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