy and procedure manual.

(A) Each agency shall develop a written manual of policies and procedures regarding all services and activities of the agency.

(B) The policy and procedure manual shall be available for review by staff, persons served and their family and significant others.

R.C. 119.032 review dates: 11/29/2010 and 11/29/2015
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91

5122-26-05 [Rescinded]Table of organization.

Effective: 07/01/2011
R.C. 119.032 review dates: 01/04/2011
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91

5122-26-06 Human resources management.

(A) The purpose of this rule is to ensure that each agency has a human resources management program, and develops written personnel policies and procedures which include the provisions of this rule.

(B) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definition shall apply to this rule:

"Personnel" means any paid or unpaid person, volunteer, contract worker, student intern or other person who is a part of an agency's workforce, including but not limited to those who perform management, clinical, operations, clerical, or other functions in support of the agency's mission, vision and goals. Contract worker does not include an individual or company with whom the agency contracts to perform occasional maintenance such as lawn care, snow removal, painting, etc. Staff shall have the same meaning as personnel.

(C) Each agency shall ensure that it has the necessary staff to support the agency's mission, vision and goals, and to provide services to persons served.

(D) Each agency shall ensure that its personnel policies and procedures include the following provisions:

(1) Prohibit discrimination in employment, training, job duties, compensation, evaluation, promotion, and any other term or condition of employment based on 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 prohibited by local, state or federal laws;

(2) Describe a formal process to express and process employee grievances;

(3) Establish recruitment and hiring practices;

(4) Establish skills, qualifications and competencies required for each position, based on mission of organization, services provided and characteristics and needs of population(s) served. The agency shall maintain a written job description for each position.

All personnel for whom licensure is required by law shall maintain current licensure by the appropriate body in the state of Ohio, and shall practice only within the scope of their license.

(5) Verify staff credentials, including licensure, certification or registration, education, and experience;

(6) Develop and maintain a staff orientation program, which shall include training on:

(a) Employee and client safety;

(b) Agency's mission, vision and goals;

(c) Characteristics of the population served;

(d) Sensitivity to cultural diversity;

(e) Agency policies and procedures, including personnel policies, and those specific to individual job duties;

(f) Confidentiality;

(g) Reporting abuse and neglect; and

(h) Client rights.

(7) Ensure direct service and supervisory staff participate in education and training. Training may be provided by direct supervision, attendance at conferences and workshops internal and external to the agency, on-line training, educational coursework, etc. Training shall:

(a) Maintain or increase competency;

(b) Include topics specific to population served; and

(c) Ensure culturally competent provision of service.

(8) Ensure each staff providing direct services receives documented supervision appropriate to his/her skill level and job duties, and in accordance with the requirements of his/her license, certificate or registration, if applicable.

Supervision may be provided in individual and group sessions, including supervisor participation in treatment plan meetings.

(9) Evaluate staff performance at a frequency required by its accrediting body, if applicable, or for an agency without behavioral health accreditation, annually.

The agency shall establish a system and frequency for evaluating volunteers, based on job duties, scope of responsibility, and frequency of service.

(E) A copy of the written personnel policies and procedures shall be available to each employee. Employees shall be notified of changes in personnel policies and procedures.

(F) Personnel files.

(1) The agency shall maintain a person file on each staff person, who shall have access to his/her own personnel file.

(2) Personnel files shall be stored in such a manner as to maintain the privacy of each staff person. Agency policies shall describe who shall have access to the various information contained within the file.

(3) Each personnel file shall include the following content:

(a) Identifying information and emergency contacts;

(b) Application for employment or resume;

(c) Verification of credentials, if applicable;

(d) Documentation of education, experience and training;

(e) Verification of references, if required for position;

(f) Job description;

(g) Compensation documentation, if applicable;

(h) Performance evaluations;

(i) Documentation of orientation;

(j) Documentation of on-going training, as required by position, state law and agency policy;

(k) Commendations or awards, if applicable; and

(l) Disciplinary actions, if applicable.

(G) The agency shall have policies and written procedures for handling cases of staff neglect and abuse of persons served, and documentation that each employee has received a copy of these policies and procedures.

(H) The agency shall have a policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee's position.

Replaces: 5122-26-06, 5122-26-07

Effective: 07/01/2011
R.C. 119.032 review dates: 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 5/10/79, 10/14/82, 1/1/91, 10/1/93

5122-26-07 [Rescinded]Personnel qualifications.

Effective: 07/01/2011
R.C. 119.032 review dates: 01/04/2011
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 5/10/79, 10/14/82, 1/1/91, 10/1/93

5122-26-08 Drug theft in agencies.

(A) The agency shall have a policy on employee drug theft and shall inform all employees concerning this policy.

(B) An employee or volunteer with knowledge of drug theft by an employee or any other person shall report such information to the executive director of the agency. If the executive director of the agency is suspected of drug theft, the employee or volunteer shall notify the department.

(C) Suspected drug theft shall be reported to the Ohio board of pharmacy. For controlled substances, suspected drug theft shall also be reported to the federal drug enforcement administration. For agencies participating in drug services with the Ohio department of mental health central pharmacy and/or pharmacy service center, these offices shall also be notified of suspected drug theft.

(D) The agency shall take all reasonable steps to protect the confidentiality of the information and the identity of the person furnishing the information.

(E) Failure to report information of drug theft shall be considered in determining the eligibility of the employee to continue to work in a secure area where drugs are stored.

(F) If an employee violates the agency's drug theft policies, the agency shall assess the seriousness of the employee's violation, whether the violation has a direct and substantial relationship to that employee's position, the past record of employment, and other relevant factors in determining whether to suspend, transfer, terminate, or take other action against the employee.

R.C. 119.032 review dates: 11/29/2010 and 11/29/2015
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91

5122-26-09 Agency service plan.

(A) The purpose of this rule is to ensure that the agency plans and develops services to meet the needs of the population served.

(B) The agency shall define in writing its mission, vision and goals.

(C) The agency shall develop a written description of each service provided, which shall include:

(1) The description of the service;

(2) Schedule of the days the service is available, and hours of operation;

(3) Needs and characteristics of the population served;

(4) Goals and scope of service; and

(5) Description of services which are offered through referral or affiliations with other providers, and the responsibilities of each agency or provider.

(D) The agency shall revise and update the service description when any of the information required in paragraph (C) of this rule changes.

(E) The agency service plan shall be available for review by persons served, their family, significant others and the public.

Replaces: 5122-26-09

Effective: 07/01/2011
R.C. 119.032 review dates: 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 5/10/79, 1/1/91, 10/1/93

5122-26-11 Affiliation agreements.

(A) Each agency shall ensure that any residential facility subject to licensure by the department in which persons served by the agency reside is affiliated with a mental health agency or the local community mental health board.

(B) Each agency designated by the community mental health board to screen, refer, and/or admit persons to a state-operated psychiatric hospital shall have a signed continuity of care agreement describing the roles and responsibilities of the community mental health board, hospital, agency and department.

Effective: 02/17/2012
R.C. 119.032 review dates: 11/30/2011 and 02/17/2017
Promulgated Under: 119.03
Statutory Authority: 5119.22 , 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.22 , 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/1991

5122-26-12 Environment of care and safety.

(A) The purpose of this rule is to ensure that each agency maintains a clean, safe environment which supports the provision of quality mental health services and minimizes the risk of harm to clients, staff, visitors, and others.

(B) Each agency shall designate the personnel who are responsible for implementing and oversight of the provisions of this rule.

(C) Each agency shall develop written policies and procedures to address emergency situations, including:

(1) Fire, including the requirement that fire exit doors shall remain unlocked and clearly marked unless a variance has been granted by a certified authority of the division of state fire marshal of the department of commerce;

(2) Bomb threat;

(3) Natural disaster;

(4) Utility outage or malfunction, e.g. a gas leak; and

(5) Other potential threats which may be applicable based upon location, e.g. nuclear power plant leak.

(D) Each agency shall conduct emergency drills and evaluate the effectiveness of the drill to ascertain the need for performance improvement:

(1) Fire drills shall be conducted at least once every twelve months.

(2) The agency shall evaluate and determine the need to conduct other drills, and the frequency. This shall be included in its policies and procedures.

(E) Each agency shall have written policies and procedure, which incorporate any applicable local, state or federal laws for:

(1) Safe handling, storage and disposal of hazardous materials.

(2) Safe handling and disposal of infectious waste materials, including applicable specifications of the occupational health and safety administration and the Ohio department of health.

(3) Infection control, including applicable specifications of the occupational health and safety administration and the Ohio department of health.

(4) Hazardous areas of the agency.

(F) The agency's policies and procedures shall include the requirement that each staff receives training during orientation on the safety procedures identified in paragraphs (C), (D) and (E) of this rule. The agency shall identify in its policies and procedures the need for on-going training on each emergency or safety procedure, and the frequency of such training.

(G) Each agency shall meet local, state and federal laws regarding accessibility.

Whenever it identifies a structural or other barrier which limits access to or within the building, the agency shall develop a plan to remove the barrier.

(H) The agency shall conduct regular safety inspections at least every six months, or more often as identified by the agency's policies and procedure or its accrediting body. Inspections shall include attention to:

(1) Physical structure;

(2) Electrical systems;

(3) Heating and cooling systems;

(4) Warning devices, e.g. exit lights, alarm systems, etc.;

(5) Fire suppression equipment;

(6) Lighting;

(7) Food preparation areas, if applicable; and

(8) Any other areas or systems as needed and identified in agency policies and procedures.

(I) Each agency shall ensure it obtains inspections and permits in accordance with local, state or federal laws.

(1) At a minimum, the agency shall obtain the following inspections every twelve months:

(a) 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, to include testing of fire alarm systems.

(b) 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.

(2) The agency shall ensure that it obtains inspections and/or maintains current permits as required by law, if applicable:

(a) Elevator inspection.

(b) Boiler inspection.

(c) Food service.

(d) Any other as required by local, state or federal law.

Replaces: 5122-26-12, 5122-26-14

Effective: 07/01/2011
R.C. 119.032 review dates: 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 5/10/79, 1/1/91, 10/1/93

5122-26-13 Incident notification and risk management.

(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed incidents. It also requires 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) "County community mental health board of residence" means the mental health board that is responsible for referring and/or paying for the client's treatment.

(2) "Incident" means an event that poses a danger to the health and safety of clients and/or staff and visitors of the agency, and is not consistent with routine care of persons served or routine operation of the agency.

(3) "Reportable Incident" means an incident that must be submitted to the department, including an incident that must then be forwarded by the department to the Ohio legal rights service pursuant to section 5123.604 of the Revised Code. As referenced in division (C) of section 5119.611 of the Revised Code, "Major Unusual Incident" has the same meaning as "Reportable Incident."

(4) "Six month reportable incident" means an incident type of which limited information must be reported to the department. A six month reportable incident is not the same as a reportable incident.

(5) "Six month incident data report" means a data report which must be submitted to the department.

(C) The agency shall 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 clients, staff, and visitors. The agency shall identify in policy other incidents to be reviewed and analyzed.

(1) An incident report shall be submitted in written form to the agency's executive director or designee within twenty-four hours of discovery of a reportable incident.

(2) As part of the agency's performance improvement process, a periodic review and analysis of reportable incidents, and other incidents as defined in agency policy, shall be performed. This shall include a review of all incident reports received from licensed type 2 and type 3 residential facilities regarding persons served by the agency, and any action taken by the agency, as appropriate.

(3) The agency shall maintain an ongoing log of its reportable incidents for departmental review.

(D) Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or neglect of:

(1) Any child or adolescent, shall immediately notify the county children's services board, the designated child protective agency, or law enforcement authorities, in accordance with section 2151.421 of the Revised Code; or

(2) An elderly person, shall immediately notify the appropriate law enforcement and county department of jobs and family services authorities in accordance with section 5101.61 of the Revised Code.

(E) Each agency shall submit reportable incidents and six month reportable incidents as defined by and according to the schedule included in appendix A to this rule.

(F) Each reportable incident shall be documented on form "DMH-LIC-015" as required by the department. Form "DMH-LIC-015" shall include identifying information about the agency, date, time and type of incident, and client information that has been de-identified pursuant to the HIPAA privacy regulations, [ 45 C.F.R. 164.514(b)(2) ].

(1) The agency shall file only one incident form per event occurrence and identify each incident report category, if more than one, and include information regarding all involved clients, staff, and visitors; and

(2) The agency shall forward each reportable incident to the department and to the county community mental health board of residence within twenty-four hours of its discovery, exclusive of weekends and holidays; and

(G) Each agency shall submit a six month incident data report to the department and to the community mental health board utilizing the form that is in appendix B to this rule.

The six month incident data report must be submitted according to the following schedule:

(1) The six month incident data report for the period of January first to June thirtieth of each year shall be submitted no later than July thirty-first of the same year; and

(2) The six month incident data report for the period of July first to December thirty-first of each year shall be submitted no later than January thirty-first of the following year.

(H) The department may initiate follow-up and further investigation of a reportable incident and six month reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation by the agency, regulatory or enforcement authority, and/or the community mental health board.

Replaces: 5122-26-13

Click to view Appendix

Click to view Appendix

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61 , 5119.611
Rule Amplifies: 5119.61 , 5119.611
Prior Effective Dates: 1/1/04

5122-26-14 [Rescinded]Infection control.

Effective: 07/01/2011
R.C. 119.032 review dates: 01/04/2011
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91, 10/1/93

5122-26-15 Medication handling.

(A) The agency shall have written policies and procedures regarding the purchasing, receipt, storage, distribution, return, and destruction of medication that include accountability for and security of medications located within any of its facilities. These policies and procedures shall include, but not be limited to the requirements that agencies handling medications shall:

(1) Hold a valid and current terminal distributor of dangerous drugs license from the Ohio board of pharmacy if maintaining a stock supply of medications and/or if participating with the department's central pharmacy to receive dispensed prescriptions.

(2) Locate all medications and prescription blanks in a locked, secure area;

(3) Designate a person(s) having access to or authorized to handle medication and shall maintain a current list of these persons, their credentials and their medication handling responsibilities.

(4) Provide a method to record and follow the medications from the time of receipt to the time of distribution, return to central pharmacy, or destruction. This record shall be retained by the agency for three years and shall include, but not be limited to the following information:

(a) The date and time the medication was received by the agency, distributed to persons served, returned to central pharmacy or, if appropriate, destroyed;

(b) The name(s), credentials and signature of all persons handling the medications; and

(c) The provision that unused medication prescribed for a person shall be appropriately destroyed or returned to central pharmacy, and that, under no circumstances shall the unused medication be issued to another individual. (Return of unused medication prescribed to a person is only allowed when the return is to central pharmacy in accordance with rule 4729-9-04 of the Administrative Code).

(5) Ensure that:

(a) Individuals providing information about the use of medications shall be educated regarding medication issues for groups such as minority-specific populations and children and youth in order to provide appropriate information to these populations, and

(b) All staff handling medications have basic and ongoing instruction and training in safe and effective handling of medications.

(6) Ensure that medications are handled only by authorized persons and that others do not have access to the medications; and

(7) Ensure that controlled substances may be destroyed only by an agent of the Ohio board of pharmacy, or the federal drug enforcement agency, or by transfer to persons registered under Chapters 3719. and 4729. of the Revised Code and according to rule 4729-9-06 of the Administrative Code.

(B) Agencies maintaining a limited stock supply of medications shall:

(1) Allow only a physician or pharmacist to dispense medication, although the following individuals may personally furnish samples of some medications if issued a certificate to prescribe :

(a) Certified nurse practitioner and clinical nurse specialist in accordance with division (D) of section 4723.481 of the Revised Code; and

(b) Physician's assistant in accordance with division (A) of section 4730.43 of the Revised Code.

(2) Have visibly posted the phone number of the nearest poison control center.

Replaces: 5122-26-15

Effective: 07/01/2011
R.C. 119.032 review dates: 01/04/2011 and 07/01/2016
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1/1/91, 10/1/93

5122-26-16 Seclusion, restraint and time-out.

(A) The provision of a physically and psychologically safe environment is a basic foundation and requirement for effective mental health treatment. Adopting trauma informed treatment practices, creating calm surroundings and establishing positive, trusting relationships are essential to facilitating a person's treatment and recovery.

The goal of reducing and minimizing the use of seclusion and restraint is one that must be shared and articulated by the organization's leadership. The elevation of oversight by leadership of each use of seclusion or restraint in order to investigate causality, ascertain relevancy of current policies and procedures, and identify any associated workforce development issues, is core to the successful achievement of this goal.

These methods are very intrusive techniques to be used by trained, qualified staff as a last resort in order to control dangerous and potentially harmful behaviors and to preserve safety. Best practices include careful early assessment of a person's history, experiences, preferences, and the effectiveness or ineffectiveness of past exposure to these methods.

Use of seclusion or restraint must be subject to performance improvement processes in order to identify ways in which the use of these methods can be decreased/avoided and more positive, relevant and less potentially dangerous techniques used in their place.

When individuals experience repeated or sustained use of these methods, leadership should evaluate all causative factors and consider alternative treatment interventions and/or possible transfer to/placement in a more structured treatment setting with the capacity to meet individual needs with reduced exposure to these intrusive interventions.

(B) The purpose of this rule is to state the general requirements applicable to the use of seclusion and restraint, and to the adoption of processes to reduce their utilization.

(C) The following definitions shall apply to rules 5122-26-16 to 5122-26-16.2 of the Administrative Code and supersede those contained in rule 5122-24-01 of the Administrative Code:

(1) "Advance directives" means a legal document an adult can use to direct in advance the decisions about his or her mental and/or physical health treatment, if in the future he/she lacks the capacity to make his/her own health care decisions. Two types of advance directives related to mental health treatment are: a "Declaration for Mental Health Treatment" subject to the requirements of Chapter 2135. of the Revised Code, and a "Durable Power of Attorney for Health Care" subject to the requirements of sections 1337.11 to 1337.17 of the Revised Code.

(2) "Behavior management" means the utilization of interventions that are applied in a systematic and contingent manner in the context of individual or group programs to change or manage behavior or facilitate improved self-control. The goal of behavior management is not to curtail or circumvent an individual's rights or human dignity, but rather to support the individual's recovery and increase his/her ability to exercise those rights.

(3) "Comfort rooms", (formerly known as quiet or time-out rooms), are adapted sensory rooms that provide sanctuary from stress and/or can be places for persons to experience feelings within acceptable boundaries.

(4) "Individual crisis plan" means a written plan that allows the person to identify coping techniques and share with staff what is helpful in assisting to regain control of his/her behavior in the early stages of a crisis situation. It may also be referred to as a "behavior support plan."

(5) "Mechanical restraint" means any method of restricting a person's freedom of movement, physical activity, or normal use of his or her body, using an appliance or device manufactured for this purpose.

(6) "Physical restraint", also known as "manual restraint", means any method of physically restricting a person's freedom of movement, physical activity, or normal use of his or her body without the use of mechanical restraint devices.

(7) "PRN (pro re nata)" means as the situation demands.

(8) "Prone Restraint" means all items or measures used to limit or control the movement or normal functioning of any portion, or all, of an individual's body while the individual is in a face-down position for an extended period of time. Prone restraint may include either physical (also known as manual) or mechanical restraint.

(9) "Qualified person" means an employee and/or volunteer who carries out the agency's tasks under the agency's administration and/or supervision, and who is qualified to utilize or participate in the utilization of seclusion or restraint by virtue of the following: education, training, experience, competence, registration, certification, or applicable licensure, law, or regulation.

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

(11) "Sensory rooms" means appealing physical spaces painted with soft colors with the availability of furnishings and objects that promote relaxation and/or stimulation.

(12) "Time-out" means an intervention in which a person is required to remove him/herself from positive reinforcement to a specified place for a specified period of time. Time-out is not seclusion.

(13) "Transitional hold" means a brief physical (also known as manual) restraint of an individual face-down for the purpose of quickly and effectively gaining physical control of that individual, or prior to transport to enable the individual to be transported safely.

(14) "Vital signs" means the rates or values indicating an individual's blood pressure, pulse, temperature, and respiration.

(D) General requirements

(1) Seclusion or restraint shall not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is identified.

(a) They shall not be used as behavior management interventions, to compensate for the lack of sufficient staff, as a substitute for treatment, or as an act of punishment or retaliation.

(b) Absent a co-existing crisis situation that includes the imminent risk of physical harm to the individual or others, the destruction of property by an individual, in and of itself is not adequate grounds for the utilization of these methods.

(2) The following shall not 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 restricts the individual's ability to communicate, including consideration given to the communication needs of individuals who are deaf or hard of hearing;

(c) Any technique that obstructs vision;

(d) Any technique that obstructs the airways or impairs breathing;

(e) Use of mechanical restraint on individuals under age eighteen;

(f) A drug or medication that is used as a restraint to control behavior or restrict the individual's freedom of movement and is not a standard treatment or dosage for the individual's medical or psychiatric condition or that reduces the individual's ability to effectively or appropriately interact with the world around him/her; and

(g) The use of handcuffs or weapons such as pepper spray, mace, nightsticks, or electronic restraint devices such as stun guns and tasers.

The presence of weaponry in an agency poses potential hazards, both physical and psychological, to clients, staff and visitors. Utilization by the agency of non-agency employed armed law enforcement personnel (e.g., local police) to respond to and control psychiatric crisis situations, shall be minimized to the extent possible.

(3) Position in physical or mechanical restraint.

(a) An individual shall be placed in a position that allows airway access and does not compromise respiration.

(i) The use of prone restraint is prohibited.

(ii) A transitional hold shall be limited to the minimum amount of time necessary to safely bring the person under control, at which time staff shall either terminate the transitional hold, and begin the post-restraint process required by this rule, or, if the individual cannot safely be released from the transitional hold, re-position the individual into an alternate restraint position.

(b) The use of transitional hold shall be subject to the following requirements:

(i) Applied only by staff who have current training on the safe use of transitional hold techniques, including how to recognize and respond to signs of distress in the individual.

(ii) The weight of the staff shall be placed to the side, rather than on top of the individual. No transitional hold shall allow staff to straddle or bear weight on the individual's torso while applying the restraint, i.e. no downward pressure may be applied that may compromise the individual's ability to breathe.

(iii) No transitional hold shall allow the individual's hands or arms to be under or behind his/her head or body. The arms must be at the individual's side.

(iv) No soft device, such as a pillow, blanket or other item, shall be used to cushion the client's head, since such a device may restrict the individual's ability to breathe.

(v) All staff involved in the procedure must constantly observe the individual's respiration, coloring, and other signs of distress, listen for the individual's complaints of breathing problems, and immediately respond to assure safety.

(4) The choice of the least restrictive, safe and effective use of seclusion or restraint for an individual is determined by the person's assessed needs, including a consideration of any relevant history of trauma and/or abuse, risk factors as identified in paragraph (G)(3) of this rule, the effective or ineffective methods previously used with the person and, when possible, upon the person's preference.

(a) Upon admission/intake and when clinically warranted, the person and his/her parent, custodian or guardian, as appropriate, shall be informed of the agency's philosophy on the use of seclusion or restraint as well as of the presence of any agency policies and procedures addressing their use by the agency. Such policies and procedures shall be made available to the person and/or to his/her parent, custodian or guardian upon request.

Adult clients shall be offered the opportunity to give consent for the notification of their use to a family member or significant other.

(5) Within twenty-four hours of the initiation of seclusion or restraint, the agency shall notify the following individuals:

(a) For children/adolescents, the client's parent, custodian or guardian;

(b) For adults, the client's guardian, when applicable, or family or significant other when the client has given his/her consent for such notification.

(6) Following the conclusion of each incident of seclusion or restraint, the client and staff shall participate in a debriefing(s).

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

(b) The following shall 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, or

(ii) For an adult client, the client's family or significant other when the client has given consent in accordance with paragraph (D)(4)(a) of this rule, or an adult client's guardian, if applicable.

(7) A thorough review and analysis of each incident of the use of seclusion or restraint shall be undertaken in order to use the knowledge gained from such analysis to inform policy, procedures, and practices to avoid repeated use in the future and to improve treatment outcomes. Secondarily, such analysis should help to mitigate, to the extent possible, the adverse and potentially traumatizing effects of a seclusion or restraint event for involved staff, clients, and for all witnesses to the event.

(8) The inclusion of clients (including children), families, and external advocates in various roles and at all agency levels to assist in reducing the use of seclusion or restraint shall be considered.

(E) Policies and procedures

(1) The agency shall establish policies and procedures that reflect how the utilization of seclusion or restraint is reviewed, evaluated, and approved for use. The agency shall document if and how the inclusion of clients and families in the development of such policies occurred.

(2) Policies and procedures governing the use of seclusion or restraint shall include attention to preservation of the person's health, safety, rights, dignity, and well-being during use. Additionally:

(a) Respect for the person shall be maintained when such methods are utilized;

(b) Use of the environment, including the possible addition of comfort and sensory rooms, shall be designed to assist in the person's development of emotional self-management skills; and

(c) The number of appropriately trained staff available to apply or initiate seclusion or restraint shall be adequate to ensure safety. The use of non-agency employed law enforcement personnel, e.g., local police, to substitute for the lack of sufficient numbers of appropriately trained staff in such situations is prohibited.

(F) Staff training.

(1) The agency shall ensure that all direct care staff and any other staff involved in the use of seclusion or restraint receive initial and annual training designed to minimize their use.

(a) Staff shall be trained and demonstrate competency in the correct and appropriate use of non-physical techniques for intervention, such as mediation and conflict resolution, and de-escalation of disruptive or aggressive acts, persons and/or situations; and

(b) Staff shall be trained in understanding how their behavior can affect the behavior of clients.

(2) The agency shall identify, educate and approve staff members to use seclusion or restraint. Competency of staff in the use and documentation of seclusion or restraint methods shall be routinely evaluated. The results of evaluations shall be maintained by the agency for a minimum of three years for each staff member identified.

(a) Staff shall have appropriate training prior to utilizing seclusion or restraint, and, at a minimum, annually thereafter. The exception to annual training is a first aid and/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.

(i) Staff shall be trained in and demonstrate competency in the identification and assessment of those possible risk factors identified in paragraph (G) of this rule and to understand how these may impact the way a client responds to seclusion or restraint, and place an individual at greater risk to experience physical or psychological trauma during an episode of seclusion or restraint;

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

(iii) Staff shall be trained in and demonstrate competency in the safe application of all seclusion or restraint interventions he or she is authorized to perform, including specific training in utilization of transitional hold, if applicable;

(iv) Staff shall be trained and certified in first aid and CPR;

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

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

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

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

(b) Leadership shall maintain a current list of staff authorized to utilize seclusion or restraint interventions which is readily available to all agency staff who may be asked to participate in these interventions; and

(c) The curriculum used to train staff shall be documented and shall be made available to ODMH upon request.

(G) Documentation.

(1) The presence of advance directives or client preferences addressing the use of seclusion or restraint shall be determined and considered, and documented in the ICR. If the agency will be unable to utilize seclusion or restraint in a manner in accordance with the person's directives or preferences, the agency shall notify the individual, including the rationale, and document such in the ICR.

(2) In conjunction with the person's active participation, an individual crisis plan shall be developed at the time of admission and incorporated in the person's ISP for each child/adolescent resident of an ODMH licensed residential facility, for each client known to have experienced seclusion or restraint, and when otherwise clinically indicated.

The plan shall be based on the initial mental health assessment, and shall include and be implemented, as feasible, in the following order:

(a) Identification of the methods or tools to be used by the client to de-escalate and manage his or her own aggressive behavior;

(b) Identification of techniques and strategies for staff in assisting the person to maintain control of his or her own behavior; and

(c) Identification, in order of least restrictive to most restrictive, of the methods/tools to be used by staff to de-escalate and manage the client's aggressive behavior.

(3) Initial and ongoing identification of individual-specific contraindications to the use of seclusion or restraint shall be documented. Consideration of the use of such methods shall take into account the following which may place the person at greater risk of physical or psychological injury as a result of the use of seclusion or restraint:

(a) Gender;

(b) Age;

(c) Developmental issues;

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

(e) History of physical and/or 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; and

(g) Physical disabilities.

(4) Debriefings following the conclusion of each incident of seclusion or restraint shall be documented, and shall include, at a minimum:

(a) The incident and antecedent behaviors which lead to the use of seclusion or restraint;

(b) What actions might have prevented the use of seclusion or restraint; and what techniques and tools might help the individual manage his or her own behavior in the future;

(c) The person's reaction to the method, including whether there is any need for counseling or other services related to the incident; and

(d) Whether any modifications to the person's ISP or individual crisis plan are needed.

(5) Each incident of seclusion or restraint shall be clinically and/or administratively reviewed. Such review shall be documented.

(H) Logs and notifications.

(1) A log shall be maintained for department review of each incident of mechanical restraint, seclusion, and physical restraint, and for time-outs exceeding sixty minutes per episode. The log shall include, at minimum, the following information:

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

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

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

(ii) For physical restraint, as follows:

(a) Transitional hold, and/or

(b) Physical restraint; and

(c) The duration of the method or methods.

If both transitional hold and physical restraint are utilized during a single episode of restraint, the duration in each shall be included on the log. For example, a physical restraint that begins with a one minute transitional hold, followed by a three minute physical restraint shall be logged as one restraint, indicating the length of time in each restraint type.

(2) Pursuant to rules 5122-26-13 and 5122-30-16 of the Administrative Code, the agency shall notify ODMH of each:

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

(b) Death that occurs while a person is restrained or in seclusion;

(c) Death occurring within twenty four hours after the person has been removed from restraints or seclusion, and

(d) 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.

(I) Performance improvement.

(1) The agency shall collect data on all instances of the use of seclusion or restraint and integrate the data into performance improvement activities.

(2) Data shall be aggregated and reviewed at least semi-annually by agencies and at least quarterly by ODMH licensed residential facilities. The minimum data to be collected for each episode shall include:

(a) Staff involved, including staff member(s) who initiated the seclusion or restraint;

(b) Duration of the method;

(c) Date, time and shift each method was initiated;

(d) Day of week;

(e) Type of method, including type of physical hold or mechanical restraints utilized;

(f) Client age, race, gender and ethnicity;

(g) Client and/or staff injuries;

(h) Number of episodes per client; and

(i) Use of psychotropic medications during an intervention of seclusion or restraint.

(3) Data shall be reviewed:

(a) For analysis of trends and patterns of use; and

(b) To identify opportunities to reduce the use of seclusion or restraint.

(4) The agency shall routinely compare how its practices compare with current information and research on effective practice.

(5) The results of data reviews and performance improvement activities shall be shared with staff at least semi-annually with the goal of reducing the use of seclusion or restraint.

(J) Plan to reduce seclusion or restraint.

(1) An agency which utilizes seclusion or restraint shall develop a plan designed to reduce its use. The plan shall include attention to the following strategies:

(a) Identification of the role of leadership;

(b) Use of data to inform practice;

(c) Workforce development;

(d) Identification and implementation of prevention strategies;

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

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

(2) A written status report shall be prepared annually, and reviewed by leadership.

(K) 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 this rule.

Replaces: 5122-26-16, Part of 5122-26- 16.1, Part of 5122-26- 16.2, Part of 5122-26- 16.3

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.22 , 5119.61 , 5119.611
Rule Amplifies: 5119.22 , 5119.61 , 5119.611
Prior Effective Dates: 1/1/91, 4/6/01

5122-26-16.1 Mechanical restraint and seclusion.

(A) The purpose of this rule is to state the specific requirements applicable to mechanical restraint and seclusion.

(B) The requirements for the use of mechanical restraint or seclusion do not apply:

(1) To restraint use that is only associated with medical, dental, diagnostic, or surgical procedures and is based on standard practice for the procedure. Such standard practice may or may not be described in procedure or practice descriptions (e.g., the requirements do not apply to medical immobilization in the form of surgical positioning, iv arm boards, radiotherapy procedures, electroconvulsive therapy, etc.);

(2) When a device is used to meet the assessed needs of an individual who requires adaptive support (e.g., postural support, orthopedic appliances) or protective devices (e.g., helmets, tabletop chairs, bed rails, car seats). Such use is always based on the assessed needs of the individual. Periodic reassessment should assure that the restraint continues to meet an identified individual need;

(3) To forensic and corrections restrictions used for security purposes, i.e., for custody, detention, and public safety reasons, and when not involved in the provision of health care.

(C) Mechanical restraint or seclusion shall not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is possible. It shall be employed for the least amount of time necessary in order that the individual may resume his/her treatment as quickly as possible.

(D) Implementation of mechanical restraint or seclusion.

(1) Authorized staff may implement mechanical restraint or seclusion at the direction and in the presence of an individual with specific clinical privileges/authorization granted by the agency to authorize mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, clinical nurse specialist, or registered nurse.

(2) Upon any implementation of mechanical restraint or seclusion, an individual with specific clinical privileges/authorization granted by the agency shall:

(a) Perform an assessment and document it in the clinical record. This assessment shall include, at minimum:

(i) The reason for the utilization of mechanical restraint or seclusion;

(ii) All prior attempts to use less restrictive interventions;

(iii) Notation that any previously identified contraindication(s) to the use of mechanical restraint or seclusion were considered and the rationale for continued implementation of mechanical restraint or seclusion despite the existence of such contraindications(s); and

(iv) A review of all current medications.

(b) Assess and document vital signs; and

(c) Explain to the individual the reason for mechanical restraint or seclusion, and the required behaviors of the individual which would indicate sufficient behavioral control so that mechanical restraint or seclusion can be discontinued.

(3) For adults in mechanical restraint, an assessment shall include health and related safety concerns including body positioning, comfort and circulation.

(E) Ordering mechanical restraint or seclusion.

(1) Orders shall be written only by an individual with specific clinical privileges/authorization granted by the agency to order mechanical restraint or seclusion, and who is a:

(a) Psychiatrist or other physician; or

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

(2) Orders may be written for a maximum of:

(a) Two hours for mechanical restraint or seclusion of adults eighteen years of age or older;

(b) One hour for seclusion of children and adolescents age nine through seventeen; or

(c) Thirty minutes for seclusion of children under age nine.

(3) Prn orders are prohibited, whether individual or as a part of a protocol.

(4) When indicated, a verbal order from an individual with specific clinical privileges/authorization granted by the agency to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist shall be obtained by a registered nurse upon implementation of mechanical restraint or seclusion, or within one hour. Such order shall be signed within twenty four hours by an individual with specific clinical privileges/authorization granted by the agency to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist.

(5) After the original order for mechanical restraint or seclusion expires, the individual shall receive a face-to-face reassessment, as described in subsection five of this paragraph. The reassessment shall be by performed by an individual with specific clinical privileges/authorization granted by the agency to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist, who shall write a new order if mechanical restraint or seclusion is to be continued. However, agency policy and the original order may permit a registered nurse to perform such reassessment and make a decision to continue the original order for an additional:

(a) Two hours for mechanical restraint or seclusion of adults eighteen years of age or older up to a maximum of twenty-four hours;

(b) One hour for seclusion of children and adolescents age nine through seventeen up to a maximum of twenty-four hours; or

(c) Thirty minutes for seclusion of children under age nine up to a maximum of twelve hours.

(6) Continuation of orders cannot under any circumstances exceed the maximums stated in this paragraph without a face-to-face reassessment and a new written order. The reassessment shall be performed and new order written by an individual with specific clinical privileges/authorization granted by the agency to order mechanical restraint or seclusion, and who is a psychiatrist or other physician, physician's assistant, certified nurse practitioner, or clinical nurse specialist.

Such assessment shall be documented in the clinical record. It shall address the need for continued mechanical restraint or seclusion. It shall include a mental status examination, physical assessment, gross neurological assessment, and an assessment of the individual's verbal statements, level of behavioral control, and responses to stimuli and treatment interventions, unless contra-indicated for clear treatment reasons which shall be documented in the clinical record.

(7) Mechanical restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

(F) Continuous monitoring of persons in mechanical restraint or seclusion.

(1) While in mechanical restraint or seclusion, persons shall be continuously monitored, i.e., constant visual observation by staff in a manner most conducive to the situation and/or person's condition.

(2) Documentation of the condition of the person shall be made in the clinical record at routine intervals not to exceed fifteen minutes or more often if the person's condition so warrants. Such documentation shall address attention to vital signs, circulation, range of motion, nutrition, hydration, hygiene, toileting, the need for continued mechanical restraint or seclusion, and other needs as necessary, and the appropriate actions taken.

(3) Upon conclusion of the mechanical restraint or seclusion, the results of a check of injuries shall be conducted and documented.

The appropriate actions taken for any injuries noted shall also be documented.

(G) Seclusion room requirements.

(1) The type of room in which seclusion is employed shall ensure:

(a) Appropriate temperature control, ventilation and lighting;

(b) Safe wall and ceiling fixtures, with no sharp edges;

(c) The presence of an observation window and, if necessary, wall mirror(s) so that all areas of the room are observable by staff from outside of the room; and

(d) That any furniture present is removable or is securely fixed for safety reasons.

(H) Clinically appropriate reason(s) for the inability to implement any portion of this rule shall be documented in the clinical record, and shall be addressed in any staff de-briefing of the episode and in the agency's performance improvement process.

Replaces: 5122-26- 16.1

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.22 , 5119.61 , 5119.611
Rule Amplifies: 5119.22 , 5119.61 , 5119.611
Prior Effective Dates: 1/1/91, 4/16/01

5122-26-16.2 Physical restraint.

(A) The purpose of this rule is to state the specific requirements applicable to physical restraint.

(B) Physical restraint shall not be used unless it is in response to a crisis situation, i.e., where there exists an imminent risk of physical harm to the individual or others, and no other safe and effective intervention is possible. It shall be employed for the least amount of time necessary in order that the individual may resume his/her treatment as quickly as possible..

(C) Implementation of physical restraint.

(1) Physical restraint must be authorized by a trained, qualified staff member in accordance with the requirements of the agency's behavioral health accrediting body; or

(2) For an agency who has not achieved appropriate behavioral health accreditation, the agency must identify and approve staff who are qualified to authorize physical restraint.

Staff approved by the agency must have received all training in accordance with paragraph (F) of rule 5122-26-16 of the Administrative Code.

(D) Documentation of each episode of the use of physical restraint shall be made in the clinical record and shall include:

(1) The reason for implementation of the physical restraint;

(2) All prior attempts to use less restrictive interventions;

(3) Notation that any previously identified contraindication(s) to the use of physical restraint were considered and the rationale for continued implementation of physical restraint despite the existence of such contraindication(s);

(4) A review of all current medications;

(5) Explanation to the person for the reason for implementation of physical restraint and the required behaviors of the person which would indicate sufficient behavioral control so that the physical restraint could be discontinued;

(6) The condition of the person at routine intervals not to exceed fifteen minutes or more often if the person's condition so warrants. Such documentation shall address attention to vital signs, circulation, range of motion, nutrition, hydration, hygiene, toileting, need for continued restraint, and other needs as necessary, and the appropriate actions taken; and

(7) Upon conclusion of the physical restraint, the results of a check of injuries shall be conducted.

The appropriate actions taken for any injuries noted shall also be documented.

(E) Clinically appropriate reason(s) for the inability to implement any portion of this rule shall be documented in the clinical record, and shall be addressed in any staff de-briefing of the episode and in the agency's performance improvement process.

Replaces: 5122-26- 16.2

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.22 , 5119.61 , 5119.611
Rule Amplifies: 5119.22 , 5119.61 , 5119.611
Prior Effective Dates: 1/1/91, 4/16/01

5122-26-16.3 [Rescinded]Aversive behavioral interventions and plans.

Effective: 01/01/2012
R.C. 119.032 review dates: 11/05/2010
Promulgated Under: 119.03
Statutory Authority: 5119.22 , 5119.61 , 5119.611
Rule Amplifies: 5119.22 , 5119.61 , 5119.611
Prior Effective Dates: 1/1/91, 4/16/01

5122-26-17 Accessibility, availability, appropriateness, and acceptability of services.

(A) Agency services shall be accessible, available, appropriate and acceptable to the persons served.

(B) Minimum criteria for accessibility of services shall include but not be limited to:

(1) Evening and/or weekend hours to meet the needs of persons receiving services;

(2) Compliance with relevant federal and state regulations, including "section 504" of the "Rehabilitation Act of 1973" ( 29 U.S.C. Section 794 et seq.); and

(3) Geographical access to services for persons served.

(C) Minimum criteria for availability of services shall include, but not be limited to:

(1) Coordinating discharge planning and mental health services for persons leaving state operated inpatient settings and participating in discharge planning for persons leaving private psychiatric inpatient settings and referred to the agency;

(2) Assuring continuity of care for persons discharged from psychiatric inpatient settings and referred to the agency through the provision of necessary services as determined by the agency in consultation with the person served and the referral source. Such necessary services shall be provided upon discharge whenever possible and no later than two weeks post discharge if it has been concluded that these services are required within two weeks;

(3) Providing assistance, as appropriate according to the person's needs, at no additional cost to persons served, to persons requesting or receiving services, and their families or significant others, who speak a language other than standard English as a primary means of communication, or who have a communication disorder, such as deafness or hearing impairment. Such assistance shall include availability of appropriate communication devices, including telecommunication devices for the deaf ("TDD" aka "TTY"), or publishing service access via use of Ohio relay service or other similar communication interpreter services, according to 29 U.S.C. 794 , 29 U.S.C. 45 CFR part 84 et seq. In situations when a client expresses a preference to communicate by use of a TDD/TTY, then the agency shall ensure one is available at the agency.

Other assistance to be provided according to the needs of persons served shall apply to all forms of communication and shall include:

(a) Interpreters fluent in the first vernacular language of the person served, and with demonstrated ability and/or certification;

(b) Services provided by a professional who is able to communicate in the same vernacular language as the person served; and

(c) Referral to a service that provides interpreters.

(4) Providing culturally sensitive and responsive treatment planning and service delivery; and

(5) Addressing mental health service needs of the relevant community(ies) as described in the community plan(s) of the community mental health board(s).

(D) Minimum criteria for acceptability of services shall include, but not be limited to:

(1) Sensitivity to ethnic and cultural differences among people;

(2) Promoting freedom of choice among therapeutic alternatives for the person receiving services; and

(3) Provision that no person served shall be denied access to any service based on their refusal to accept other services recommended by the agency.

(E) Minimum criteria for appropriateness of services shall include, but not be limited to:

(1) Provision of services in the least restrictive setting;

(2) Delivery of service in the natural environment of the person receiving services as appropriate;

(3) Continuity of therapeutic relationships;

(4) Perceived needs of the person receiving services; and

(5) Culturological assessment.

(F) Minimum criteria for appropriateness of services for persons with a severe mental disability or children with severe emotional disturbance shall also include referral to other systems or organizations to meet identified needs if the agency does not provide such services.

(G) The agency shall review annually the effectiveness of its efforts to ensure accessibility, availability, appropriateness, and acceptability of services.

Effective: 02/17/2012
R.C. 119.032 review dates: 11/30/2011 and 02/17/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 1-1-1991; 10-1-1993

5122-26-18 Client rights and grievance procedure, and abuse.

(A) Each agency shall develop policies and procedures regarding staff neglect and abuse of persons served including, but not limited to, the following requirements:

(1) Each allegation of neglect and/or abuse by agency staff of a person served, regardless of the source, shall be investigated. The written results of an investigation into an allegation of neglect and/or abuse of persons served shall be reviewed by the executive director of the agency. The agency shall keep documentation of the findings of the investigation and of actions taken as a result of the investigation.

(2) The agency shall report any allegation of staff neglect or abuse to the community mental health board within twenty-four hours of the event occurring and shall communicate the results of the investigation to the community mental health board.

(3) In situations that involve child abuse or adult abuse, any notification required by law shall be made to the appropriate authorities.

(B) Each agency shall have written policies and procedures that are consistent with state law and with the Ohio department of health's and the department's guidelines regarding rights of persons served, such as persons with human immunodeficiency virus ("HIV").

(C) Each agency shall develop a policy on the rights of persons receiving services and a grievance policy for those persons according to relevant federal, state, and local statutes. The following definitions are in addition to or supersede the definitions in rule 5122-24-01 of the Administrative Code:

(1) "Client" means an individual applying for or receiving mental health services from a board or mental health agency.

(2) "Client rights specialist " means the individual designated by a mental health agency or board with responsibility for assuring compliance with the client rights and grievance procedure rule as implemented within each agency or board. For these purposes the individual holds the specific title of client rights officer.

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

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

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

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

(D) Client rights.

Except for clients receiving forensic evaluation service as defined in rule 5122-29-07 of the Administrative Code, from a certified forensic center, each client has all of the following twenty-five rights as listed in paragraphs (D)(1) to (D)(15) of this rule. Rights of clients receiving only a forensic evaluation service from a certified forensic center are specified in paragraph (E) of this rule.

(1) All who access mental health services are informed of these rights:

(a) The right to be informed of the rights described in this rule prior to consent to proceed with services, and the right to request a written copy of these rights;

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

(c) The right to be fully informed of the cost of services.

(2) Services are appropriate and respectful of personal liberty:

(a) The right to be treated with consideration, respect for personal dignity, autonomy, and privacy, and within the parameters of relevant sections of the Ohio Revised Code and the Ohio Administrative Code;

(b) The right to receive humane services;

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

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

(e) The right to reasonable protection from physical, sexual and emotional abuse, inhumane treatment, assault, or battery by any other person.

(3) Development of service plans:

(a) The right to a current ISP 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 ISP reviews with the staff including services necessary upon discharge.

(4) Declining or consenting to services:

(a) The right to give full informed consent to any service including medication prior to commencement and the right to decline services including medication absent an emergency;

(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 technology. This right does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms; and

(c) The right to decline any hazardous procedures.

(5) Restraint, seclusion or intrusive procedures:

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

(6) Privacy:

The right to reasonable privacy and freedom from excessive intrusion by visitors, guests and non agency surveyors, contractors, construction crews or others.

(7) 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 an agency 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) 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 a grievance process, including the right to appeal a decision.

(9) Non-discrimination:

The right to receive services and participate in activities free of discrimination on the basis of 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 prohibited by local, state or federal laws.

(10) No 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) Outside opinions:

The right to have the opportunity to consult with independent specialists or legal counsel, at one's own expense.

(12) No conflicts of interest:

No agency employee may be a person's guardian or representative if the person is currently receiving services from said facility.

(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 client for clear treatment reasons in the client's treatment plan. If access is restricted, the treatment plan shall also include a goal to remove the restriction.

(14) The right to be informed in advance of the reason (s) 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.

(E) Client rights.

Each client receiving a forensic evaluation service from a certified forensic center has the rights specified in paragraphs (E)(1) to (E)(12) of this rule.

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

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

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

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

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

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

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

(8) The right not to be discriminated against in the provision of service 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 prohibited by local, state or federal laws;

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

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

(11) The right to file a grievance; and

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

(F) Client rights procedures.

(1) Each agency must have a written client rights policy which contains the following:

(a) Specification of the client rights as listed in paragraphs (D)(1) to (D)(15) and/or (E)(1) to (E)(12) of this rule; and

(b) Assurance that staff will explain any and all aspects of client rights and the grievance procedure upon request.

(2) Each agency policy shall specify how explanation of client rights shall be accomplished, and shall include:

(a) Provision that in a crisis or emergency situation, the client or applicant shall be verbally advised of at least the immediately pertinent rights, such as the right to consent to or to refuse the offered treatment and the consequences of that agreement or refusal. Full verbal explanation of the client rights policy may be delayed to a subsequent meeting; and

(b) Provision that clients or recipients of information and referral service, consultation service, mental health education service, and prevention service as described in Chapter 5122-29 of the Administrative Code may have a copy and explanation of the client rights policy upon request.

(3) A copy of the client rights policy shall be posted in a conspicuous location in an area of each building operated by the agency that is accessible to clients and the public. It shall also include the name, title, location, hours of availability, and telephone number of the client rights officer with a statement of that person's responsibility to accept and oversee the process of any grievance filed by a client or other person or agency on behalf of a client (4) Each agency shall provide that every staff person, including administrative and support staff, is familiar with all specific client rights and the grievance procedure.

(G) Grievance procedure.

(1) Each agency must have a written grievance procedure which provides for the following:

(a) Assistance in filing the grievance if needed by the griever, investigation of the grievance on behalf of the griever, and agency representation for the griever at the agency hearing on the grievance if desired by the griever. The grievance procedure shall clearly specify the name, title, location, hours of availability, and telephone number of the person(s) designated to provide the above activities;

(b) An explanation of the process from the original filing of the grievance to the final resolution, which shall include reasonable opportunity for the griever and/or his designated representative to be heard by an impartial decision-maker;

(c) A specification of time lines for resolving the grievance not to exceed twenty working days from the date of filing the grievance;

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

(e) Opportunity to file a grievance within a reasonable period of time from the date the grievance occurred;

(f) A statement regarding the option of the griever to initiate a complaint with any or all of several outside entities, specifically the community mental health board, the Ohio department of mental health, the Ohio legal rights service, the U.S. department of health and human services, and appropriate professional licensing or regulatory associations. The relevant addresses and telephone numbers shall be included; and

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

(2) Each agency shall make provision for posting the grievance procedure in a conspicuous place and for distributing a copy of the written grievance procedure to each applicant and each client, upon request.

(3) Each agency shall make provision for prompt accessibility of the client rights officer to the griever.

(4) Each agency shall provide alternative arrangements for situations in which the client rights officer is the subject of the grievance.

(5) Each agency shall provide that every staff person, including administrative, clerical, and support staff, has a clearly understood, specified, continuing responsibility to immediately advise any client or any other person who is articulating a concern, complaint, or grievance, about the name and availability of the agency's client rights officer and the complainant's right to file a grievance.

(6) Each agency shall provide for the client rights officer to take all necessary steps to assure compliance with the grievance procedure.

(H) Implementation and monitoring.

(1) An agency may accomplish its responsibilities in regard to the provisions of this rule through utilization of its own staff or board members as appropriate, or through agreement with outside staff, agencies, or organizations, except that:

(a) Each agency must assure prompt accessibility of the client rights officer.

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

(2) The agency client rights officer shall assure the keeping of records of grievances received, the subject matter of the grievances, and the resolution of the grievances, and shall prepare an annual summary for review by agency governance in accordance with rule 5122-26-03 of the Administrative Code. The annual summary shall include the number of grievances received, type of grievances, and resolution status of grievances, and shall be forwarded to the mental health board. The agency records shall be available for review by the community mental health board and the department of mental health upon request.

(3) Each agency shall maintain a client rights policy and grievance procedure that is approved by the department of mental health. Subsequent substantive changes to such written policy and procedure shall also be submitted to and approved by the department before enactment.

Replaces: 5122-26-18, 5122:2-1-02 (part)

Effective: 03/01/2012
R.C. 119.032 review dates: 07/28/2011 and 03/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611 , 5119.613
Rule Amplifies: 5119.61(A) , 5119.611 , 5119.613
Prior Effective Dates: 5-10-1979, 1-1-1991

5122-26-19 [Rescinded]Uniform cost reporting.

Effective: 06/19/2014
R.C. 119.032 review dates: 04/02/2014
Promulgated Under: 119.03
Statutory Authority: 5119.22
Rule Amplifies: 5119.22
Prior Effective Dates: 7/22/04, 2/24/05, 7/1/05, 01/09/2006

5122-26-19.1 [Rescinded]Actual uniform cost report (AUCR) agreed upon procedures and report submission requirement.

Effective: 06/19/2014
R.C. 119.032 review dates: 04/02/2014
Promulgated Under: 119.03
Statutory Authority: 5119.22
Rule Amplifies: 5119.22
Prior Effective Dates: 7/22/04, 2/24/05, 7/1/05, 01/09/2006