5122-7-02 Client rights within regional psychiatric hospitals.

(A) The purpose of this rule shall be to promote and protect the rights of clients receiving services in Ohio's regional psychiatric hospitals (RPHs).

(B) The provisions of this rule shall be applicable to all RPHs providing inpatient services under the managing responsibility of the Ohio department of mental health and addiction services (OhioMHAS).

(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 or outpatient 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 OhioMHAS shall be to promote and protect the rights of clients receiving 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 OhioMHAS' advocacy program:

(1) An OhioMHAS client rights and advocacy specialist lead for inpatient services shall be appointed for the department .

General responsibilities of the OhioMHAS client rights and advocacy specialist lead 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 OhioMHAS 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 OhioMHAS staff, including executive committee team, regarding responses to mediations, complaints, grievances and grievance appeals including those having a potential impact on policy development;

(g) 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;

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

Each RPH shall have a designated client rights specialist alternate, appointed by the CEO and who reports to the CEOor designee.

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

(a) Planning, implementing and coordinating RPH advocacy programs, including:

(i) Mediation;

(ii) Developing policies and procedures in accordance with state and federal statutes, the joint commission, and the centers for medicare and medicaid services, which promote and protect human rights;

(iii) Monitoring and evaluating RPH compliance;

(iv) Establishing mechanisms for resolution of client advocacy problems;

(v) Providing consultation, mediation negotiation, training and technical advice; and,

(vi) Representing RPH on matters concerning patient rights.

(b) Providing client advocacy services; including:

(i) Mediation;

(ii) Assuring that persons served are informed of and have access to mediation services;

(iii) Assuring adequate privacy for client interviews;

(iv) Being accessible to clients in person and at work locations;

(v) Representing and assisting clients especially in the areas of rights, abuse and neglect, and fulfillment of recovery and human dignity;

(vi) Investigating and responding to grievances on behalf of clients;

(vii) Attending RPH investigatory interviews with clients, as requested by clients;

(viii) Protecting human and civil rights;

(ix) Reviewing unusual incident reports as part of the quality assurance process;

(x) Ensuring that clients have legal representation at court hearings related to hospital services; and,

(xi) 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) Providing input into program and environmental changes 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 client's rights; consulting with appropriate department staff, including legal staff, regarding policy issues and 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 that people with disabilities are to be free from discrimination in the provision of service on the basis of religion, race, ethnicity, color, creed, sex, national origin, age, lifestyle, sexual orientation, gender identity, physical or mental handicap, disability, developmental disability, or inability to pay as prescribed in department policies and rules, and state and federal statutes;

(h) Ensuring that each client understands their rights and is provided with the client rights in oral and written format, including the functions of and resources available through the Ohio protection and advocacy system , and explanation of their rights as indicated in this paragraph:

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

(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 their ability to communicate effectively, such as deafness or hearing impairment, the list of rights shall be explained to them by providing interpreters, readers or appropriate communication devices or other assistance; and,

(iii) The notification and explanation of client rights shall be documented in the client's health record.

(4) Compliance with paragraph (E)(3)(h) of this rule shall be monitored by the RPH quality assurance programs.

Effective: 6/1/2017
Five Year Review (FYR) Dates: 03/14/2017 and 06/01/2022
Promulgated Under: 119.03
Statutory Authority: 5122.33
Rule Amplifies: 5122.29
Prior Effective Dates: 6/5/1978, 7/1/1980, 9/6/1999. 9/18/2010