Chapter 5122-7 Client Services; Personnel

5122-7-02 Advocacy and administrative oversight for client rights within regional psychiatric hospitals.

(A) The purpose of this rule shall be to promote and protect the rights of clients receiving intensive and specialized services and forensic inpatient services.

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

(C) 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:

"Consumer" means a person who is or has received inpatient services; a client, an ex-patient; a parent; a relative of the consumer; or guardian of person; an advocacy group; or other interested citizen.

(D) The policy of the department shall be to promote and protect the rights of clients receiving inpatient services consistent with a concern for human dignity, respect, recovery and quality clinical care; to respond promptly and effectively to consumer concerns, inquiries, and complaints; and to promote and evaluate consumer satisfaction with services provided.

(E) Organization and responsibilities of ODMH's advocacy program:

(1) An ODMH client rights and advocacy specialist lead for inpatient services shall be appointed for the department under the supervision of the chief of the office of consumer advocacy and protection (CAP) in central office.

General responsibilities of the ODMH client rights and advocacy specialist lead, under the supervision of the CAP chief shall include, but are not be limited to the following:

(a) Providing support for client rights specialists within the RPHs;

(b) Serving as resource person for statewide and individual client advocacy;

(c) Evaluating and reviewing department policies, procedures, and mechanisms for assurance of client rights;

(d) Ensuring that alleged client abuse and neglect cases receive prompt and appropriate action;

(e) Promoting liaison with federal, state, local, community, legal and civil rights advocacy groups;

(f) Consulting with appropriate department staff, including executive committee team, regarding responses to mediations, complaints, grievances and grievance appeals including those having a potential impact on policy development;

(g) Under the supervision/direction of the CAP chief, referring matters requiring legal expertise in the area of client rights to the department's office of legal services;

(h) Investigating and responding to client grievance appeals;

(i) Meeting with RPH client rights specialists on at least a quarterly basis;

(j) Preparing quarterly and annual reports on RPH and central office mediations, complaints, grievances and grievance appeals including number received, types, and resolution status of complaints, grievances and appeals; and

(k) Meeting semi-annually, or more often as needed, with the policy committee for RPH advocacy to review and address trends and patterns, review policies and procedures, and provide direction on departmental response to mediations, complaints, grievances and grievance appeals, as warranted.

(2) Each RPH or campus of multi-site RPH shall have at least one full-time client rights specialist for inpatient services, who reports directly to the chief executive officer (CEO).

Each RPH or campus of multi-site RPH shall have a designated client rights specialist alternate, appointed by the CEO and who reports to the CEO.

(3) Duties for the RPH client rights specialist shall include, but are not limited to the following:

(a) Planning, implementing and coordinating RPH or campus of multi-site RPH client advocacy programs, including mediation; developing policies and procedures which promote and protect human rights; monitoring and evaluating RPH or campus of multi-site RPH compliance; establishing mechanisms for resolution of client advocacy problems; providing consultation, mediation negotiation, training and technical advice; representing RPH or campus of multi-site RPH on matters concerning patient rights;

(b) Providing client advocacy services; including mediation; assuring that persons served are informed of and have access to mediation services; assuring adequate privacy for client interviews; being accessible to clients in person and at work locations; representing and assisting clients especially in the areas of rights, abuse and neglect, and fulfillment of recovery and human dignity; investigating and responding to grievances on behalf of clients; attending RPH investigatory interviews with clients, as requested by clients; protecting human and civil rights; reviewing unusual incident reports as part of the quality assurance process; ensuring that clients have legal representation at court hearings related to hospital services intensive and specialized services and forensic inpatient service; and ensuring that client rights are prominently displayed in writing on every unit;

(c) Attending meetings related to client advocacy; serving as a member of the executive governing body and other committees to ensure representation of the advocacy program; preparing reports for RPH or campus administration and central office; maintaining records; responding in writing to correspondence pertaining to client advocacy;

(d) Involvement in providing input into program and environmental improvements to meet the needs as identified by clients, and assuring protection of patient rights; involvement in and notification of administrative decisions affecting client rights, choice, dignity and recovery;

(e) Advising all levels of RPH staff and volunteers of clients' rights; meeting with policy committee as necessary; consulting with appropriate department staff, including legal staff, regarding policy issues and/or responses to complaints or grievances;

(f) Advocating for clients' access to community mental health systems, and facilitating access to other outside entities, including legal counsel, as needed;

(g) Assuring that equal opportunity is implemented with particular emphasis on advocating for the rights of people with disabilities not to be discriminated against in the provision of service on the basis of religion, race, ethnicity, color, creed, sex, national origin, age, lifestyle, physical or mental handicap, disability, developmental disability, or inability to pay as prescribed in department policies, rules, and state and federal statutes;

(h) Ensuring that each client understands his/her rights and is provided with the client rights in oral and written format, including the functions of and resources available through the Ohio legal rights service, and explanation of his/her rights as indicated in this paragraph:

(i) The written rights shall be furnished to a client within twenty-four hours after admission; and

(ii) If a client is unable to read or speaks a language other than standard English as a primary means of communication, or has a limitation on his/her ability to communicate effectively, such as deafness or hearing impairment, the list of rights shall be explained to him/her by providing interpreters, readers and/or appropriate communication devices or other assistance.

(4) Compliance with paragraph (E)(3)(h) of this rule shall be monitored by the RPH quality assurance programs and shall be documented in the client's medical record; and

(5) An RPH policy committee on client advocacy for intensive and specialized services and forensic inpatient services shall be established by the department in central office to monitor and oversee the hospital services client complaint and grievance procedure, review policies and procedures, and provide direction to the client rights and advocacy specialist lead and RPH client rights specialists on department responses to mediations, complaints, grievances, and grievance appeals.

(a) The committee shall be comprised of the RPH client rights specialists, the deputy director for hospital services, chief of the office of consumer advocacy and protection and/or the client rights and advocacy specialist lead, legal counsel, and the director of the department or designee.

(b) The committee shall meet at least semi-annually or more frequently as determined by the members of the committee.

Replaces: 5122-7-02

Effective: 09/18/2010
Promulgated Under: 111.15
Statutory Authority: 5119.01 , 5119.02 , 5122.27 through 5122.301
Rule Amplifies: 5119.01 , 5119.02 , 5122.27 through 5122.301
Prior Effective Dates: 6-5-1978, 7-1-1980, 9-6-1999

5122-7-04 Responsibilities of ODMH regional psychiatric hospital police and firearms restrictions.

(A) The purpose of this rule shall be to establish the minimum duties and responsibilities of Ohio department of mental health (ODMH) hospital police, and to establish that no firearms shall be dispensed, carried or discharged in any building or on the grounds of any facility that is operating under the control of ODMH, except as provided below.

(B) The provisions of this rule shall be applicable to all facilities under the managing responsibility of ODMH. The firearms restrictions stated in this rule shall include, but not be restricted to, employees of ODMH hospital police departments.

(C) 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) "Chief of police" means an individual appointed to supervise ODMH hospital police department personnel, operations, and security functions. This individual is appointed by the hospital chief executive officer, subject to joint selection or approval by the ODMH security consultant (or in his/her absence, the ODMH chief legal counsel) and final approval by the director.

(2) "Police officer" means any special police officer, as defined in section 5119.14 of the Revised Code, who is under the supervision of the hospital chief of police. A police officer has special training and authority, including the power to arrest under section 5119.14 of the Revised Code. Hereinafter, ODMH police officers are referred to collectively as "hospital police."

(3) "Firearm" means any pistol, revolver, rifle, shotgun, or any part of any such weapon (or any ammunition for any such weapon, or any other weapon capable of discharging a projectile or projectiles that can wound, fatally or otherwise, the person of another). This definition includes unloaded firearms and any firearm which is inoperable but which can readily be rendered operable.

(4) "Securing the scene" means taking actions necessary to stabilize all existing factors and conditions which could destroy or disturb evidence at the scene of a death, an alleged patient abuse, or where any other suspected criminal offense has been committed.

(5) "Safety officer" means a hospital employee designated by the chief executive officer to develop, implement, and supervise the hospital's safety program.

(6) "Safety committee" and/or "environment of care committee" means a group of hospital employees responsible for reviewing, advising, and/or promoting the hospital's safety program.

(7) "Stun gun" means a weapon designed to stun or temporarily immobilize a victim, especially by delivering a high-voltage electric shock. This includes the trademark taser device.

(D) Requirements ofhospital police

(1) Hospital police shall provide protection and security for the patients , visitors, staff, grounds and buildings under the operating authority of the hospital.

(2) Hospital police shall be aware of and sensitive to the therapeutic needs of patients, and shall participate whenever possible in assisting patients in their recovery.

(3) Hospital police may be required to serve as patient escorts as deemed necessary on a facility-by-facility basis.

(4) All reports, including reports of investigations, shall be properly filed, maintained, and secured to protect the confidentiality of persons involved as required by section 5122.31 of the Revised Code. All reports shall be made using standardized departmental forms or forms approved by the chief of police. Requests for access to, or copies of police reports shall follow ODMH policy L-13, "ODMH Public Records Policy".

(5) All inpatient and CSN incidents of workplace violence shall be reviewed annually by the hospital police department, as required by ODMH policy L-01, "Workplace Violence Policy and Procedure" and shared with the hospital chief executive officer in order to identify trends and learning opportunities.

(E) Responsibilities of hospital police

(1) The chief of police shall be responsible for all police department functions, supervision of all police department personnel, and regular performance of the following duties:

(a) Submission of routine reports to the chief executive officer, security consultant, and/or director as directed. An annual report shall be completed which includes measures to improve the operation of the hospital's police department.

(b) Preparation of a policy and procedure manual, which shall be reviewed and approved by the chief executive officer and used to instruct hospital police with respect to the police department's role in assisting patients in their recovery, police functions, and relationships with other departments and programs of the hospital.

(c) Immediate securing of the scene and notifying the chief executive officer or designee, the ODMH security consultant, and the Ohio state highway patrol of any criminal offense or of any allegation of patient/client abuse occurring on any property under the control of ODMH.

(2) Hospital police shall provide the following services:

(a) Enforce the laws of the state of Ohio and investigate any alleged violation of a state statute or organizational policy (as needed). In general, hospital police shall not manage the activities or behavior of patients unless a violation of state law is evident.

(b) Provide assistance to patients, family members and clinical staff in the ongoing process of recovery from the effects of a severe and persistent mental illness.

(c) Investigate all alleged crimes and report suspected illegal activities by employees to the hospital chief of police, who shall then make certain that the ODMH security consultant and the Ohio state highway patrol are both notified. If the Ohio state highway patrol elects not to handle a case, prosecution of suspected illegal activities will be pursued by the hospital police when the chief executive officer and ODMH security consultant concur.

(d) Investigate incidents, fires, and accidents pursuant to the applicable administrative rules promulgated by the department. A safety officer may be assigned to handle certain of these designated duties.

(e) Patrol the hospital's property and buildings in order to identify and report security, fire and safety hazards found and to request corrective maintenance action. Damaged property or conditions which are potentially dangerous to life or property and which are to be reported include defective fire or first aid equipment or unavailability of equipment.

(f) Remove or cause to be removed nuisances or obstructions from the hospital's property.

(g) Assist in the evacuation of patients, staff members and visitors in the event of an emergency and also to assist in providing security and shelter for those persons evacuated.

(h) Provide security, as needed, for public meetings on the property.

(i) Assist consumers, employees, or visitors by rendering emergency first aid, requesting medical assistance, or assisting in their transportation in emergencies.

(j) As an emergency intervention at the request of a clinical supervisor, assist in the control of a patient's behavior when such behavior presents a danger of physical harm to himself/herself and/or others.

(k) Investigate and file reports of vehicle accidents occurring on hospital property.

(l) Investigate employee accidents and complete police reports of these accidents; complete necessary documentation for possible workers' compensation claims in accordance with the hospital's written policies and procedures.

(m) Unless handled by the hospital's safety officer or safety/environment of care committee, develop and implement procedures for emergency evacuations and fire drills pursuant to the applicable rules promulgated by the department.

(n) Actively participate on the hospital's safety/environment of care committee, as appointed.

(o) Control the flow of vehicle traffic and parking on hospital property in accordance with hospital directives and the applicable administrative rules and state statutes.

(p) Maintain a daily radio/telephone log and make written reports of all activities.

(q) In addition to the aforementioned duties, hospital police shall observe the powers and duties as provided in section 5119.14 of the Revised Code.

(3) Training and expectations

(a) Training in job functions shall be available to all hospital BHO police and shall follow guidelines established by the training component of the appropriate division, including at least the minimum number of hours of training as mandated by the Ohio peace officers training council and provided by an academy which is recognized and accredited by the Ohio peace officers training council.

(b) First aid classes shall be mandatory for all hospital police.

(c) Hospital police shall not be expected to place their lives or the lives of other persons in jeopardy in order to discharge their duties.

(d) Hospital police shall not be expected to violate administrative rules or policies in the discharge of their duties.

(e) If the chief executive officer or any member of his or her administrative staff directs or orders the chief of police or a police officer to cease or not initiate an investigation of a reported or suspected violation of any state statute or administrative rule, such order shall not be carried out without first consulting the department security consultant. The order shall then be placed in writing with a copy to the director.

(F) Firearms restrictions

(1) Firearms shall not be stored, dispensed, carried or discharged in any building or on the grounds of any facility under the operating control of ODMH, except when a visiting police agency needs to lock its gun(s) in a safe area.

(2) No patient, visitor, hospital employee, including police officers, shall possess, store, dispense, carry or discharge a personally-owned firearm on the grounds of a facility under the operating control of ODMH.

(3) Ohio state highway patrol officers, local law enforcement authorities, or other persons duly authorized to carry firearms may not carry such weapons into patient contact areas of the facility unless a special request has been made by the chief executive officer in the event of a life-threatening emergency situation which could require the use of deadly force.

(4) Special requests granted by the chief executive officer, which are exceptions to the rule stated in paragraph (F)(1) of this rule, shall be reported immediately to the director of ODMH, or designee, and a written report of such incident shall be made to the director within twenty-four hours explaining the need for such actions.

(5) Any person who violates this policy shall have committed an action which may be cause for removal, as well as, arrest and prosecution under section 2921.36 of the Revised Code.

(G) Stun gun restrictions

(1) Except as authorized in ODMH policy L-14, "ODMH Hospital Police Use of Electronic Control Device" and when a visiting policy agency needs to lock its stun gun(s) in a safe area, stun guns shall not be stored, dispensed, carried or discharged in any building or on the grounds of any facility under the operating control of ODMH.

(2) No person, including police officers and other hospital employees, shall possess, store, dispense, carry or discharge a personally-owned stun gun on the grounds of a facility under the operating control of ODMH.

(3) Ohio state highway patrol officers, local law enforcement authorities, or other persons duly authorized to carry stun guns may not carry such weapons into patient contact areas of the facility unless a special request has been made by the chief executive officer in the event of a life-threatening emergency situation which could require the use of deadly force.

(4) Special requests granted by the chief executive officer, which are exceptions to the rule stated in paragraph (G)(1) of this rule shall be reported immediately to the director of ODMH, or designee, and a written report of such incident shall be made to the director within twenty-four hours explaining the need for such actions.

(5) Any person who violates this policy shall have committed an action which may be cause for removal.

(H) Equipment

(1) A night stick or riot baton may be carried by hospital police only when patrolling outside of buildings, and then only with prior approval of the chief executive officer. The use of a blackjack, slapjack, or similar type of weapon is prohibited.

(2) Equipment which discharges chemical gases, such as chemical mace, may be carried with prior approval of the chief executive officer, but only for patrolling outside of buildings. Such equipment shall not be used to control or subdue a patient.

(I) Implementation. The chief executive officer of each hospital shall be responsible for prescribing guidelines for implementation of this rule.

Effective: 05/10/2010
Promulgated Under: 111.15
Statutory Authority: 111.15 , 2921.36 , 5119.01 , 5119.14 , 5122.31 , 5503.02
Rule Amplifies: 2921.36 , 5119.01 , 5119.14 , 5122.31 , 5503.02
Prior Effective Dates: 1-15-1979, 7-1-1980, 7-24-1981, 11-19-1981,
4-16-2001, 12-10-2005, 3-8-2009

5122-7-11 [Rescinded] Unclassified service.

Effective: 08/14/2014
R.C. 119.032 review dates: 05/28/2014
Promulgated Under: 119.03
Statutory Authority: 124.11 , 5119.071
Rule Amplifies: 124.11 , 124.152 , 5119.071
Prior Effective Dates: 11-26-1979, 7-1-1980, 2-1-2000, 1-14-2008

5122-7-21 Background check on applicants.

[This rule designated an internal management rule. For a copy of this rule, contact the Ohio Legislative Service Commission.]