Chapter 5122-3 Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc

5122-3-01 Consultation with constituencies affected by rules.

(A) Purpose

The purpose of this rule is to establish procedures by which the department of mental health will notify and consult with relevant constituencies that may be affected by rules, regulations, standards, and guidelines issued by the department.

(B) Application

This rule shall apply to all rules, regulations, standards, and guidelines issued by the department.

(1) “Administrative rules coordinator” means the individual within the central office designated to promulgate rules on behalf of the director.

(2) “Board” means, at the same time, both a community mental health board and a board of alcohol, drug addiction and mental health services. If the term community mental health board is used, it also refers at the same time, to a board of alcohol, drug addiction and mental health services. If the term board of alcohol, drug addiction and mental health services is used, it also refers at the same time, to a community mental health board.

(3) “Central office” means the executive office of the department in Columbus, Ohio.

(4) “Chief” means an individual who is the chief managing officer of a unit within the central office of the department.

(5) “Consultation” means the process described in this rule for communications between the department and relevant constituencies prior to the establishment of rules, regulations, standards, and guidelines. Such communications may be written or oral, in group or individual meetings, by review of proposals or responses, or other appropriate methods.

(6) “Director” means the director of the Ohio department of mental health.

(7) “Guideline” means a written set of principles by which to make a judgment or determine a course of action and which is required to be issued by the department under Chapter 340. or 5119. of the Revised Code.

(8) “Office” means an organizational unit designated within the central office of the department.

(9) “Regulation” means the same as rule.

(10) “Rule,” as defined by division (C) of section 119.01 of the Revised Code, means a written statement having a general and uniform operation, adopted under Chapter 119. of the Revised Code, and enforced by the department under the authority of the laws governing the department.

(11) “Standard” means those standards required to be adopted as rules under Chapter 5119. of the Revised Code pursuant to division (G) of section 5119.01, section 5119.20 and division

(G) of section 5119.22 of the Revised Code.

(D) Relevant constituencies

(1) Prior to amending, adopting or rescinding any rule, standard or guideline, the department shall consult with representatives of consumers of mental health services, their families, and alcohol, drug addiction and mental health services boards.

This consultation may include, but not be limited to, the following organizations:

(a) The alliance for the mentally ill of Ohio, or other family organizations.

(b) The Ohio association of alcohol, drug addiction and mental health services boards.

(2) Prior to amending, adopting or rescinding a rule, standard, or guideline, the department shall consult with other appropriate constituencies, based on the content of the material and the potential impact on their memberships or the exercise of their responsibilities.

Consultation may include, but not be limited to, the following listed organizations. If an organization, not on this list has an interest in mental health issues and desires also to be consulted with, they may be included by requesting such consultation and indicating the particular rule of interest in a letter to the Director, Department of Mental Health, Room 1180, State Office Tower, 30 East Broad Street, Columbus, Ohio, 43266-0414.

(a) The county commissioners association of Ohio.

(b) Employee organizations representing employees of the department pursuant to Chapter 4117. of the Revised Code.

(d) The Ohio affiliate of the national association of black social workers.

(e) Ohio association of child caring agencies.

(f) The Ohio association for counseling and development

(g) The Ohio chapter of the national association of social workers.

(h) The Ohio council of community mental health agencies.

(i) The Ohio hospital association.

(j) The Ohio juvenile judges association.

(k) Ohio legal rights service.

(l) The Ohio nurses association.

(m) The Ohio probate judges association.

(n) The Ohio psychiatric association.

(o) The Ohio psychological association.

(p) Organizations or persons representing or reflecting the views of deaf Ohioans.

(q) Organizations or persons representing or reflecting the views of minority Ohioans.

(r) Other affected constituencies.

(s) Other state departments to be impacted.

(t) The public children services association of Ohio.

(3) Consultation shall occur as early as practicable but not less than thirty days prior to the commencement of proceedings under Chapter 119. of the Revised Code if a rule is involved and thirty days prior to issuance of guidelines or standards, except in an emergency.

(E) Consultation process

(1) When a rule, standard or guideline is to be adopted, amended, or rescinded, the director or deputy director of the department shall designate the office chief to be responsible for the content.

(2) After an office is designated to prepare a rule, standard, or guideline, the chief will recommend to the director which individuals or groups noted in paragraph (D) of this rule are to be consulted and the method for doing so. The director will designate the constituencies to be consulted and the method for accomplishing this consultation.

(3) The chief will prepare the draft of the rule, standard or guideline, and have it reviewed by the director or designee prior to beginning the consultation process. A group of representatives may be asked to help develop the proposed rule, standard or guideline.

(4) Upon the director’s approval of the draft rule, standard or guideline, all organizations identified in paragraph (D) of this rule will be sent a copy of the draft.

(5) The chief will maintain a file of any comments provided by those consulted. A log will be kept of all consultation contacts, whether written or oral, including the person(s) contacting the department and the date of the contact. It is the responsibility of the chief to maintain this material until after the final issuance of the rule, standard or guideline. If a rule is adopted, the file will be transferred to the administrative rules coordinator.

(6) Upon completion of the consultation and approval of the director of any necessary revisions, the director will issue the guideline and, in the case of a rule or standard, the administrative rules coordinator will file the proposed rule.

(7) When an emergency is declared by the director, consultation shall occur as soon as possible, but not necessarily prior to the commencement of proceedings under Chapter 119. of the Revised Code if a rule is involved and not necessarily prior to issuance of guidelines or standards. The director shall state the reason for declaring an emergency. Emergency includes but is not limited to any delay in the issuance of a rule, standard, or guideline which may likely prevent compliance with federal and state laws or regulations, impede utilization of appropriated funds, or pose a serious risk to the provision of mental health services or the rights of consumers.

(8) The chief will prepare a summary of the comments received and the response of the department to the comments and will make this summary available on request.

R.C. 119.032 review dates: 01/09/2004 and 01/09/2009

Promulgated Under: 119.03

Statutory Authority: 5119.06

Rule Amplifies: 5119.06

Prior Effective Dates: 5/24/90

5122-3-03 Evaluation and referral for electroconvulsive therapy (ECT).

(A) The purpose of this rule shall be to establish standards and criteria, indications, contraindications and limits for referral of adult ODMH regional psychiatric hospital (RPH) inpatients to an outside facility for ECT.

(B) The provisions of this rule shall be applicable to all RPHs under the managing responsibility of the department.

(1) “Chief clinical officer” and “CCO” mean the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(2) “Psychiatrist” means a licensed physician who has satisfactorily completed a residency training program in psychiatry, as approved by the residency review committee of the American medical association, the committee on post-graduate education of the American osteopathic association, or the American osteopathic board of neurology and psychiatry, or who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state medical association or the Ohio osteopathic association on the basis of formal training and five or more years of medical practice limited to psychiatry.

(3) “ECT” is a somatic psychiatric treatment mediated by a modified grand mal seizure, which is induced by the application of electrical current of the brain.

(4) “Informed consent” means the voluntary and knowing permission given by a person who has received all appropriate information.

(D) Requirements for referral

(1) ECT shall not be administered in ODMH RPHs.

(2) Only adult ODMH RPH inpatients shall be referred for ECT.

(3) The RPH psychiatrist must present clinical data to the RPH CCO to obtain approval for ECT referrals.

(4) It is required that any patient, voluntary or involuntary, competent or incompetent, shall be given a full explanation of ECT consistent with the specific items cited below:

(a) An explanation of the procedures to be followed and their purposes including identification of any procedures which are experimental. This explanation is to be given in such a way as to enable the individual to make a decision to grant/deny consent;

(b) A description of any attendant discomforts and risks reasonably to be expected;

(d) A disclosure of any appropriate alternative procedures/treatments that might be advantageous for that patient including an explanation of the consequences of those procedures/treatments;

(e) An offer to answer any inquiries concerning the procedures and answers to any such inquiries;

(f) An instruction that the individual may refuse to consent and that the individual is free to withdraw his consent and to discontinue the treatment at any time without prejudice unless informed consent for the ECT is given by guardian or court-ordered; and

(g) A notification that the individual may consult with an independent specialist and counsel.

(5) The competence of a patient to give informed consent shall be determined by the attending psychiatrist. The written opinion shall be incorporated into the patient’s permanent medical record.

(6) The criteria for determining the competence of the patient, include but are not limited to:

(a) Whether or not the patient is physically and mentally able to receive the information required to be furnished;

(b) Whether or not the patient is able to explain his/her understanding of the information provided; and

(7) Competent adult patients

No competent adult patient shall be given ECT unless his/her informed consent has been obtained.

(8) Adult incompetent involuntary patients

(a) If an adult patient has been adjudicated incompetent to give informed consent for medical treatment by a probate court, the patient’s guardian may give informed consent.

(b) If an adult patient has been determined to be incompetent to give consent according to the procedure outlined above, and has no guardian, ECT may be administered only under the following conditions:

(i) The attending psychiatrist must certify in writing that an indication for ECT use as outlined in paragraph (E) of this rule is evident;

(ii) The chief clinical officer recommends in writing the administration of ECT; and

(iii) If a durable power of attorney for healthcare issues exist, it should be followed. Otherwise, approval for ECT shall be obtained from the probate court.

(E) Indications for use

(1) General statement

Referrals for ECT are based upon a combination of factors, including the patient’s diagnosis, nature and severity of symptomatology, treatment history, consideration of anticipated risks and benefits of viable treatment options, and patient preference. At present there are no diagnoses which should automatically lead to treatment with ECT. In most cases, ECT is used following treatment failure on psychotropic agents, although specific criteria do exist for use of ECT as a first-line treatment.

(2) Primary use of ECT Situations where ECT may be used prior to a trial of psychotropic agents include, but are not limited to, the following:

(a) Where a need for rapid, definitive response exists on either medical or psychiatric grounds; or

(b) When the risks of other treatment outweigh the risks of ECT; or

(d) Patient preference.

(3) Secondary use of ECT

In other situations, a trial of an alternative therapy should be considered prior to referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

(a) Treatment failure, taking into account issues such as choice of agent, dosage, and duration of trial;

(b) Adverse effects which are unavoidable and which are deemed less likely and/or less severe with ECT; and

(4) Major diagnostic indications Diagnoses for which either compelling data are present for efficacy of ECT or a strong consensus exists in the field supporting such use.

(a) Major depressive disorder. ECT is an effective treatment for all subtypes of major depressive disorder;

(b) Bipolar disorder. ECT is an effective treatment for all sub-types and phases of bipolar disorder including manic, depressed and mixed phases.

ECT may be an effective treatment for psychotic schizophrenic exacerbations including catatonia, when prominent affective symptoms are present and when there is a history of favorable response. ECT may be effective in other psychotic disorders.

(d) Mental disorders due to a general medical condition. ECT may be effective in the management of severe affective and psychotic symptoms concomitant with general medical conditions, or in treating delirium of various etiologies, including toxic and metabolic.

(e) Other diagnostic indications.

(i) For people with diagnoses for which efficacy data for ECT are only suggestive, or where only a partial consensus exists in the field, support its use. In such cases, ECT should be recommended only after standard alternatives have been considered as a primary intervention. The existence of such indications, however, should not deter the use of ECT for treatment of a concurrent major diagnostic medication.

(ii) Although ECT has sometimes been of assistance in the management of mental disorders other than those described above, such usage i snot adequately substantiated and should be carefully justified in the clinical record on a case-by-case basis.

(f) Medical disorders

(i) The neurobiologic effects associated with induced generalized seizure activity may be of benefit in treating a small number of medical disorders.

(ii) Such conditions include, but are not limited to:

(a) Catatonia secondary to medical conditions (ECT is indicated for catatonia of all causes);

(b) Hypopituitarism;

(c) Intractable seizure disorder;

(d) Neuroleptic malignant syndrome; and

(e) Parkinson’s disease.

(F) Contraindications and situations of high risk

(1) There are no absolute contraindications to ECT.

(2) Situations associated with substantial risk

(a) Situations exist in which ECT is associated with an appreciable likelihood of serious morbidity or mortality. In such cases, the decision for ECT should be based upon the premise that the patient’s condition is too grave, (i.e., life threatening) to leave untreated, and that ECT is the safest treatment available.

(b) In these instances, careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to treatment modifications which may diminish the level of risk.

(i) Space-occupying cerebral lesion, or other conditions with increased intracranial pressure;

(ii) Seizure disorder;

(iii) Recent myocardial infarction with unstable cardiac function;

(iv) Recent intracerebral hemorrhage;

(v) Bleeding, or otherwise unstable, vascular aneurysm or malformation;

(vi) Retinal detachment;

(vii) Pheochromocytoma; and

(viii) Significant anesthetic risk.

(d) Concomitant medications. The following medications should be discontinued or dosage reduced:

(i) Benzodiazapines, as they are anti-convulsants – should be held for at least eight hours;

(ii) Lithium, as it can increase postictal delirium and prolong seizure activity – should be reduced in dose;

(iii) Bupropion, as it can induce late appearing seizures – should be discontinued;

(iv) Lidocaine markedly increases seizure threshold – should be held for at least eight hours;

(v) Theophylline increases the duration of seizures – should be discontinued;

(vi) Reserpine can cause respiratory and cardiovascular problems and should be discontinued; and

(vii) Other medications as determined by the IBHS pharmacy and therapeutics committee.

(G) Medical evaluation When a patient remains an ODMH RPH patient when receiving ECT, the following medical evaluation will need to be completed by the ODMH RPHstaff:

(1) Medical examination;

(2) Neurological examination;

(3) Laboratory evaluations including CBC and differential; blood and urine chemistries;

(4) Electrocardiogram;

(5) X-ray of lumbosacral region if spinal problems are suspected;

(6) Chest x-ray, if clinically indicated;

(7) In the presence of central nervous system symptoms (seizure disorder or a space occupying lesion), EEG and brain computed tomographic scan or magnetic resonance imaging;

(8) Dental examination for elderly patients and those with dental problems; and

(9) Anesthesiologist consults to evaluate risk of anesthesia. This may be completed at the facility where ECT is administered prior to ECT occurring.

(H) Referred facility requirement

(1) Properly accredited hospital or outpatient facility.

(2) The psychiatrist who is responsible for the administration of ECT has been credentialed and privileged in ECT by the facility where the ECT is being administered.

(I) Training When ODMH RPH patients are receiving ECT as outpatients, the RPHnursing staff shall be provided with appropriate training on nursing care for these patients to assure competent care of pre- and post-ECT treatment.

(J) Reference “Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, 2nd ed., 2001”.

Effective: 09/20/2010

Promulgated Under: 111.15

Statutory Authority: 5119.01, 5122.271, 5122.29

Rule Amplifies: 5119.01, 5122.271, 5122.29

Prior Effective Dates: 3-27-1978, 7-1-1980, 1-27-1984, 8-1-1998, 12-1-2000, 12-9-2002

5122-3-05 Competency to stand trial assessment and restoration services for serious youthful offenders (SYOs).

(A) Purpose and background

(1) The purpose of this rule shall be to establish guidelines for competency assessment and restoration treatment of serious youthful offenders (SYOs). Pursuant to section 2152.13 of the Revised Code, effective January 1, 2002, SYOs are afforded all the rights a person who is criminally prosecuted would have if the crime were committed by an adult. This includes the right to be competent to stand trial and utilization of the procedure outlined in Chapter 2945. of the Revised Code, related to competency to stand trial.

(2) Placement/treatment of young children on adult units raises fundamental concerns about the safety and effectiveness of treatment, since ODMH only operates adult inpatient facilities. Treatment of children/adolescents must consider the child’s developmental needs and mental status in order to be safe and effective. This rule establishes separate and distinct procedures and guidelines for competency assessment and restoration of children/adolescents. This rule will provide procedures for handling potential referrals from the juvenile courts in Ohio to ODMH facilities. Substantial precedent and common sense support the separation of children from adults in inpatient settings. Prior to the closure of ODMH children’s hospitals, in accordance with section 5119.03 of the Revised Code, the department operated separate institutions for children and adults. ODMH private psychiatric hospital licensure rules require that children and adult beds be separate, except for certain emergency admissions of brief periods (forty-eight to seventy-two hours) for older adolescents, aged fifteen through seventeen.

Under this rule, seventeen year olds may be admitted and treated in an adult bed if the person is functioning as an adult in such areas as employment, family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult bed.

National professional guidelines clearly recognize that children and adolescents younger than fourteen should be admitted only to programs that are designed for youth and physically distinct from adult psychiatric inpatient programs. Adolescents sixteen and older may be admitted to adult units for valid clinical reasons, but should be treated in a program designed to meet their specific needs. Children and adolescent programs should address the youth’s developmental needs including those for education and age-appropriate social interaction.

(B) Definitions

The following definition shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

“Serious youthful offender” and “SYO” have the same meaning as in division (X) of section 2152.02 of the Revised Code, i.e., a person who is eligible for a mandatory SYO or discretionary SYO, but who is not transferred to adult court under a mandatory or discretionary transfer.

(1) Young children (under age fourteen years) and younger adolescents (ages fourteen to fifteen) should not be placed in an ODMH regional psychiatric hospital (RPH) because adult facilities are not designed or staffed to provide age-appropriate services for youth. Additionally, because interaction with adult patients on these units may be problematic, these children should be placed in an age-appropriate inpatient psychiatric unit for children or a community residential treatment facility that would specifically meet their individual needs. Older immature adolescents and those not medically cleared for admission to an adult facility should also be treated in these types of settings

(2) Older adolescents (ages sixteen to seventeen) and some younger adolescents (ages fourteen to fifteen) in limited exceptional cases, may be admitted to adult units for valid clinical reasons but should be treated in an individualized program designed to meet their specific needs.

(D) Procedures for admission of adolescents to ODMH RPH inpatient units. Prior to such admissions for competency restoration services, the RPH chief clinical officer shall assure the following:

(1) The child must be medically assessed as appropriate for admission to an adult inpatient unit by a board-eligible or board-certified child psychiatrist with documented specialized training and experience in working with adolescents and their families in an inpatient treatment program;

(2) Other available less restrictive treatment resources (e.g., residential treatment, intensive outpatient), must have been considered and determined to not be available or not appropriate to meet the youth’s mental health and safety needs; and

(3) An individual plan of care must be developed by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist to meet the adolescent’s restoration to competency needs including the developmental, educational, safety, and environmental needs.

(E) Guidelines for adolescent competency to stand trial restoration treatment services provided in the RPH.

(1) Treatment for the adolescent should be supervised by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist;

(2) All relevant components of the competency to stand trial restoration service are to be adjusted to meet the adolescent’s developmental, educational, safety, and environmental needs;

(3) Upon admission, an objective competency assessment should be performed.

Standardized competency assessment tools may be utilized;

(4) Multi-modal, experiential competency restoration educational experiences, (e.g., discussions, reading, video, role playing or mock trial), may be utilized;

(5) An educational component should be included regarding the criminal charges, severity of charges, sentencing, pleas, plea bargaining, roles of the courtroom personnel, adversarial nature of the trial process and evaluating evidence;

(6) Periodic reassessment of competency should be made regarding the adolescent’s progress toward restoration to competence; and

(7) Medication treatment may be needed in order for restoration to competence to occur.

Effective: 01/24/2011

Promulgated Under: 111.15

Statutory Authority: 5119.01

Rule Amplifies: 2152.13

Prior Effective Dates: 1-2-2002 (Emer.), 4/3/02

5122-3-09 Regional psychiatric hospital tuberculosis control program.

(A) The purpose of this rule shall be to establish a policy that will conform to current medically recommended measures for the control of tuberculosis in all regional psychiatric hospitals under the managing responsibility of the department of mental health (ODMH).

(B) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) “Active tuberculosis disease” means that tuberculosis has been demonstrated by clinical, bacteriological, or radiographic evidence to be present in an individual who has not completed an appropriate course of anti-tuberculosis medication, regardless of the stage of communicability of the tuberculosis, and includes both pulmonary and extrapulmonary tuberculosis.

(2) “Case record” means a specific clinical record maintained at a department operated facility or program which documents the current physical condition and treatment of a patient or an employee who presently has, or has had, tuberculosis.

(3) “Chemoprophylactic therapy” means the treatment applied to prevent development of active disease in an already infected individual.

(4) “Communicable tuberculosis” means active tuberculosis that has been determined, through examination of an individual’s respiratory tract cultures, to be in a stage at which it can be transmitted to another individual.

(5) “Community support network (CSN)” means a system of integrated clinical community mental health services designed through the local board, community service network and the department of mental health, collaborating with consumer needs in the forefront.

(6) “Extrapulmonary tuberculosis” means tuberculosis that affects tissue other than the lungs. Extrapulmonary tuberculosis is not communicable.

(7) “Infectious” means capable of transmitting infection. (When persons who have clinically active pulmonary or laryngeal tuberculosis (TB) disease cough or sneeze, they can expel droplets containing mycobacterium tuberculosis into the air).

(8) “Medical advisor” means a designated physician who is available to the regional psychiatric hospital and is responsible for monitoring such clinical activities as the treatment and chemoprophylaxis of both active tuberculosis cases and positive reactors.

(9) “Mycobacterium tuberculosis (TB)” means the organism that causes TB and is sometimes called the tubercle bacillus. It belongs to a group of bacteria called mycobacteria.

(10) “Purified protein derivative (PPD) – tuberculin test” means a skin test used to evaluate the likelihood that a person is infected with mycobacterial tuberculosis.

(11) “Pulmonary tuberculosis” means tuberculosis that affects the lungs.

(12) “Qualified medical provider” means any general hospital or clinic, private physician, health maintenance organization and/or preferred provider organization which is duly licensed and/or certified.

(13) “Regional psychiatric hospital” means the five state mental healthcare facilities run by ODMH which represent seven hospital sites across the state of Ohio. A broad array of mental health services are provided in acute and long-term environments and to community support networks (CSN).

(14) “Tuberculosis control officer” means the individual assigned responsibility by the chief executive officer for designing, implementing, evaluating and maintaining the tuberculosis control program of the regional psychiatric hospital.

(15) “Tuberculosis infection” means means the condition of a person who is purified protein derivative (PPD) mantoux positive, but whose x-ray changes are compatible with tuberculosis which is stable in serial x-rays, and whose bacteriology study results are negative whether the situation has been previously known or not. 5122-3-09 2

(1) Every patient upon admission to the regional behavioral hospital shall receive tuberculosis testing with informed consent unless documentation is available that tuberculosis testing has been performed by a qualified medical provider within the past six months, or more frequently based on exposure and risk factors, or the patient refuses to be tested. If the patient refuses to be tested or if prior positive or allergic, he/she shall be referred to the tuberculosis control officer to determine if he/she meets the criteria defined in paragraph (C)(5) of this rule.

(2) All newly hired employees shall be required to submit to tuberculosis screening as a condition precedent to starting work unless documentation is provided that the employee has received tuberculosis testing by a qualified medical provider within the past twelve months, or more frequently based on exposure and risk factors or the person is allergic, or a prior positive reactor.

(3) At least annually or more frequently based on exposure and risk factors, all patients and employees at each regional psychiatric hospital and patients and employees in CSN programs operated by the department shall be screened for tuberculosis. In those situations where employees are working in a community based program or CSN not operated directly by the department, employees will be screened for tuberculosis by the community based program facility. Where such screening is not offered, employees shall be screened for tuberculosis by the department.

(4) Any employee who is symptomatic of tuberculosis disease process or is found to have active tuberculosis shall be removed from active duty and referred for medical care and not return to work until he/she is no longer infectious and is fit for duty.

(5) Any patient with symptoms of active tuberculosis (e.g., blood in sputum, night sweats, weight loss), or has had significant exposure to tuberculosis, or is found to have an active tuberculosis disease case shall be immediately referred to the tuberculosis control officer for evaluation, counseling, education and referral for appropriate treatment. This may include isolation and evaluation for court-ordered testing and treatment.

(6) Each regional psychiatric hospital shall establish a written tuberculosis control program that satisfies the current center for disease control and prevention (CDC) guidelines, OSHA regulations, and is consistent with the 5122-3-09 3 current department tuberculosis control plan.

(7) Pregnant females are to be screened for TB. A pregnant female may be excluded from screening only with written permission from her medical provider.

(8) Volunteers who provide ten or more hours of service in a thirty-day period shall be subject to the TB testing requirements articulated above.

(D) Leadership and implementation of tuberculosis control program

(1) Leadership

(a) The chief executive officer (CEO) of each regional psychiatric hospital, in consultation with the regional psychiatric hospital’s chief clinical officer (CCO), shall appoint a physician to serve as a medical advisor for the tuberculosis control program.

(b) The CEO of each regional psychiatric hospital BHO, in consultation with the CCO, shall appoint a registered nurse or a physician to serve as the tuberculosis control officer.

(c) In the event that the medical advisor and the tuberculosis control officer are unavailable, the CEO shall defer to the CCO for advice.

(2) Implementation

(a) The tuberculosis control officer shall become thoroughly acquainted with the department’s tuberculosis control program as outlined in this rule and, with the assistance from the medical advisor as needed, shall be responsible for the following:

(i) Directing annual tuberculosis screening evaluation of all patients and all employees, utilizing appropriate screening and methods;

(ii) Verifying that treatment for patients and employees who have been confirmed to have active tuberculosis disease has been accomplished;

(iii) Monitor the continued prescribing of chemoprophylactic therapy 5122-3-09 4 for patients and employees who are newly positive skin test convertors;

(iv) Developing and distributing continuing education materials and tuberculosis screening questionnaires for use by patients and employees who fail to submit to initial and/or annual tuberculosis screening opportunities;

(v) Ensuring that appropriate measures are taken to isolate and treat active tuberculosis disease in the regional psychiatric hospital or, if adequate treatment is not available, arranging to transfer patients to hospitals where appropriate treatment can be given;

(vi) Directing the follow-up program for patients and employees with old, inactive tuberculosis disease, ensuring that the recommended x-rays and bacteriological evaluations are completed;

(vii) Establishing and maintaining up-to-date case records of all patients and employees who have or have had tuberculosis, and submitting reports to ODMH central office as required; and

(viii) Assuring that required reports are completed and forwarded to appropriate staff and the proper agencies (e.g., local health department, the CDC, etc.).

Effective: 06/13/2009

Promulgated Under: 111.15

Statutory Authority: 111.15, 5119.01, 5119.07

Rule Amplifies: 5119.01

Prior Effective Dates: 11-16-1978, 7-1-1980, 3-10-2000, 7/15/02

5122-3-12 Duty to protect.

(A) The purpose of this policy is to implement the duty to protect requirements per section 2305.51 of the Revised Code.

(B) This policy shall apply to all mental health professionals employed or contracted by Ohio department of mental health hospitals.

(1) “Independently-licensed mental health professional” means psychiatrists, psychologists, social workers, counselors and clinical nurse specialists licensed to independently provide mental health services.

(2) “Knowledgeable person” means any person who has reason to believe that a patient has the intent and ability to carry out an explicit threat of inflicting imminent and serious physical harm to a clearly identifiable potential victim(s), who is either an immediate family member of the patient, an employee of the hospital, or an individual who, otherwise, personally knows the patient.

(3) “Mental health professional” means any individual who is licensed, certified or registered under the Revised Code, or otherwise authorized in this state, to provide mental health services.

(D) Procedures:

(1) Any mental health professional to whom an explicit threat of serious physical harm to another person or persons or identifiable structure is made, or who is made aware by a knowledgeable person of an explicit threat made by a patient, will initiate the duty to protect process.

(2) Any explicit threat by a patient shall be promptly communicated by the mental health professional who heard the threat or was made aware of the threat, to a registered nurse or psychiatrist on the patient’s treatment team. The treatment team shall determine, based on the patient’s history and current condition, whether the threat represents a credible danger to others.

(a) If the treatment team does not consider the threat to be a credible danger to others, this decision and the reason for this determination shall be documented in the medical record.

(b) If the treatment team considers the threat to be a credible danger, the threat shall be reported promptly by the treatment team to the chief clinical officer or designee of the hospital.

(3) The chief clinical officer or designee of the hospital shall assign an independently-licensed mental health professional to conduct a face-to-face evaluation with the patient as soon as possible after receiving notification of the threat, but no longer than two working days, in order to give a second opinion risk assessment of the threat.

(4) If the independently-licensed mental health professional determines that the threat does not meet the threshold requiring discharge of the duty to protect (e.g., threat is not imminent), this assessment should be documented on a form authorized by the regional psychiatric hospital (RPH) or in a progress note in the medical record.

(a) Each RPH shall establish policies and procedures that assure patient re-evaluation occurs prior to the patient being discharged or receiving unsupervised movement, including placing a “Duty to Protect” sticker on the patient’s chart and adding a “Duty to Protect” problem on the treatment plan. (See Appendix 1 [DMH-0040a] for “Duty to Protect Tracking Form” which may be used by the RPH to monitor procedure compliance).

(b) The independently-licensed mental health professional shall record, in a progress note or indicate on a RPH form, that the patient does not have either the intent or ability to carry out the threat and record the reason(s) for this conclusion.

(c) Other clinical recommendations may be considered for this patient and should be documented as appropriate in the medical record.

(5) If the independently-licensed mental health professional determines that there is an explicit threat of imminent and serious physical harm and there is reason to believe the patient has the intent and ability to carry out the threat, the independently-licensed mental health professional completing the RPH form or documenting this assessment in a progress note in the medical record, must address each of the relevant options to discharge the duty to protect in section 2305.51 of the Revised Code and indicate the reason(s) each was, or was not, chosen.

(a) Since the patient in these instances is already hospitalized, the relevant options for further action under section 2305.51 of the Revised Code for discharging the duty to protect are as follows:

(i) Establishing and undertaking a treatment plan that is reasonably calculated to eliminate the possibility that the patient will carry out the threat (having performed this second opinion risk assessment consultation); and

(ii) Communicating to a law enforcement agency either where the victim or patient resides and, if feasible, communicating with the potential victim(s) and/or guardian(s) about the threat;

(b) If the option chosen by the independently-licensed mental health professional is to warn the potential victim(s) and appropriate law enforcement agency, the independently-licensed mental health professional shall notify the chief clinical officer (or designee) who will designate the person to give the warning;

(i) The information about who was warned, what information was shared, and the time of the warning shall be documented on the RPH form (Appendix 2 [DMH-0040]) or in the progress note in the medical record; and

(ii) Information shared should be restricted to the name and the description of the patient, the nature of the threat, and the name of potential victim(s) and/or potential structure threatened.

(6) Progress notes in the medical record should reflect any contacts with consultants, chief clinical officer (or designee), or the patient’s treatment team as appropriate.

(7) The RPH authorized form, or a copy of the progress notes about the threat should be filed in the legal section of the medical record. A copy should be forwarded to the legal assurance administrator of the hospital.

(8) If the threat is considered to be serious but not imminent, and the independently-licensed mental health professional believes the threat should be re-evaluated closer to unsupervised movement, conditional release or discharge of the patient, the independently-licensed mental health professional will contact the treatment team social worker who will affix or cause to be affixed, a prominent sticker on the front of the patient’s medical record noting a “Duty to Protectr” and add a “Duty to Protect” problem to the treatment plan.

(9) When a “Duty to Protect” sticker is affixed to the medical record and a problem is added to the treatment plan, prior to unsupervised movement, conditional release or discharge, the treatment team social worker will notify the chief clinical officer (or designee) who will assign an independently-licensed mental health professional to conduct a face-to-face re-evaluation of the presence or absence of the threat, and if present, the credibility of the threat.

(10) If a patient with a “Duty to Protect” problem goes AWOL from a RPH, the treatment team (or on evenings, weekends, and holidays, the nurse manager) shall promptly give a recommendation to the chief clinical officer regarding warning law enforcement and, if feasible, potential victims in the community.

(11) In all re-evaluations, the independently-licensed mental health professional should locate the original RPH form or progress notes about the threat in the medical record or in the file of the legal assurance administrator.

(a) After the face-to-face re-evaluation, a new RPH authorized form or medical record progress note shall be completed and filed in the legal section of the medical record with a copy to the legal assurance administrator.

(i) If no active serious threat is present, this should be noted on the RPH form or in a progress note and no further formal action is necessary;

(ii) If an active, serious, and imminent threat remains, this should be documented on the RPH form or in a progress note and the actions identified in paragraphs (D)(5) to (D)(7) of this rule should be followed. In addition, the independently-licensed mental health professional shall promptly notify the treatment team for appropriate action regarding the pending unsupervised movement, conditional release, or discharge.

Click to view Appendix

Effective: 08/05/2011

Promulgated Under: 111.15

Statutory Authority: 111.15, 5119.01

Rule Amplifies: 2305.51

Prior Effective Dates: 1-1-2006

5122-3-13 Regional psychiatric hospital (RPH) incident reporting rule.

(A) Purpose

The purpose of this rule is to establish standards and procedures to ensure that prompt and accurate reporting, immediate evaluation, implementation of corrective/remedial action, and preventive measures take place with the occurrence of each incident. Effective incident reporting provides each hospital with individual and cumulative incident report data to find problem areas and to implement corrective measures designed to prevent recurrence and manage risk. Analysis of this data can reveal systems issues and problems in need of corrective action.

(B) Applicability

The provisions of this rule shall be applicable to all hospital inpatient and community support network (CSN) programs under the managing responsibility of the department.

The following definitions shall apply to this rule in addition to those appearing in rule 5122-1-01 of the Administrative Code:

(1) “Abuse” means any act or absence of action caused by an employee inconsistent with rights which results, or could result in physical injury to a patient; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against a patient under that chapter; insulting or coarse language or gestures directed toward a patient which subjects the patient to humiliation or degradation; or depriving a patient of real or personal property by fraudulent or illegal means.

(2) “Chief clinical officer” or “CCO” means the medical director of a hospital.

(3) “Chief executive officer” or “CEO” means an individual who is the managing officer of the hospital operated by the department of mental health.

(4) “Confirmed abuse/neglect” means the abuse/neglect has been proven to have occurred.

(5) “Critical major incident” means those events for which there is a need to immediately advise the deputy director of hospital services, and ODMH director of the situation.

(6) “Fire”, for qualification as a major incident, means any fire that results in an injury and/or that a fire department responded to and extinguished and/or that caused the evacuation of a building.

(7) “Incident” means any occurrence which is not consistent with the routine care of a patient; the routine services provided by the hospital; or the routine standard of care for the hospital. Incidents include accidents, unusual occurrences, or situations which might result in injury to a person or damage to property or equipment. Incidents may involve patients, employees, visitors, and other persons.

Incidents involving patients are not restricted to those occurrences on the hospital’s premises. Also included is any patient who is on the rolls of the hospital and is involved in an incident while away from the hospital.

(8) “Major incident” means an occurrence severe enough to warrant special categorization for purposes of reporting.

(9) “Minor incident” means those types of occurrences which do not appear to be severe or detrimental to the best interests of the patient, department, hospital, or personnel.

(10) “Neglect” means a purposeful or negligent disregard of duty imposed on an employee by statute, rule, hospital policy, position description, or professional standard and owed to a client by that employee.

(11) “Office of quality assurance/improvement” means the office of quality assurance/improvement of ODMH.

(12) “Patient care system” or “PCS” means the official secure centralized ODMH automated database where patient demographic and related information is maintained.

(13) “Program” means any services provided by the ODMH employees.

(14) “Sentinel event” means those events as defined in rule 5122-2-25 of the Administrative Code.

(15) “Unfounded abuse/neglect” means it was proven that the abuse/neglect did not occur.

(16) “Unproven abuse/neglect” means it could not be proved that the incident happened or did not happen. There may have been conflicting or inadequate evidence to either prove or disprove that the abuse/neglect occurred.

(D) Reporting of incidents

(1) All incidents shall be documented and reported in accordance with the provisions of this rule and on the forms and database prescribed by the department.

(2) Investigation of incidents

(a) The CEO shall develop an investigative procedure to be followed by employees in response to the occurrence of all incidents.

(b) Based on the severity of the occurrence, some incidents are considered as major or critical and shall be reported to central office.

(3) Incidents classified as major

(a) Major incidents shall include, but not be limited to, the following:

(i) All sentinel events.

(ii) All deaths. In addition, the following deaths shall be reported immediately to the coroner and the Ohio state highway patrol:

(a) Suicide;

(b) Accidental death regardless of cause;

(c) Apparent or possible homicide; and

(d) Any suspicious or unusual death .

(iii) All allegations of abuse and/or neglect.

(iv) Events determined by the CEO or designee and/or CCO or designee that require the immediate investigation by the local law enforcement agency and/or the Ohio state highway patrol. Examples of these are:

(a) Serious injury caused by another person, whether another patient, employee, or any other person;

(b) Alleged criminal act of an employee committed on hospital grounds or while performing occupational duties off grounds which may result in a felony or misdemeanor charge;

(c) Alleged criminal act of a patient which may result in a felony or misdemeanor charge;

(d) Alleged criminal act on hospital grounds by person other than an employee or patient which may result in a felony or misdemeanor charge; and,

(e) The absence without leave (AWOL) of a forensic patient, as defined in ODMH policy MF-02, “AWOL Reporting” or its replacement, or any patient determined to be dangerous.

(v) Events primarily related to medical and/or nursing practice requiring immediate evaluation/investigation as determined by the CEO or designee, the CCO or designee, or the director of nursing or designee. Examples of these incidents are:

(a) The attempted suicide or any action of self-injurious behavior by a patient considered serious in nature;

(b) An accidental injury of a person considered to be serious that was not caused by the direct action or inaction of another person;

(c) The adverse drug reaction of a patient to a life threatening degree;

(d) A medication error that results in serious consequences;

(e) A medical emergency that was serious or life threatening; and

(f) The unauthorized use of restraint/seclusion or locked time-out.

(vi) Property damage or loss resulting in replacement/repair cost of more than one thousand dollars;

(vii) Fires, as previously defined;

(viii) Bomb threats or other threats made, written, or telephoned considered to be major in consequence as determined by the CEO or designee; and

(ix) Any serious situation disrupting the normal operation, safety, and/or security of the hospital or facility, patients, and/or staff, such as the malfunction, damage, or unscheduled loss of mechanical systems, floods, or severe weather conditions.

(b) Based upon evaluation of available facts and consultation with staff, the CEO or designee shall be responsible for making the final determination as to whether an incident shall be classified as a major incident, except for those incidents mentioned in paragraphs (D)(3)(a)(i) to (D)(3)(a)(iii) of this rule, and suicide attempts, which are always major incidents. If the facts are unusual, or when in doubt, the CEO or designee shall handle the incident as a major incident.

(4) Minor incidents include those types of occurrences which do not appear to be severe or detrimental to the best interests of the patient, department, hospital facility, or personnel.

(5) Reporting

(a) The employee who discovers or witnesses an incident, or to whom an incident is reported, is responsible for documenting the incident, cooperating in the investigation, and providing the investigating officer/staff with a complete statement or statements as needed.

(b) The incident notification report (DMH-ADM-005a or DMH-CSN-008, as appropriate) required by ODMH shall be completed for each incident. Each CSN also has additional reporting responsibilities as described in paragraph (D)(7)(c) of this rule, utilizing form DMH-0484/LIC-015.

(c) Facts regarding the incident shall be reported in writing. No unsubstantiated conclusions, opinions, hearsay, assumptions, or accusations shall be included in the incident report.

(d) The incident report shall not be filed, nor references to an incident report made, in the patient medical record. The incident report shall be maintained in an administrative file. The CEO shall utilize a procedure for the filing and internal management of incident reports.

(e) The fact that an incident report has been completed shall not be documented in the patient medical record. However, those events which have a direct medical/clinical effect on the patient should be recorded in the patient medical record, but with no mention of completion of an incident report.

(f) The hospital shall develop policies regarding the copying of incident report materials.

(g) Incident reports shall be maintained in a confidential manner and be accessible only to authorized employees except by consent of the CEO, or the order of a judge of a court of law.

(h) The Ohio state highway patrol may have access only to the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008) should it make such a request.

(i) The CEO shall designate a person to be responsible for notifying the parents/spouse, legal guardian, or legal custodian of a patient about the occurrence of an incident involving a patient. This disclosure shall require the consent of the patient except if the patient is deceased, AWOL, or unconscious.

(j) The CEO shall develop a policy that determines which hospital staff are to be notified of the occurrence of incidents.

(k) If requested by the local mental health board, the mental health board shall have access to only the information on the incident notification report form (DMH-ADM-005a) or the CSN incident notification report form (DMH-CSN-008).

(6) Immediate telephone reporting to central office

(a) Utilizing the telephone call-in procedure, the CEO or designee shall report at all times, the occurrence of any of the following major incidents to the deputy director of hospital services.

(i) All deaths;

(ii) AWOL of a forensic patient as defined in the ODMH policy MF-02, “AWOL Reporting” or its replacement, or dangerous patient, or a patient whose medical condition or nursing/medical needs are such that his/her AWOL status might be life-threatening or the weather conditions are such that the patient’s life may be in danger;

(iii) Fires, as previously defined in paragraph (C)(7) of this rule;

(iv) Equipment malfunction, damage, or unscheduled loss of mechanical systems that may result in significant potential danger as determined by the CEO or designee to staff and/or patients (for example: loss of fire alarm/suppression systems, telephone service, emergency generator, or water/sanitary systems);

(v) Other incidents that the CEO or designee determines are critical in nature that may result in significant danger to staff and/or patients (for example: a hostage situation, a flood, severe weather conditions, bizarre or unusual crimes or events); and,

(vi) Any incident as determined by the CEO or designee that would likely result in news media coverage.

(b) All incidents that involve a morbidity, mortality, or reviewable sentinel event, as defined in rule 5122-2-25 of the Administrative Code,”Morbidity, mortality, and sentinel event”, shall be reported to the ODMH medical director or designee by the hospital CCO or designee via telephone or email.

(c) For critical major incidents occurring five p.m. to eight a.m. Monday through Friday and all day on weekends and holidays the CEO or designee, shall contact the ODMH deputy director of hospital services (refer to ODMH policy I-05 or its replacement).

(7) Other procedures for reporting to central office

(a) All incidents involving a morbidity, mortality, or sentinel event shall be reviewed and reported to the hospital services morbidity and mortality committee as specified by rule 5122-2-25 of the Administrative Code,”Morbidity, mortality, and sentinel event”.

(b) For inpatient programs, all major incidents, including those mentioned in paragraph (D)(6) of this rule, shall be reported to the ODMH office of quality assurance/improvement in central office within twenty-four hours of the incident using the automated PCS incident notification report system.

(c) For CSN programs, all major incidents must be reported to the ODMH office of quality assurance/improvement in central office within twenty-four hours of learning of the incident, using form DMH-CSN-008.

In addition, the CSN, including its licensed residential facilities, shall report outpatient services incidents in accordance with rule 5122-26-13 of the Administrative Code and report residential facility incidents in accordance with rule 5122-30-16 of the Administrative Code. These reports shall be made using form DMH-0484/LIC-015.

(d) The ODMH office of quality assurance/improvement may require such other reports/documents as are necessary to conclude a review of any incident (major critical or minor). Data regarding all incidents shall be maintained in a form specified by central office.

(e) Data regarding minor incidents shall be maintained in a form specified by central office using the automated PCS incident notification report system.

(E) Individual and aggregate analysis

(1) Each hospital and CSN program shall ensure that all incidents are thoroughly and comprehensively reviewed and analyzed:

(a) At the time of submission, on an individual basis, for adequacy of documentation and to effect necessary follow-up; and,

(b) At regular intervals and yearly, on an aggregate basis, to determine trends or patterns indicative of a need for corrective action.

(2) At regular intervals, the ODMH office of quality assurance/improvement shall supply hospitals/facilities with aggregate data on incidents.

(F) Implementation of incident reporting

The CEO of each hospital shall be responsible for prescribing guidelines for implementation of this rule.

Effective: 09/20/2010

Promulgated Under: 111.15

Statutory Authority: 5119.01, 5119.07, 5119.27, 5119.43, 5119.82

Rule Amplifies: 5119.01

Prior Effective Dates: 7-27-1979, 7-1-1980, 2-5-1982, 2-1-2000, 7-15-2002

5122-3-14 Abuse/neglect of patients receiving services in regional psychiatric hospitals.

(A) The purpose of this rule shall be to define patient abuse and neglect for persons receiving Ohio department of mental health (ODMH) services inregional psychiatric hospitals (RPHs); to establish policies to prevent abuse and neglect of persons served; to provide guidelines for preventive and corrective measures; and to establish policies and procedures regarding reports and investigations of abuse or neglect of persons served.

(B) The provisions of this rule shall be applicable to all RPHs providing services under the managing responsibility of the department.

(D) The following definitions shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

(1) “Abuse” means any act or absence of action caused by an employee inconsistent with rights which results or could result in physical injury to a client; any act which constitutes sexual activity, as defined under Chapter 2907. of the Revised Code, where such activity would constitute an offense against a client under that chapter; insulting or coarse language or gestures directed toward a client which subjects the client to humiliation or degradation; or depriving a client of real or personal property by fraudulent or illegal means.

(2) “Neglect” means a purposeful or negligent disregard of duty imposed on an employee by statute, rule, RPH policy, position description, or professional standard and owed to a client by that employee.

(E) The department shall promote policies governing patient services that assure protection of persons served from abuse or neglect caused by employees, other persons served, programs, and procedures. Protection shall include informing employees of their duty to prevent and report abuse or neglect of persons served and disciplinary action against employees who have abused or neglected persons served. Volunteers, contractors and other on-grounds non-employees are covered by this rule and are subject to civil/criminal statutes.

(F) Standards.

(1) The standard and quality of care owed to a person served shall be in keeping with current professional standards of care, federal and state laws and regulations, administrative rules of the department, accreditation standards of the joint commission (TJC), as applicable, and instructions, guidelines, or procedures and requirements of court as applicable.

(2) Each employee shall be responsible for safeguarding persons served from abuse or neglect which could be self-inflicted or caused by other persons served, other employees, or other non-hospital persons.

(G) Duties of the chief executive officer (CEO).

(1) The CEO or designee shall adhere to the guidelines established under rule 5122-3-13 of the Administrative Code including, but not limited to, reporting of incidents and providing for investigative and follow-up procedures to ensure that preventive measures take place to reduce the occurrence of future incidents.

(2) The CEO shall be responsible for making every effort to assure the prevention of patient abuse or neglect by the following measures:

(a) Provision of a safe and quality environment for persons served through the physical environment, good maintenance, housekeeping practices, adequate equipment, buildings, grounds, culture, and therapeutic milieu;

(b) Establishment of a policy that requires assigned personnel to know the whereabouts of each person served at all times;

(c) Provision of quality clinical services that meet the individual medical, psychological, personal needs, choices and promotes individual recovery of persons served; and

(d) Periodic determination of trends related to patient abuse or neglect.

(3) The CEO shall be responsible for reporting and investigating procedures for inpatient services as follows:

(a) Requiring the RPH police chief to:

(i) Thoroughly investigate reports of alleged patient abuse or neglect in accordance with rule 5122-7-04 of the Administrative Code, submit a written report on a security report form to the chiefCEO or designee within forty-eight hours of the reported incident, and determine if the conduct of the employee is in violation of any standard of care under paragraph (F) of this rule;

(ii) prior to any interviews or conversations regarding the allegation of abuse/neglect, persons served are to be provided any reasonable accommodation, close-captioned TV, qualified interpreter, reader, communication device or other communication assistance; and

(iii) Based on the provision of the reasonable accommodation outlined in paragraph (G)((3)(a)(ii) of this rule, advise the person served of his/her right to request the presence of the client rights advocate during the interview.

(b) Notifying the following persons and agencies:

(i) The deputy director of hospital services of ODMH;

(ii) The Ohio state highway patrol immediately, and sheriff, or police if applicable when there are allegations of criminal acts;

(iii) With appropriate authorizations for release of information, the patient’s family, next of kin, or guardian(s) of the person as soon as possible but no later than twenty-four hours and, when completed, ofthe results ofthe investigation; and

(iv) The RPH client rights specialist.

(c) Immediately removing an employee alleged to be involved in suspected patient abuse or neglect from direct patient care until completion of the investigation when the incident dictates such action.

(4) Each CEO or designee shall promulgate procedures for reporting, investigating, and resolving incidents of alleged abuse and neglect for community support network employees.

(5) The CEO or designee shall be responsible for implementing prompt employee disciplinary action pursuant to departmental policy and under section 124.34 of the Revised Code when a charge of patient abuse or neglect by an employee is substantiated.

(H) Employee responsibility

(1) Each employee who has knowledge of apparent or alleged abuse or neglect of a person served shall be obligated to report such incidents to his or her immediate supervisor, or designee, who will immediately inform the CEO and the security/police department. Any injury to a person served shall be reported immediately to a physician.

(2) The employee shall follow through by completing the appropriate ODMH designated incident form. Failure to do so shall be considered neglect of duty and the employee will be subject to disciplinary action.

Effective: 08/25/2011

Promulgated Under: 111.15

Statutory Authority: 5119.01

Rule Amplifies: 5119.01, 5119.02, 5119.27 through 5122.301

Prior Effective Dates: 12-24-1979, 7-1-1980, 11-22-1981, 2-1-2000, 7-15-2002