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: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.01(H), 5119.22, 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.

HISTORY: Eff 1-1-91; 10-1-03

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.611(C), 5119.01(H), 5119.22, 5119.61(A)

Rule amplifies: RC 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

R.C. 119.032 review dates: 03/12/2003 and 10/01/2008

5122-26-03 Governing body.

(A) Each agency shall have a governing body. Governing body shall have the same meaning as governing board.

(B) Each agency shall have by-laws, a code of regulation, or policies for the following:

(1) Selection of members of the governing body;

(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.

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

(2) Approve the annual budget and plan for services;

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

(a) Review of the summary of quality assurance activities and governing body actions taken as a result of this review; and

(b) Review of a summary of client rights activities.

(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

(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) Establish, review and update as necessary the agency’s policies, and document that this review has occurred;

(9) Ensure that the agency has a table of organization;

(10) Review the annual service evaluation conducted according to rule 5122-28-04 of the Administrative Code;

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

(12) 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;

(13) 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, sex, and socioeconomic status;

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

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

HISTORY: Eff 5-10-79; 1-1-91

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

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: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.01(H), 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.01(H), 5119.61(A), 5119.611(C)

Prior Effective Dates: 1/1/91

5122-26-05 Table of organization.

Each agency shall prepare and have on file at the agency a current table of organization that shall include, but not be limited to:

(A) Lines of responsibility for all administrative and service staff of the agency, including the governing board and executive director; and

(B) Advisory boards, advisory committees and/or other agency-related bodies, if the agency has any.

Replaces: 5122:3-7-06

R.C. 119.032 review dates: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.61(A), 5119.611(C), 5119.01(H)

Rule Amplifies: 5119.01(H), 5119.61(A), 5119.611(C)

Prior Effective Dates: 1/1/91

5122-26-06 Personnel management.

(A) Each agency shall maintain written personnel policies and procedures that comply with relevant federal, states, and local statutes. Personnel policies and procedures shall include, but not be limited to:

(1) A compensation plan that shall establish policies and procedures related to pay for time worked and not worked and benefit programs in addition to pay for duties performed; and

(2) Assurance of non-discrimination against any person or group of persons on the grounds of race, ethnicity, age, color, religion, sex, national origin, sexual orientation, physical or mental handicap, or developmental disability according to Title VII of the “Civil Rights Act of 1964;” or any person with “HIV” or “AIDS-Related Complex”; or in any manner prohibited by the laws of the state of Ohio and the United States in the recruitment, selection, promotion, evaluation or retention of employees or volunteers;

(3) Provisions for the professional development of the agency’s employees including any continuing education requirements, training and education opportunities provided by the agency, and the agency’s expectations for employee advancement. Such policies and procedures shall encourage participation in cultural sensitivity training for all staff, and training in ethnically sensitive methods of practice for staff members and volunteers who provide services directly to clients;

(4) Provisions for promotion, termination of employment, discipline, leave of absence and layoff;

(5) Provisions for employee grievances;

(6) Provisions for employee safety;

(7) Provisions for supervision of staff providing services, according to Chapter 5122-23 of the Administrative Code. Such supervision shall be documented.

(8) Provisions for assessments of each employee’s performance including, but not limited to the following requirements:

(a) Each employee’s job performance shall be reviewed at least annually;

(b) Each employee’s job performance evaluation shall be signed by the employee to reflect that he or she has seen the report;

(d) A description of procedures to appeal the performance evaluation shall be made available to the employee.

(9) A description of the required content of the personnel records, including the following information:

(a) Application for employment;

(b) Verification of credentials (i.e., documentation or visual verification of the original professional license or certificate);

(d) Copy of notification of hiring, to include starting date and starting salary;

(e) Wage and salary information, to include adjustments;

(f) Copy of position description;

(g) Employee performance evaluations;

(h) Commendations, if any;

(i) Disciplinary actions, if any;

(j) Documentation of employee orientation to mission, policies and procedures of the agency;

(k) Documentation that employee has received and reviewed a copy of the agency’s personnel policies and procedures;

(l) Record of employee references (written or verbal); and

(m) Verification of citizenship and employment eligibility according to Title 8, United States Code, section 1324A.

(10) Specifying which staff have access to various types of personnel information, and assuring an employee’s access to his or her own record; and

(11) Provisions for storage, retention and disposal of personnel records to safeguard physical integrity and confidentiality.

(B) The agency shall ensure that a copy of its personnel policies and procedures is available to each employee and a process shall be established for notifying employees and volunteers of changes in personnel policies and procedures.

(C) Volunteers in the agency shall have orientation, training and supervision commensurate with their responsibility and shall be evaluated according to agency policy.

(D) Each budgeted staff position description shall include the following:

(1) Duties of the position;

(2) Immediate administrative and/or clinical supervisor;

(3) Immediate subordinates; and

(4) Special working conditions, if applicable.

(E) There shall be a written affirmative action plan including:

(1) The hiring of culturally diverse staff at all levels of the agency. These staff shall have the ability to address the need for culturally specific and relevant programming for ethnic minorities, deaf or hearing-impaired persons, and others; and

(2) Goals for the employment and effective utilization of, including contracts with, “African-American,” “native American,” “Hispanic” and “Oriental” and other persons in percentages reflecting, as nearly as possible, the composition of the community mental health service district served by the board.

(F) 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.

(G) Screening procedures for all staff members shall include inquiries to establish that the applicant is qualified for the position and may include inquiry to establish that the person is without any record of misconduct or criminal convictions that might bear a direct and substantial relationship to that applicant’s position.

(H) Notification shall be given to the applicant that the agency follows rules and regulations governing fair employment practices, that the applicant’s right to privacy shall be respected and that the results of inquiries shall be treated in confidence by the agency.

(I) 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.

HISTORY: Eff 5-10-79; 1-1-91

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-07 Personnel qualifications.

(A) Services to be provided to all persons eligible for third party reimbursement for mandated insurance coverage under sections 1737.28, 3923.28 and 3923.30 of the Revised Code shall be legally performed by, or under the clinical supervision of, a physician or psychologist or other person as required by the third party payor.

(B) 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. The agency shall ensure that staff are hired with education and/or training appropriate to specialized services they provide, including services such as those provided for children and elderly persons.

(C) All personnel shall be qualified by education and/or experience to function in their assigned tasks, as defined in the job descriptions and hiring process.

(D) All personnel who provide mental health services shall be qualified to provide those services according to Chapter 5122-23 of the Administrative Code.

(E) The agency shall ensure that mental health personnel are qualified by training or continuing education regarding cultural sensitivity and cultural competence sufficient to provide culturally relevant services to persons served of culturally diverse backgrounds. These qualifications shall include, but are not limited to knowledge of:

(1) Effects on persons of cultural and ethnic minority groups of psychiatric interventions, including psychotropic medications;

(2) Issues related to differential diagnosis of persons of cultural and ethnic minority groups; and

(3) Vernacular language patterns of ethnic minority persons and of individuals who are deaf and hard of hearing.

HISTORY: Replaces rule 5122-26-07; Eff 5-10-79; 10-14-82; 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I)

119.032 REVIEW DATE: 9-17-01; 9-16-06

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: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.01(H), 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.01(H), 5119.61(A), 5119.611(C)

Prior Effective Dates: 1/1/91

5122-26-09 Agency service plan.

(A) Each agency shall have a current service plan that shall be revised and updated annually as appropriate including, but not be limited to:

(1) A statement of the agency’s purpose, goals and objectives in relation to the needs of the community as identified in the community mental health board community plan for the service district if the agency has a contract with the board, and the agency’s own needs assessment activities;

(2) A narrative description of the agency’s contribution to the development and implementation of a community support system, or of a system of care for children and adolescents.

(3) A narrative description of each service provided, the needs of persons served that will be addressed by that service, and the characteristics of the people to be served

(4) A schedule of the hours of operation of the various services of the agency

(5) When services are to be provided through affiliations with other community agencies, a list of specific responsibilities of each agency involved; and

(6) Amendments to the plan, as appropriate, based on the results of service evaluation activities, quality assurance reports, or other internal evaluation programs.

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

HISTORY: Replaces rule 5122-26-09; Eff 5-10-79; 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-11 Affiliation agreements.

(A) If an agency does not provide crisis intervention services, the agency shall have a written affiliation agreement with a certified provider(s) of crisis intervention services.

(B) 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.

(C) 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 agreement describing the roles and responsibilities of the community mental health board, hospital, agency and department.

R.C. 119.032 review dates: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

Prior Effective Dates: 1/1/91

5122-26-12 Physical plant and safety.

(A) Each agency shall meet all applicable federal, state and local requirements for health, safety and accessibility including Section 504 of the “Rehabilitation Act of 1973” (20 U.S.C. section 795 et seq.).

(B) An administrative staff member shall be designated as safety officer and shall be given responsibility and authority for seeing that the agency is in compliance with this rule.

(C) Each agency shall develop policies and procedures regarding physical plant and safety, including, but not limited to:

(1) Fire safety procedures, including:

(a) Fire drill and evacuation procedures, including the evaluation of effectiveness;

(b) Fire drills to be held at least quarterly;

(c) Annual 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;

(d) All fire exit doors to be 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; and

(e) Fire extinguishers to be inspected annually, and recharged or replaced as appropriate.

(2) Hazardous materials procedures, including:

(a) Handling and disposal of hazardous materials according to any applicable federal, state or local laws and regulations;

(b) Infectious waste disposal and standards for universal precautions according to consultation with specifications of the occupational health and safety administration in “CPL” 2 to 2.44B, and the Ohio department of health; and

(3) General safety procedures, including:

(a) Electrical equipment use and regular inspection procedures;

(b) Safety orientation and education programs;

(d) External disaster evacuation procedures;

(e) Elevator permits and current license permits, such as boiler or food services, to be maintained;

(f) Storage areas, basements, attics and stairwells to remain uncluttered; and

(4) A reporting system that includes documentation to agency administration of all accidents, injuries, and safety hazards.

HISTORY: Replaces rule 5122-26-12; Eff 5-10-79; 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-13 Incident reporting.

(A) An incident reporting system shall be developed to require written reports of incidents and major unusual incidents that pose a danger to the health and safety of persons served and staff of the agency.

(B) Written incident reports shall be submitted to and reviewed by the executive director of the agency or designee.

(C) Review of written incident reports and corrective action taken, if any, shall be included in quality assurance activities.

(D) A copy of all major unusual incident reports related to the agency shall be sent to the agency director and the community mental health board within twenty-four hours after the event occurs.

(E) The agency shall receive and review all major unusual incident reports from licensed residential facilities regarding persons served by the agency, and shall take action, as appropriate, and according to rule 5122:3-5-01 of the Administrative Code.

HISTORY: Eff 1-1-91

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-14 Infection control.

(A) Each agency shall have policies and procedures on infection control in accordance with applicable specifications of the occupational health and safety administration in “CPL” 2 to 2.44C, and applicable regulations of the Ohio department of health.

(B) There shall be documentation of training of all employees on universal precautions for infection control.

(C) A system shall be developed and implemented for reporting, monitoring and evaluating infection control measures, in accordance with paragraph (A) of this rule.

HISTORY: Replaces rule 5122-26-14; Eff 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

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) Prohibit any person. other than a physician or pharmacist from dispensing medication; and

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

HISTORY: Replaces rule 5122-26-15; Eff 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-16 Special treatment and safety measures.

(A) Philosophy

The provision of a physically and psychologically safe environment is a basic foundation and requirement for effective mental health treatment. Creating calm surroundings and establishing positive, trusting relationships are essential to facilitating a person’s treatment and recovery.

We share a goal of reducing and minimizing the use of special treatment and safety measures. We must recall that these measures 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 and preferences and the effectiveness or ineffectiveness of past exposure to these methods.

When individuals in less restrictive settings experience repeated or sustained use of these measures, providers in such settings should consider possible transfer/placement to a more structured treatment environment with the capacity to meet individual needs with reduced exposure to these intrusive interventions.

Use of special treatment and safety measures must be subject to quality improvement processes in order to identify ways in which the use of these measures can be decreased/avoided and more positive, relevant and less potentially dangerous techniques used in their place.

(B) The purpose of this rule is to state the general requirements applicable to special treatment and safety measures. These measures include the following:

(1) Mechanical restraint;

(2) Seclusion;

(3) Physical restraint; and

(4) Major aversive behavioral interventions.

(C) The following definitions shall apply to rules 5122-26-16 to 5122-26-16.3 of the Administrative Code and supercede those contained in rule 5122-24-01 of the Administrative Code:

(1) “Aversive behavioral intervention” means any behavior management intervention that employs any unpleasant or aversive stimuli. The two levels of such an intervention are:

(a) “Minor aversive behavioral interventions”, which include: time-out, loss of tokens, the contingent removal of items that are reinforcing to the person that are not listed as major aversive behavioral interventions, and the contingent loss of access to the person’s room; and

(b) “Major aversive interventions”, which include: the contingent loss of the regular meal, the contingent loss of bed (mattress must be provided at regularly scheduled hours of sleep), and the contingent use of unpleasant substances or stimuli such as bitter tastes, bad smells, splashing with cold water, and loud or annoying noises.

(2) “Behavior management” means the utilization of interventions in which positive reinforcers or aversive stimuli 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 assist the individual in increasing his/her ability to exercise those rights.

(3) “Behavior management plan” means an agreement negotiated with the person served, and as appropriate, parent or guardian, in which mutually agreeable behavioral goals and interventions are specified.

(4) “Clear treatment reasons” means that a person would present an imminent, substantial risk of physical harm to him/herself or others.

(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” 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. These methods include the utilization of physical holds by one or more qualified persons with the goal of either assisting the person to reestablish internal and behavioral control, or of stopping a dangerous behavior when verbal directions and/or non-verbal prompts have been ineffective.

(7) “Qualified person” means an individual or staff member who is qualified to participate in one or all of the mechanisms identified in rules 5122-26-16 to 5122-26-16.3 of the Administrative Code by virtue of the following: education, training, experience, competence, registration, certification, or applicable licensure, law or regulation.

(8) “Ready behavior” means the behavior that the person needs to demonstrate to signal that an intervention can be terminated. Ready behavior shall be explained to the person and shall include a specific description and length of time. Ready behavior should be displayed for as short a time as possible.

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

(10) “Targeted behavior” means the behavior that is addressed in the behavior management plan as the behavior in need of changing/enhancing. The behavior should be observable/measurable and so stated in the plan.

(11) “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 or until ready behavior occurs.

(D) General requirements

(1) The use of special treatment and safety measures shall be in accordance with either a behavior management plan or in response to a crisis situation (i.e., where there exists an immediate risk of danger to the individual or others and no other safe and effective intervention is possible).

(2) The following shall not be used under any circumstances:

(a) Face down restraint with back pressure;

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

(d) Any technique that restricts the recipient’s ability to communicate;

(e) Pepper spray, mace, handcuffs or electronic restraint devices such as stun guns, and

(f) A drug or medication that is used as a restraint to control behavior or restrict the individual’s freedom of movement that is not a standard treatment for the individual’s medical or psychiatric condition.

(3) The agency shall ensure that the use of special treatment and safety measures is routinely reviewed for safety, effectiveness and appropriateness and that the competency of staff in the use and documentation of these measures is routinely evaluated.

(a) Quality improvement processes shall identify opportunities, when appropriate, to reduce the use of special treatment and safety measures;

(b) The agency shall continuously review the reason(s) for the use of such measures and determine whether desired results might be achieved by some other less restrictive means; and

(c) The agency shall establish policies and procedures which shall reflect how special treatment and safety measures are reviewed, evaluated and approved for use.

(4) The choice of the least restrictive, safe and effective special treatment and safety measure for an individual is determined by the person’s assessed needs, the effective or ineffective measures previously used with the person, and, when possible, upon the person’s preference.

(a) The presence of advance directives addressing the use of special treatment and safety measures shall be determined and considered. Documentation of such shall be entered in the clinical record.

(b) When appropriate, and as part of a documented initial clinical assessment, the person and/or his/her custodian or guardian, shall assist in the identification of techniques that would help the person control his or her behavior; and where appropriate, the person’s need for methods or tools to manage his or her own aggressive behavior shall be identified. As clinically warranted, this information shall be incorporated in the ISP/ITP.

(c) Upon admission/intake and when clinically warranted, the person and/or his/her custodian or guardian, as appropriate, shall be informed of the agency’s philosophy on the use of special treatment and safety measures. the role of the family, custodian or guardian and their notification of the use of such measures shall also be discussed.

(d) Requirements for the initial and ongoing identification and documentation of individual-specific contraindications for the use of special treatment and safety measures shall be documented.

(i) Consideration of the use of such measures shall take into account the following which may place the person at greater risk for their use:

(a) Gender;

(b) Age;

(d) Ethnicity;

(e) History of physical or sexual abuse;

(f) Medical conditions; and

(g) Physical disabilities.

(5) The agency shall identify, educate and approve staff members to use special treatment and safety measures.

(a) Staff shall have appropriate training prior to commencing use of special treatment and safety measures and annually thereafter.

(i) Staff shall be trained in non-physical techniques for intervention and de-escalation of disruptive or aggressive acts, persons and/or situations.

(ii) Training will address the identification and assessment of those items noted in paragraph (D)(4)(d) of this rule.

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

(c) The number of appropriately trained staff available to apply or initiate special treatment and safety measures shall be adequate to ensure safety.

(6) Policies and procedures governing the use of special treatment and safety measures shall include attention to preservation of the person’s health, safety, rights, dignity, and well-being during use. Further, policies and procedures shall reflect how:

(a) Respect for the person is maintained during the application or initiation of such measures;

(b) The person is able to continue his or her care and participate in care processes;

(d) Physical well-being is preserved through adequate exercise, nourishment, and personal care; and

(e) Modesty, visibility to others, and comfortable body temperature are maintained.

(7) When special treatment and safety measures are used in crisis situations, policies and procedures shall include:

(a) Development of staff orientation and education that creates a culture emphasizing prevention, appropriate use of the measures, and encourages alternatives such as de-escalation techniques; and

(b) Assurance that such measures will not be utilized to compensate for the lack of sufficient staff, as a substitute for treatment, or as retaliation.

(8) When special treatment and safety measures are used in a behavior management program, policies and procedures shall include:

(a) The requirement of a positive approach to behavior management and the progressive use of the least restrictive alternatives;

(b) The requirement that behavior management programs identify and teach the individual appropriate expression of the target behavior or alternative adaptive behaviors;

(d) Prohibition of seclusion, mechanical and/or physical restraint;

(e) Prohibition of corporal punishment; and

(f) Prohibition of other patients/clients from carrying out a person’s behavior management plan.

(9) The agency shall notify ODMH of each death that occurs while a person is restrained or in seclusion, of each death occurring within twenty four hours after the person has been removed from restraints and seclusion, or where it is reasonable to assume that a person’s death is a result of such seclusion or restraint. Such notification shall include the name of the person and shall be provided not later than twenty four hours after the time of the person’s death.

(10) A log shall be maintained for department review of each incident of mechanical restraint, seclusion, physical restraint, major aversive behavioral interventions, and for time-out exceeding fifteen 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 special safety and treatment measure; and

(11) Internal review for clinical appropriateness and documentation of such review(s) shall be made:

(a) For all instances of repeated or continual use of mechanical restraint and/or seclusion consisting of more than:

(i) Eight continuous hours for adults; or

(ii) Four continuous hours for children and adolescents ages nine to eighteen; or

(iii) Two continuous hours for children under age nine.

(b) For any physical restraint, major aversive behavioral intervention, and time-out that exceeds fifteen minutes per episode; and

(c) To ascertain overall patterns and trends of the agency’s use of special treatment and safety measures. Such utilization review shall occur at least monthly.

(12) Reviews as prescribed in paragraph (D)(11) of this rule shall consist of one of the following:

(a) An ITP/ISP review by appropriate members of the treatment team which shall be included in the person’s medical/clinical record; or

(b) A review by the service’s clinical/medical director or his/her designee; or

(d) Documentation of such reviews shall include, at minimum:

(i) Identification of data used, both internal and external;

(ii) A summary of clinical conclusions reached regarding the data; and

(iii) As warranted, specific steps taken to improve clinical practice including an identification of ways to reduce the use of special treatment and safety measures, if possible.

(13) Instances of special treatment and safety measures resulting in staff or patient/client injury shall also be reviewed via quality improvement processes to ascertain if appropriate policies and procedures were followed, and if so, whether a need to revise such policies and procedures currently exists.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M)

Rule amplifies: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006

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) Mechanical restraint and seclusion shall be used only when there exists an immediate risk of danger to the individual or others and no other safe and effective intervention is possible.

(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 physical restraint, time-out or comforting of children when its use is consistent with rules 5122-26-16 to 5122-26-16.3 of the Administrative Code; and

(4) 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.

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

(1) Appropriate temperature control, ventilation and lighting;

(2) The absence of unsafe wall or ceiling fixtures and sharp edges;

(3) 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

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

(E) Provisions of this rule shall be carried out by qualified staff only.

(1) Training for staff implementing mechanical restraint and seclusion shall include but not be limited to:

(a) Current certification in cpr and first aid;

(b) The identification and utilization of less restrictive alternatives. Training of staff shall focus upon identifying the earliest precipitant of aggression for patients/clients with a known, suspected, or present history of aggressiveness, and on developing treatment strategies to prevent exacerbation or escalation of these behaviors. Patient/client involvement in the identification of precipitants is paramount; and

(F) Orders shall be written only by a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency for implementation of mechanical restraint and seclusion. Orders may be written for a maximum of:

(1) Two hours for adults;

(2) Two hours for children and adolescents age nine to eighteen; or

(3) One hour for children under age nine.

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

(H) In an emergency:

(1) Mechanical restraint and/or seclusion may be implemented by staff at the direction and in the presence of a registered nurse.

(2) A verbal order from a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency shall be obtained by the registered nurse upon implementation of mechanical restraint or seclusion or within one hour. Such order shall be signed by a psychiatrist or other physician with specific clinical privileges or authorization granted by the agency within twenty four hours.

(I) After the original order for mechanical restraint and/or seclusion expires, the individual shall receive a face-to-face reassessment by the psychiatrist or other physician with specific clinical privileges or authorization granted by the agency, 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:

(1) Two hours for adults up to a maximum of twenty-four hours;

(2) Two hours for children and adolescents age nine to eighteen up to a maximum of twenty-four hours; or

(3) One hour for children under age nine up to a maximum of twenty-four hours.

(J) When mechanical restraint or seclusion is terminated early and the same behavior is still evident, the original order can be reapplied if it is within one hour of the early release and if alternatives remain ineffective. Otherwise, a new order for application must be obtained.

(K) Continuation of orders cannot under any circumstances exceed the maximums stated in paragraphs (I)(1) to (I)(3) of this rule without a face-to-face reassessment by the psychiatrist or other physician with specific clinical privileges or authorization granted by the agency and a new order.

(1) Such assessment shall be documented in the clinical record. It shall address the need for continued mechanical restraint and/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.

(L) Upon any implementation of mechanical restraint or seclusion, a registered nurse, psychiatrist, or other physician with specific clinical privileges or authorization granted by the agency shall:

(1) Perform and document in the clinical record an assessment, including the reason(s) for mechanical restraint or seclusion, prior attempts to use less restrictive interventions, review of any contra-indications for mechanical restraint use or seclusion, and review of all current medications;

(2) Assess and document vital signs including temperature, pulse, respiration and blood pressure; and

(3) 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.

(M) While in mechanical restraint and/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. 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 needs regarding meals, fluid intake, hygiene, toileting, ambulation and other needs, as necessary, and the appropriate actions taken.

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

(N) Upon conclusion of mechanical restraint and/or seclusion interventions, staff shall meet with the individual for the purpose of:

(1) Assisting the individual to develop an understanding of the precipitants which may have evoked the behaviors necessitating the use of the intervention(s);

(2) Assisting the individual to develop appropriate coping mechanisms or alternate behaviors that could be effectively utilized should similar situations/emotions/thoughts present themselves again; and

(3) Developing and documenting a specific plan of intervention(s) for inclusion in the ITP/ISP, with the intent to avert future need for mechanical restraint and/or seclusion.

(O) Staff shall document the interview process outlined in paragraph (N) of this rule in the clinical record.

(P) Clinically appropriate reason(s) for the inability to implement any portion of this rule shall be documented in the clinical record.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M), 5119.01(G), 5119.01(I)

Rule amplifies: RC 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006

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 may be used as a response to an emergency only.

(1) Training for staff implementing physical restraint shall include but not be limited to:

(a) Current certification in CPR and first aid;

(b) The identification and utilization of less restrictive alternatives; and

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

(1) Reason for implementation of the physical restraint;

(2) Less restrictive interventions attempted first, if the situation allowed;

(3) Notation that a review and description of any known contraindications for the use of physical restraint was conducted;

(4) 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;

(5) Upon conclusion of the physical restraint, assessment of the need for ambulating, fluid intake, toileting, and other needs;

(6) Results of a check for injury;

(7) Documentation of staff’s efforts to process the circumstances surrounding the physical restraint with the individual; and

(8) Notation of any concerns for the subsequent utilization of physical restraint.

(E) Clinically appropriate reason(s) for the inability to carry out any portion of paragraph (D) of this rule shall be documented in the clinical record.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M)

Rule amplifies: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006

5122-26-16.3 Aversive behavioral interventions and plans.

(A) The purpose of this rule is to state the specific requirements applicable to aversive behavioral interventions and plans.

(B) The use of minor aversive behavioral interventions by the agency shall require, at minimum, policies and procedures prescribing their use, who may use them, and required training for individuals allowed to use them.

(1) Policies and procedures prescribing their use, who may use them, and required training for individuals allowed to use them;

(2) Documentation in the clinical record of such use and how the evaluation of the effectiveness and appropriateness of their use is routinely conducted and documented; and

(3) The development of an individualized behavior management plan.

(D) The individualized behavior management plan shall be developed only after positive and less restrictive interventions have failed or are deemed clinically inappropriate. Such plans shall be documented as part of the ISP/ITP and shall include:

(1) Written consent to the plan by the person served and/or parent, custodian or guardian;

(2) A summary outlining how the person has responded to previous interventions and the rationale as to why the use of aversive behavioral interventions is now indicated;

(3) Notation that a review and description of any known contraindications for the use of the intervention was conducted;

(4) Identification of target behaviors;

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

(6) A plan for monitoring the relationship between target behavior(s), behavioral intervention(s), and outcomes; and

(7) A review of the plan’s effectiveness at minimum every thirty days. If the plan is determined to be ineffective and little or no progress has been made, a re-evaluation of the plan shall be performed and documented.

(E) Clinically appropriate reason(s) for the inability to include any of the information required in paragraph (D) of this rule in the individualized behavior management plan shall be documented.

(F) Documentation of each aversive behavioral episode as outlined in the plan shall be made in the clinical record.

(G) Implementation of the plan may not occur until the following conditions have been met:

(1) Staff implementing the plan have been trained in the proper use of the intervention(s); and

(2) All necessary approval(s) required by the agency prior to implementation of the plan has been obtained.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M)

Rule amplifies: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006

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.

(1) Availability of those services which are under a contract or sub-contract with the community mental health board for persons served regardless of ability to pay for such services;

(2) 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;

(3) 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;

(4) 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”), according to 29 U.S.C. 794, 45 CFR part 84 et seq.

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

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

(6) 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 assessment of needs and advocacy with other systems or organizations to meet those needs if the agency does not provide such services. Such needs and advocacy shall include, but are not limited to:

(1) Mental health service needs;

(2) Housing;

(3) Employment and/or educational status;

(4) Health;

(5) Income;

(6) Recreation;

(7) Cultural characteristics;

(8) Spiritual needs; and

(9) Family.

(G) The agency shall review annually the effectiveness of its efforts to ensure accessibility, availability, appropriateness, and acceptability of services. This review shall be incorporated in service evaluation and quality assurance activities.

HISTORY: Replaces rule 5122-26-17; Eff 1-1-91; 10-1-93

Rule promulgated under: RC 119.03

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.61(M)

119.032 REVIEW DATE: 9-17-01; 9-16-06

5122-26-18 Client rights and abuse.

(A) 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 and rule 5122:2-1-02 of the Administrative Code.

(B) 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.

(C) 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”).

Replaces: 5122:3-7-13

R.C. 119.032 review dates: 03/12/2003 and 03/12/2008

Promulgated Under: 119.03

Statutory Authority: 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

Rule Amplifies: 5119.01(H), 5119.22, 5119.61(A), 5119.611(C)

Prior Effective Dates: 5/10/79, 1/1/91

5122-26-19 Uniform cost reporting.

(A) Definitions

(1) The following definitions apply to this rule:

(a) “ADAMHS board” means an alcohol, drug addiction and mental health services board as defined in Chapter 340. of the Revised Code.

(b) “CMH agency” means any community mental health agency as defined in section 5122.01 of the Revised Code which has been certified by the Ohio department of mental health in accordance with the requirements of section 5119.611 of the Revised Code.

(d) “CMS” means the Centers for Medicare and Medicaid Services.

(e) “ODMH” means the Ohio department of mental health.

(f) “OMB A-87” means the most current version of the office of management and budget circular “A-87, Cost Principles for State, Local, and Indian Tribal Governments”. This can be found at the following internet site: http://www.whitehouse.gov/omb/circulars/index.html.

(g) “OMB A-122” means the most current version of the office of management and budget circular “A-122, Cost Principles for Non-Profit Organizations”. This can be found at the following internet site: http://www.whitehouse.gov/omb/circulars/index.html.

(h) “PRM, Part 1” means the most current version of the provider reimbursement manual, part 1 as published by CMS. This can be found at the following internet site: http://www.cms.hhs/gov/manuals/cmsindex.asp.

(i) “SFY” means state fiscal year. This is the time period commencing on July first of any given calendar year and completing on June thirtieth of the following calendar year.

(j) “UCR” means uniform cost report. The form is designated as “ODMH-FIS-047” in appendix A of this rule. When completed on a prospective basis using budget cost information for a SFY, it is considered a budgeted UCR. When completed on a retrospective basis using actual cost information for a SFY, it is considered an actual UCR.

(k) “UFMS” means uniform financial management system. Appendix A of this rule in its entirety, including the UCR.

(l) “UPI” means unique provider identification number. This number represents an ODMH certified community mental health agency and owner (indicated by a single federal tax identification number) operating at a discrete physical location.

(B) Beginning with SFY 2006 cost reporting, the principles set forth in this rule are applicable to all UCRs filed with ODMH for the purpose of reporting costs associated with providing mental health services as defined in Chapter 5122-29 of the Administrative Code. All UCRs must be completed by utilizing generally accepted accounting principles and all costs must be allocated, either directly or indirectly, to the services that benefit from the cost.

(C) All mental health agencies must use the uniform cost report to report all costs associated with providing mental health services regardless of anticipated or actual payor source(s).

(1) The three options for completion and filing of UCRs are:

(a) By discrete UPIs;

(b) By bundling costs from multiple physical locations and reporting these under a single UPI; or

(c) At the corporate level by reporting all service costs associated with multiple physical locations under a single UPI and federal tax identification number combination.

(D) Any community mental health agency not receiving funding from an ADAMHS board, a CMH board, or directly from ODMH, may file the following statement in lieu of an actual UCR: “I do hereby certify that my agency has not received any funding from an ADAMHS board, a CMH board, or directly from ODMH, in the past SFY and am filing this statement in lieu of an actual UCR.” This statement must be submitted on agency letterhead and signed by the agency director.

(E) All programs must file an actual UCR or the statement in lieu of an actual UCR with ODMH within one hundred eighty days of the close of a SFY. Any ODMH certified CMH agency failing to file an actual UCR or the statement in lieu of an actual UCR with ODMH, and sending a copy to the local ADAMHS/CMH board in which the agency’s primary place of business is located, within one hundred eighty days after the close of a SFY may have its ODMH certification status terminated in accordance with rule 5122-25-07 of the Administrative Code.

(F) When an incomplete or inadequate actual UCR is filed with ODMH within the prescribed time period, ODMH will notify the ODMH certified CMH agency of the discrepancy(ies) and send a copy of the notification to the local ADAMHS/CMH board in which the agency’s primary place of business is located. The ODMH certified CMH agency has forty-five days from the date of the notification of the discrepancy(ies) to re-file a complete and adequate UCR with ODMH, including sending a copy to the local ADAMHS/CMH board in which the agency’s primary place of business is located. Failure to re-file a complete and adequate UCR may result in ODMH proposing that the agency’s certification status be terminated in accordance with rule 5122-25-07 of the Administrative Code.

(G) All cost data must be reported using the accrual basis of accounting.

(H) Cost categories

(1) Allowable costs – for privately owned and/or operated not-for-profit programs, allowable costs shall be determined in accordance with 42 CFR 413 and OMB A-122 . For governmentally owned and/or operated programs, allowable costs shall be determined in accordance with 42 CFR 413 and OMB A-87 . For privately owned and/or operated for-profit programs, allowable costs shall be determined in accordance with 42 CFR 413 and the PRM, Part 1.

(2) Unallowable costs – for privately owned and/or operated not for profit programs, unallowable costs shall be determined in accordance with 42 CFR 413 and OMB A-122 . For governmentally owned and/or operated programs, unallowable costs shall be determined in accordance with 42 CFR 413 and OMB A-87 . For privately owned and/or operated for-profit programs, unallowable costs shall be determined in accordance with 42 CFR 413 and the PRM, Part 1.

(3) Direct service personnel costs – direct service personnel costs shall represent the full salary and benefit costs of those personnel who provide direct services to the clients.

(4) Support service personnel costs – support service personnel costs shall represent the full salary and benefit costs of those personnel who directly support a specific mental health service or services.

(5) Nonpersonnel costs – are those costs necessary for, and allocated to, specific direct services.

(6) Administrative overhead costs – administrative overhead costs are those personnel and nonpersonnel costs that benefit the agency as a whole and cannot be allocated to a specific service or services.

(I) An actual UCR must be audited in accordance with the UCR audit requirements and procedures as set forth in rules established by ODMH.

(J) Certified CMH agencies must keep all actual UCRs and the supporting documentation necessary to fully disclose the extent of services provided and costs associated with providing those services for a period of seven SFYs from the date a service is rendered, or until all financial reporting obligations which include data contained in the UCR have been completed, whichever is longer.

See the following Appendices to this rule at http://www.mh.state.oh.us/licensurecert/rules.cert.standards/5122-26-19.pdf

Uniform Cost Reporting

Form A-1 Uniform Cost Report (UCR)

Personnel Services Costs Worksheet

Non-Personnel Cost Worksheet

Administrative Overhead Cost Distribution Worksheet

Effective: 01/09/2006

R.C. 119.032 review dates: 10/25/2005 and 01/09/2011

Promulgated Under: 119.03

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

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

Prior Effective Dates: 7/22/04, 2/24/05, 7/1/05

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

(A) This rule establishes the requirement for all ODMH certified community mental health (CMH) agencies that the actual uniform cost report (AUCR) submitted in accordance with rule 5122-26-19 of the Administrative Code was examined by an independent public accounting (IPA) firm using the agreed upon procedures contained in Appendix A of this rule prior to submission to ODMH. The ODMH certified CMH agency shall assure any recommendations contained in the agreed upon procedures report are made and a new original AUCR is completed.

(B) Beginning with the AUCR period July 1, 2005 through June 30, 2006 and for subsequent state fiscal year (SFY) reporting periods thereafter, the ODMH certified CMH agency shall submit the following to ODMH within one hundred eighty days after the end of a SFY:

(1) The originally prepared AUCR that was completed prior to the agreed upon procedures review and in accordance with rule 5122-26-19 of the Administrative Code;

(2) A copy of the agreed upon procedures report completed in accordance with Appendix A of this rule and issued by the IPA; and

(3) If appropriate, a new original AUCR adjusted based upon the recommendations of the IPA firm as documented in the agreed upon procedures report.

(C) An ODMH certified CMH agency reporting costs on the AUCR’s “Ohio Department of Alcohol and Drug Addiction Services” line will also need to submit a copy of its information as required in rule 3793:2-1-10 of the Administrative Code.

(D) An ODMH certified CMH agency that is also subject to rule 5101:2-47-26.2 of the Administrative Code may submit the information required in that rule in place of the information required by paragraph (B) of this rule with the following exception: the ODMH certified CMH agency is responsible for making all recommended adjustments to the AUCR and, if appropriate, submitting the new, original AUCR.

(E) The ODMH certified CMH agency shall send the AUCR agreed upon procedures report and, if applicable, the new, original AUCR to the Ohio department of mental health, office of fiscal services. A copy of the AUCR report and, if applicable, a copy of the new AUCR shall be sent to the local alcohol, drug addiction and mental health services or mental health board where the agency’s primary place of business is located.

Appendix A Actual Uniform Cost Report (AUCR) Agreed Upon Procedures and Report Submission Requirement

(A) An independent public accounting (IPA) firm shall use the following procedures when performing an Actual Uniform Cost Report (AUCR) in order to:

(1) report on the accuracy of the data reported on the AUCR;

(2) report on the allocation methods used for actual cost reporting;

(3) report on the allowability and unallowability of the cost data reported on the AUCR;

(4) determine if the data reported on the AUCR is in accordance with the applicable federal and state resources as stated in rule 5122-26-19 of the Administrative Code, as in effect for the State Fiscal Year (SFY) being reported; and

(5) report on the consistency between the first budget uniform cost report (BUCR) and the AUCR.

(B) Work completed in other areas or during other agreed upon procedures reviews may be used to satisfy these procedures as long as it is documented by the independent audit firm how the work satisfies these procedures. Work completed during a review required by rule 5101:2-47-26.2 of the Ohio Administrative may be used for completing the review required by this rule. If reliance is placed upon work completed by an independent audit firm from another engagement, such as an Office of Management and Budget (OMB) circular A-133 audit, a financial statement audit, or other such audit or review, or some other auditor’s work, it must be documented in the agreed upon procedures report required by this rule, how the work being relied upon meets the requirements contained in these procedures.

(C) If it is available, the previous SFY AUCR, AUCR report, and independent financial audit report are to be reviewed to determine if any management comments and/or findings will impact the current actual uniform cost report data.

(D) Obtain and inspect the program’s chart of accounts, including all revenue and expense accounts.

(E) Obtain and inspect a copy of rule 5122-26-19 of the Administrative Code as in effect for the SFY AUCR being reviewed.

(F) Obtain and inspect the first BUCR and all supporting documentation.

(G) Agreed Upon Procedures

(1) Procedure One – Mathematical Accuracy Testing

(a) Obtain a reconciliation of the total costs reported on the AUCR to the general ledger and/or the independent audited financial statements for the SFY being verified. Compare the amounts listed on the reconciliation to the amounts listed on the general ledger and/or the independent audited financial statements for the SFY being verified. Identify and document any material variances (variances greater than plus or minus two percent) and obtain management’s explanation of the material variance(s) for inclusion in the actual uniform cost report agreed upon procedures (AUP) report.

(b) For and by each service with costs being reported on the AUCR:

(i) sum the values reported in columns 4, and 5 to verify the result is equal to the value reported in the corresponding column 6;

(ii) sum the values reported in columns 6 and 7 to verify the result is equal to the value reported in the corresponding column 8;

(iii) verify the value reported in column 9 is equal to the result of dividing the value in column 9 by the value in column 2;

(iv) verify the value reported in column 11 is equal to the result of subtracting the value in column 10 from the value in column 8;

(v) verify the value reported in column 12 is equal to the result of dividing the value in column 11 by the value in column 2;

(vi) verify the values reported in the “Total MH Services” are equal to the sum of the values reported in the corresponding column; and

(vii) verify the values reported in the “Agency Total” are equal to the sum of the values reported in the corresponding column.

(2) Procedure Two – Personnel Costs Verification

(a) Compare the personnel costs reported in column 4 of the AUCR to the salaries, wages, and fringe benefits reported on the independently audited financial statements or Federal Internal Revenue Service Employer Form 941 for the SFY. Identify and document any material variances (variances greater than plus or minus two percent) and obtain management’s explanation of the material variance(s) for inclusion in the actual uniform cost report agreed upon procedures (AUP) report.

(b) From the personnel costs reported in column 4 of the AUCR, select ten employees whose personnel costs roll-up to those costs. Either for one pay period or on the year end totals, perform the following procedures on the sample by inspecting the following supporting documentation:

(i) compare the costs for allowability and unallowability as defined in sections (1) and

(2) of paragraph (H) of rule 5122-26-19 of the Administrative Code;

(ii) compare the allocation methods used to determine whether the costs are documented as direct service (column 4a) or support service (column 4b) costs;

(iii) compare the allocation methods used to determine which service personnel costs have been allocated to;

(iv) verify any unallowable costs are allocated in the same manner they were originally allocated and are documented in the appropriate service row of column 10 of the AUCR; and

(v) identify and document any material variances (variances greater than plus or minus two percent) and obtain management’s explanation of the material variance(s) for inclusion in the actual uniform cost report agreed upon procedures (AUP) report.

(3) Procedure Three – Non-Personnel Costs Verification

(a) From the non-personnel costs reported in column 5 of the AUCR, select a haphazard sample (as defined in the American Institute of Certified Public Accountants audit sampling guide), of checks and/or electronic funds transfer (EFT) disbursements, equal to twenty percent or forty checks and/or EFT disbursements, whichever is less. Perform the following procedures on each selected check or EFT disbursement:

(i) compare the costs the check or EFT disbursement is for to the appropriate allowability or unallowability criteria listed in sections (1) and (2) of paragraph (H) of rule 5122-26-19 of the Administrative Code;

(ii) verify the allocation method or methods used for the sampled non-personnel costs have been made in accordance with the procedures outlined in the Appendix to rule 5122-26-19 of the Administrative Code;

(iii) verify any unallowable costs are allocated in the same manner as they were originally allocated and are documented in the appropriate service row of column 10 of the AUCR; and

(iv) identify and document any material variances (variances greater than plus or minus two percent) and obtain management’s explanation of the material variance(s) for inclusion in the actual uniform cost report agreed upon procedures (AUP) report.

(4) Procedure Four – Administrative Overhead Costs Verification

(a) From the administrative overhead costs reported in column 7 of the AUCR, select a haphazard sample (as defined in the American Institute of Certified Public Accountants audit sampling guide) of checks and/or electronic funds transfer (EFT) disbursements, equal to ten percent or twenty checks and/or EFT disbursements, whichever is less. Perform the following procedures on each selected check or EFT disbursement:

(ii) determine if the administrative overhead costs were allocated using only one of the allowable methods described in the Appendix to rule 5122-26-19 of the Administrative Code;

(iii) verify that any unallowable costs are allocated in the same manner they were originally allocated and are documented in the appropriate service row of column 10 of the AUCR; and

(5) Procedure Five – Units of Service Verification

(a) From and by each service with costs reported on the AUCR, select a haphazard sample

(as defined in the American Institute of Certified Public Accountants audit sampling guide) of the reported units of service, equal to twenty percent or forty total units, whichever is less. Perform the following procedures on the selected units:

(i) verify documentation exists in client records to support the number of units selected ;

(ii) compare the type of service selected to determine it is reported in the appropriate service line of column 2; and

(iii) identify and document any material variances (variances greater than plus or minus two percent) and obtain management’s explanation of the material variance(s) for inclusion in the actual uniform cost report agreed upon procedures (AUP) report.

(6) Procedure Six – First BUCR to AUCR Comparison

(a) Compare the first BUCR to AUCR and verify that the methods of cost reporting selected for the first BUCR are the same as the methods used when completing the AUCR.

(H) Actual Uniform Cost Report Agreed Upon Procedures Report

(1) A written report on the findings of these agreed upon procedures shall be completed by the independent public accounting (IPA) firm for the Ohio Department of Mental Health (ODMH) certified CMH agency to submit to ODMH. The report shall be completed in accordance with the American Institute of Certified Public Accountants Statement on Standards for Attestation Engagements Statement number 11, 12 or its successor, and the work papers shall be completed in accordance with Government Auditing Standards. At a minimum, the report shall include the following:

(a) the procedures performed and the findings;

(b) a schedule listing the number of variances, if any, per procedure and a list of unallowable costs noted during the agreed upon procedures (AUP);

(d) any other observations and/or comments of note the auditor, using his/her professional judgment, deems relevant.

(I) The AUCR agreed upon procedures report shall be given to the ODMH certified CMH agency.

Effective: 06/30/2006

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

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

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